Exam (elaborations) NURSING 201 INTEGRATED PROCESS Nursing Process Dat

Exam (elaborations) NURSING 201 INTEGRATED PROCESS Nursing Process Dat 1. The RN employed in a long-term care facility is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a licensed practical (vocational) nurse and three nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a) The client who requires a bed bath b) An older client requiring frequent ambulation c) A client who requires a 24-hour urine collection * d) A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours R: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine sample, giving a bed bath, and assisting with frequent ambulation can be provided most appropriately by the nursing assistant. The licensed practical (vocational) nurse is skilled in wound irrigations and dressing changes and most appropriately would be assigned to the client who needs this care. 2. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child that was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document the GTPAL for this client as a) G = 3, T = 2, P = 0, A = 0, L = 1 * b) G = 2, T = 1, P = 0, A = 0, L = 1 c) G = 1, T = 1, P = 1, A = 0, L = 1 d) G = 2, T = 0, P = 0, A = 0, L = 1 R: Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies. T is term births, the number born at term (longer than 37 weeks), P is preterm births, the number born before 37 weeks’ gestation, A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks’ gestation; included in parity if past 20 weeks’ gestation), and L is the number of current living children. Therefore, a woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1 and the number of preterm births is 0. The number of abortions is 0 and the number of living children is 1. 3. The registered nurse (RN) is planning assignments for the clients on a nursing unit. The RN needs to assign four clients and has a registered nurse, a licensed practical (vocational) nurse, and two nursing assistants on a nursing team. Which of the following clients would the nurse most appropriately assign to the licensed practical (vocational) nurse? a) The client who requires a 24-hour urine collection b) An elderly client requiring assistance with a bed bath and frequent ambulation c) A client on a mechanical ventilator requiring frequent assessment and suctioning * d) A client with an abdominal wound requiring wound irrigations and dressing changes every 3 hours R: When delegating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Collecting a 24-hour urine and frequent ambulation can most appropriately be provided by the nursing assistant, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning should most appropriately be cared for by the registered nurse. The licensed practical (vocational) nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. 4. A client is seen in the clinic for complaints of thirst, frequent urination, and headaches. Following diagnostic studies, diabetes insipidus in diagnosed. Lypressin is prescribed. The nurse instructs the client that the medication is prescribed to: a) Relieve the headaches. * b) Increase water reabsorption. c) Decrease the production of the antidiuretic hormone. d) Stimulate the production of aldosterone. R: Lypressin is an antidiuretic hormone used in the treatment of diabetes insipidus. It promotes renal conservation of water by acting on the collecting ducts of the kidney to increase the permeability to water, which results in increased water reabsorption. Options 1, 3, and 4 are not actions of the medication. 5. A nurse is preparing to collect a 24-hour urine specimen from the client. Which of the following is an inaccurate action in collecting the specimen? * a) Asking the client to void, saving the specimen, and noting the start time b) Discarding the urine specimen at the start time c) Placing the specimen on ice or refrigerated d) Asking the client to void at the end of the collection and adding this to the collection R: Because the 24-hour urine is a timed, quantitative determination, it is essential to start the test with an empty bladder. The collected urine should be refrigerated or placed on ice to prevent changes in the urine. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. 6. A clinic nurse is providing instructions to a female client regarding the procedure for collecting a midstream (“clean-catch”) urine sample. The nurse would instruct the client to: a) Scrub the perineum with povidone-iodine solution in the evening and again in the morning before collecting the specimen. b) Cleanse the perineum from back to front before collecting the specimen. * c) Begin the flow of urine and only then collect the specimen. d) Collect the specimen in the evening before going to bed and deliver it to the laboratory immediately the next morning. R: As part of the correct procedure, the client should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit, to prevent contamination of the specimen. The client should briefly delay collecting the sample until after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results. The client is not instructed to scrub the perineum with povidone-iodine in the evening and again in the morning before collecting the specimen. This action is unnecessary and can cause irritation. 7. A nurse who is collecting data from the client notes that the client’s left eyelid is drooping. The nurse documents that the client is exhibiting which of the following conditions? * a) Ptosis b) Blockage of the lacrimal duct c) Arcus senilis d) Abnormal corneal reflex R: Ptosis is a sagging of the upper lid of the eye so that it covers part of the pupil. It can be caused by edema or be the result of third cranial nerve disorders or neuromuscular disorders. It is not caused by blockage of the lacrimal duct. Arcus senilis is an age-related change, characterized by formation of a yellow-gray ring around the periphery of the cornea surrounding the iris. The corneal reflex is the blink reflex. 8. A client is experiencing syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in: a) The glomerulus and calices b) The proximal tubule and the loop of Henle c) The loop of Henle and the distal tubule * d) The distal tubule and the collecting duct R: The distal tubule and the collecting duct of the nephron require the presence of ADH for water reabsorption. The hormone increases the permeability of the membranes to allow water to flow more easily along the concentration gradient. The glomerulus filters but does not reabsorb. The calices are responsible for collecting the urine. The proximal tubule and the loop of Henle reabsorb water without the assistance of ADH. 9. A nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen? a) Ask the client to expectorate a small amount of sputum into the emesis basin. b) Ask the client to obtain the specimen after breakfast. * c) Use a sterile plastic container for obtaining the specimen. d) Provide tissues for expectoration and obtaining the specimen. R: Sputum specimens for culture and sensitivity testing need to be obtained using sterile techniques because the test is done to determine the presence of organisms. If the procedure for obtaining the specimen is not sterile, then the specimen would be contaminated and the results of the test would be invalid. A first-morning specimen is preferred because it represents overnight secretions of the tracheobronchial tree. 10. A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level? a) The client with renal failure * b) The client who is taking diuretics c) The client with hyperaldosteronism d) The client who is taking corticosteroids R: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with renal failure or hyperaldosteronism are at risk for hypernatremia. 11. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present? a) Dry skin b) Decreased urinary output * c) Hyperactive bowel sounds d) Increased specific gravity of the urine R: Hyperactive bowel sounds indicate hyponatremia. Options 1, 2, and 4 are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urine would be noted. Dry skin occurs in deficient fluid volume. 12. A nurse is reviewing a client’s laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level? * a) Prolonged bed rest b) Renal insufficiency c) Hyperparathyroidism d) Excessive ingestion of vitamin D R: The normal serum calcium level is 8.6 to 10.0 mg/dL. A client with a serum calcium level of 4.0 mg/dL is experiencing hypocalcemia. The excessive ingestion of vitamin D and hyperparathyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. 13. A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client? * a) Twitching b) Negative Trousseau’s sign c) Hypoactive bowel sounds d) Hypoactive deep tendon reflexes R: Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. 14. A nurse caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram? a) Widened T wave b) Prominent U wave * c) Prolonged QT interval d) Shortened ST segment R: Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged ST or QT interval. A shortened ST segment and a widened T wave occur with hypercalcemia. Prominent U waves occur with hypokalemia. 15. A nurse caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic change would the nurse expect to note based on the magnesium level? a) Prominent U waves b) Prolonged PR interval * c) Depressed ST segment d) Widened QRS complexes R: The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 1.0 mg/dL indicates hypomagnesemia. In hypomagnesemia, the nurse would note tall T waves and a depressed ST segment. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia. 16. A nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level? * a) Alcoholism b) Renal insufficiency c) Hypoparathyroidism d) Tumor lysis syndrome R: The normal serum phosphorus level is 2.7 to 4.5 mg/dL. The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide–based or magnesiumbased antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. 17. A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which of the following? a) A decreased pH and an increased CO2 b) An increased pH and a decreased CO2 c) A decreased pH and a decreased HCO3 – * d) An increased pH with an increased HCO3 – R: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3 – to increase. Symptoms experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition. Option 3 reflects a metabolic acidotic condition. 18. A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3 – is 22 mEq/L. The nurse interprets the results as indicating which condition? a) Metabolic acidosis with compensation b) Respiratory acidosis with compensation c) Metabolic acidosis without compensation * d) Respiratory acidosis without compensation R: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3 – ) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. Therefore, the condition is without compensation. Options 1, 2, and 3 are incorrect. 19. A nurse reviews the blood gas results of a client with Guillain-Barré syndrome. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which of the following validates the nurse’s findings? * a) pH 7.25, PCO2 50 mm Hg b) pH 7.35, PCO2 40 mm Hg c) pH 7.50, PCO2 52 mm Hg d) pH 7.52, PCO228 mm Hg R: The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the PCO2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition. Option 4 identifies respiratory alkalosis. 20. A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, PCO2of 30 mm Hg, and HCO3 – of 22 mEq/L. The nurse analyzes these results as indicating which condition? a) Metabolic acidosis, compensated * b) Respiratory alkalosis, compensated c) Metabolic alkalosis, uncompensated d) Respiratory acidosis, uncompensated R: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the PCO2. In this situation, the pH is at the high end of the normal value and the PCO2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis. Compensation occurs when the pH returns to a normal value. Because the pH is in the normal range at the high end, compensation has occurred. 21. A client is brought to the emergency room stating that he has accidentally been taking two times his prescribed dose of warfarin (Coumadin) for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to do which of the following next? a) Prepares to administer an antidote b) Draws a sample for type and crossmatch and transfuse the client c) Draws a sample for an activated partial thromboplastin time (aPTT) level * d) Draws a sample for prothrombin (PT) and international normalized ratio (INR) level R: The next action is to draw a sample for PT and INR level to determine the client’s anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client if an antidote (vitamin K) or blood transfusion is needed. The aPTT monitors the effects of heparin therapy. 22. The nurse is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicates a serum amylase level of: a) 45 units/L b) 100 units/L * c) 300 units/L d) 500 units/L R: The normal serum amylase level is 25 to 151 units/L. With chronic cases of pancreatitis, the rise in serum amylase levels usually does not exceed three times the normal value. In acute pancreatitis, the value may exceed five times the normal value. Options 1 and 2 are within normal limits. Option 4 is an extremely elevated level seen in acute pancreatitis. 23. A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to: a) 3 mg/dL * b) 15 mg/dL c) 29 mg/dL d) 35 mg/dL R: The normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options 3 and 4 reflect continued dehydration. Option 1 reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. 24. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a: a) Normal level b) Low value that indicates possible gastritis * c) Level that indicates a myocardial infarction d) Level that indicates the presence of possible angina R: Troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is lower than 0.6 ng/mL. 25. An adult client has had laboratory work done as part of a routine physical examination. The nurse interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted? a) 0.2 mg/dL b) 0.5 mg/dL * c) 1.9 mg/dL d) 3.5 mg/dL R: The normal serum creatinine level for adults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slightly elevated level. A creatinine level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creatinine level of 3.5 mg/dL may be associated with acute or chronic renal failure. 26. A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders? a) Adding a dose of heparin sodium * b) Holding the next dose of warfarin c) Increasing the next dose of warfarin d) Administering the next dose of warfarin R: The normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time. 27. A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. The client’s baseline before the initiation of therapy was 30 seconds. The nurse anticipates that which action is needed? a) Discontinuing the heparin infusion b) Increasing the rate of the heparin infusion c) Decreasing the rate of the heparin infusion * d) Leaving the rate of the heparin infusion as is R: The normal activated partial thromboplastin time (aPTT) varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. Thus, the client’s aPTT is within the therapeutic range, and the dose should remain unchanged. 28. An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal? a) 20 units/L b) 80 units/L * c) 135 units/L d) 350 units/L R: The normal serum lipase level is 10 to 140 units/L. The client who is recovering from acute pancreatitis usually has elevated lipase levels for about 10 days after the onset of symptoms. This makes lipase a valuable test in monitoring the client’s pancreatic function because serum amylase levels usually return to normal 3 days after the onset of symptoms. Option 3 is the only option that contains a value just below the upper limit of normal. 29. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client’s history? a) Dehydration b) Heart failure * c) Iron deficiency anemia d) Chronic obstructive pulmonary disease R: The normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body’s need for more oxygen-carrying capacity. 30. The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client’s white blood cell count was which of the following? * a) 2,000 cells/ mm3 b) 5,800 cells/ mm3 c) 8,400 cells/ mm3 d) 11,500 cells/ mm3 R: The normal white blood cell count ranges from 4,500 to 11,000/mm3 . The client who is immunosuppressed has a decrease in the number of circulating white blood cells. The nurse implements neutropenic precautions when the client’s values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options 2, 3, and 4 are normal values. 31. The nurse instructs a client with renal failure who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? * a) Cream of wheat, blueberries, coffee b) Sausage and eggs, banana, orange juice c) Bacon, cantaloupe melon, tomato juice d) Cured pork, grits, strawberries, orange juice R: The diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Options 2, 3, and 4 are high in sodium, phosphorus and potassium. 32. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu? a) Nuts and milk b) Coffee and tea c) Cooked rolled oats and fish * d) Oranges and dark green leafy vegetables R: Dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C. 33. A client who recently has been started on enteral feedings begins to complain of abdominal cramping, followed by the passage of two liquid stools. A nurse notes that the client has abdominal distention as well. The nurse reviews the nutritional content on the label of the can of feeding to see if it has which of the following ingredients? * a) Lactose b) Sucrose c) Fructose d) Maltose R: Several tube feeding formulas contain lactose. A client with an unreported history of lactose intolerance would develop symptoms such as abdominal cramping, distention, and the passage of liquid stool in response to nutritional therapy with these formulas. If the client is diagnosed as lactose intolerant, a lactose-free formula should be prescribed by the physician. This will resolve the client’s symptoms and promote adequate nutrition for the client. 34. A nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of: * a) Pork b) Milk c) Chicken d) Broccoli R: The client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamins A, D, and B2. Poultry contains niacin. Broccoli contains vitamins C, E, and K and folic acid. 35. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hr. A nurse anticipates that which of the following orders regarding the PN solution will accompany the diet order? a) Discontinue the PN. * b) Decrease PN rate to 50 mL/hr. c) Hang 1000 mL 0.9% normal saline. d) Continue current infusion rate orders for PN. R: When a client begins eating a regular diet after a period of receiving parenteral nutrition, the PN is decreased gradually. Parenteral nutrition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline will not provide the glucose needed during the transition of discontinuing the PN and also could cause the client to experience hypoglycemia. 36. A client receiving parenteral nutrition (PN) complains of a headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of PN therapy? a) Sepsis b) Air embolism * c) Hypervolemia d) Hyperglycemia R: The client’s signs and symptoms are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate hyperglycemia, air embolism, or sepsis. 37. A nurse enters the room of a client receiving parenteral nutrition (PN) and discovers that the electronic infusion pump has been shut off. After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms? a) Fever and chills b) Dyspnea and hypotension c) Weakness, thirst, and excessive urination * d) Weakness, shakiness, diaphoresis, and complaints of hunger R: If the pump that is infusing PN shuts off for a period of time, the nurse assesses the client for signs and symptoms of hypoglycemia. These signs include weakness, shakiness, headache, anxiety, diaphoresis, and complaints of hunger. The blood glucose level will be lower than 70 mg/dL. The other signs and symptoms described are those of infection (option 1), air embolism (option 2), and hyperglycemia (option 3). 38. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse next assesses the client to detect the presence of which of the following? a) Thirst b) Polyuria c) Decreased blood pressure * d) Crackles on auscultation of the lungs R: Optimal weight gain on PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Options 1 and 2 are associated with hyperglycemia. Option 3 is likely to be noted in deficient fluid volume. 39. A nurse in an ambulatory care clinic is performing an admission assessment for an African-American client scheduled for a cataract removal with an intraocular lens implant. Which question would be inappropriate for the nurse to ask on an initial assessment? a) “Do you ever experience chest pain?” b) “Do you have any difficulty breathing?” * c) “Do you have a close family relationship?” d) “Do you frequently have episodes of headache?” R: In the African-American culture, asking personal questions on the initial contact or meeting is considered intrusive. African Americans are highly verbal and express feelings openly to family or friends, but what transpires within the family is viewed as private. Cardiovascular, respiratory, and neurological assessments include physiological assessments, which are the priority assessments. 40. A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet. The nurse would offer which full liquid item to the client? a) Tea b) Gelatin * c) Custard d) Popsicle R: Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. The food items in options 1, 2, and 4 are clear liquids. 41. A nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food item on the list? a) Oranges b) Broccoli * c) Cream cheese d) Broiled haddock R: Fruits and vegetables tend to be lower in fat because they do not come from animal sources. Fish is also naturally lower in fat. Cream cheese is a high-fat food. 42. A client is recovering from abdominal surgery and has a large abdominal wound. A nurse encourages the client to eat which food item that is naturally high in vitamin C to promote wound healing? a) Milk * b) Oranges c) Bananas d) Chicken R: Citrus fruits and juices are especially high in vitamin C. Bananas are high in potassium. Meats and dairy products are two food groups that are high in the B vitamins. 43. The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit which of the following foods? a) Apples b) Bananas * c) Smoked sausage d) Steamed vegetables R: Smoked foods are high in sodium. Options 1, 2, and 4 are fruits and vegetables that are low in sodium. 44. A postoperative client has been placed on a clear liquid diet. Select the items that the client is allowed to consume on this diet. Select all that apply. * a) Broth * b) Coffee * c) Gelatin d) Pudding e) Vegetable juice f) Pureed vegetables R: A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, Popsicles, and regular or decaffeinated coffee or tea. The incorrect food items are items that are allowed on a full liquid diet. 45. A nurse is preparing to care for a client who will receive parenteral nutrition (PN) support. The client is receiving dextrose, amino acids, and lipids all in one solution (total nutrient admixtur e). The nurse plans to do which of the following? * a) Use a 1.2-µm filter. b) Use a 0.22-µm filter to ensure sterility. c) Use a 0.10-µm filter to ensure sterility. d) Administer the solution without a filter. R: A total nutrient admixture (TN A) is a solution that combines dextrose, amino acids, and lipids in one solution. A 1.2-µm filter or larger filter should be used because the lipid particles are too large to pass through a smaller (0.22- or 0.10-µm) filter. A 0.22-µm filter is used for 2-in-1 solutions containing only dextrose and amino acids. A 0.10-µm filter is smaller than a 1.2-µm filter. Administering the solution without using a filter is not an appropriate action. 46. At 8 AM, a nurse checks the amount of solution left in a parenteral nutrition (PN) infusion bag for an assigned client. It is a 3000-mL bag with 1000 mL remaining. The solution is running at a rate of 100 mL/hr. The bag was hung the previous day at noon. The nurse plans to change the infusion bag and tubing today at: * a) Noon b) 2 PM c) 4 PM d) 8 PM R: Parenteral nutrition solution should be changed every 24 hours because the PN solution is a high-concentrate glucose solution and is a medium for bacterial growth. Infection control is also aided by use of aseptic technique with bag and tubing changes. Most agencies recommend that tubing be changed every 24 hours along with the bag, although some agencies recommend changing tubing every 48 to 72 hours. The nurse always should adhere to specific agency policies. Options 2, 3, and 4 identify insufficient time frames and present the risk for infection. 47. A nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse next assesses which of the following items? * a) Client’s temperature b) Expiration date on the bag c) Time of last dressing change d) Tightness of tubing connections R: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change. 48. A nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse takes which of the following actions? a) Rolls the bottle of solution gently * b) Obtains a different bottle of solution c) Shakes the bottle of solution vigorously d) Runs the bottle of solution under warm water R: The nurse should examine the bottle of fat emulsion for separation of emulsion into layers or fat globules or for the accumulation of froth. The nurse should not hang a fat emulsion if any of these are observed and should return the solution to the pharmacy. Options 1, 3, and 4 are inappropriate actions. 49. A nurse is preparing to change the total parenteral nutrition (TPN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse asks the client to take which most essential action during the tubing change? a) Breathe normally. b) Turn the head to the right. c) Exhale slowly and evenly. * d) Take a deep breath, hold it, and bear down. R: The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns his or her head to the left. This position will increase intrathoracic pressure. Options 1 and 3 are inappropriate and could cause the potential for an air embolism during the tubing change. 50. A client with total parenteral nutrition (TPN) infusing has disconnected the tubing from the central line catheter. A nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position? * a) On the left side, with the head lower than the feet b) On the left side, with the head higher than the feet c) On the right side, with the head lower than the feet d) On the right side, with the head higher than the feet R: When air embolism is suspected, the client should be placed in a left side-lying position. The head should be lower than the feet. This position is used to try to minimize the effect of the air traveling as a bolus to the lungs by trapping it in the right side of the heart. Options 2, 3, and 4 are incorrect positions if an air embolism is suspected. 51. A client receiving parenteral nutrition (PN) suddenly spikes a fever. A nurse notifies the physician, and the physician initially orders that the solution and tubing be changed. The nurse should do which of the following with the discontinued materials? a) Discard them in the unit trash. b) Return them to the hospital pharmacy. * c) Send them to the laboratory for culture. d) Save them for return to the manufacturer. R: When the client who is receiving PN spikes a temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms. The other options are incorrect. 52. A nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which of the following solutions readily available on the nursing unit should the nurse hang until another PN solution is mixed and delivered to the nursing unit? a) 5% dextrose in water * b) 10% dextrose in water c) 5% dextrose in Ringer’s lactate d) 5% dextrose in 0.9% sodium chloride R: The solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. Options 1, 3, and 4 will not be as effective in minimizing the risk of hypoglycemia. 54. At the beginning of a shift, a nurse assesses a client receiving parenteral nutrition (PN) with fat emulsion (lipids) piggybacked to the line. The nurse notes that the fat emulsion tubing has a 0.22-μm filter. Which of the following actions by the nurse is appropriate? a) Leave the system alone. b) Check the line for patency. c) Inspect the filter for clogging. * d) Replace with a tubing without a filter. R: The appropriate action by the nurse is to replace the tubing. A 0.22-µm filter is appropriate for the administration of PN, but fat emulsion should be administered without a filter. If fat emulsion is mixed into the PN solution, then a 1.2-µm or larger filter should be used to allow the fat emulsion to pass through. Therefore, options 1, 2, and 3 are incorrect. 55. A nurse is monitoring the status of a client’s fat emulsion (lipi d) infusion and notes that the infusion is 1 hour behind. Which of the following actions by the nurse is appropriate? a) Adjust the infusion rate to catch up over the next hour. b) Increase the infusion rate to catch up over the next 2 hours. * c) Ensure that the fat emulsion infusion rate is infusing at the prescribed rate. d) Adjust the infusion rate to run wide open until the solution is back on time. R: The nurse should not increase the rate of a fat emulsion to make up the difference if the infusion timing falls behind. Doing so could place the client at risk for fat overload. The same principle applies to PN; increasing the rate suddenly in this case could cause hyperglycemia and fluid overload. Therefore, options 1, 2, and 4 are incorrect. 56. A nurse is caring for a restless client who i