HESI RN MED SURG EXAM 100% CORRECT

S - The Marketplace to Buy and Sell your Study Material HESI RN MED SURG 1. The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65. An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. Normal ABI 1-1.4. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history. 2. A client with peripheral vascular disease has undergone a right femoral popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? 1. IV fluid solution. 2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained. CN: Reduction of risk potential; CL: Analyze Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. An overweight client taking warfarin (Coumadin) has dry skin due to decreased Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet.- promote circulation by reducing weight. 3. Inspect the involved areas daily for new ulcerations. 4. Instruct the client to limit activities of daily living (ADLs). 5. Use an electric razor to shave. 1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body. CN: Health promotion and maintenance; CL: Synthesize 4. The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. “I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth.” 2. “It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach.” 3. “I should stop taking Plavix if it makes me feel weak and dizzy.” 4. “The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming.” Weakness, dizziness, and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. CN: Pharmacological and parenteral therapies; CL: Evaluate Downloaded by Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 5. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following? 1. “I am having fewer aches and pains.” 2. “I do not have headaches anymore.” 3. “I am able to walk further without leg pain.” 4. “My toes are turning grayish black in color.” Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. “Aches and pains” does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body. CN: Pharmacological and parenteral therapies; CL: Evaluate 6. The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation. Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 7. The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise Downloaded by Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity. 8. When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure. 9. The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate information about the client's postoperative status? NA 10. The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences. 11. The nurse is assessing the lower extremities of the client with peripheral Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. 1. Hairy legs. Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin. 12. The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity. 13. Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease? 1. Low concentration of triglycerides. 2. High levels of high-density lipid (HDL) cholesterol. 3. High levels of low-density lipid (LDL) cholesterol. 4. Low levels of LDLcholesterol. 14. When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. Aching pain in the left calf. 2. Burning pain in the left calf. 3. Numbness and tingling in the left leg. 4. Coldness of the left foot and ankle. 15. A client with peripheral vascular disease returns to the surgical care unit after Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Postoperative pain. 2. Peripheral pulses. Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Urine output. 4. Incisionsite. 2,4,3,1 16. Aclient with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? 1. Decrease venous congestion. 2. Maintain normal respirations. 3. Maintain body temperature. 4. Prevent injury to lower extremities. 17. The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 1. Atrophy. 2. Contraction. 3. Gangrene. 4. Rubor. 18. A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the nurse, “I've really tried to manage my condition well.” Which of the following routines should the nurse evaluate as having been appropriate for this client? Downloaded by Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity. Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Wearing antiembolism stockings at all times when out of bed. 19. Aclient is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: 1. Showing the location of the obstruction and the collateral circulation. 2. Scanning the affected extremity and identifying the areas of volume changes. 3. Using ultrasound to estimate the velocity changes in the blood vessels. 4. Determining how long the client can walk. 20. A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: 1. Administer epinephrine. 2. Inform the physician. 3. Administer oxygen. 4. Inform the client that the procedure is almost over. 21. Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions. 22. The nurse is preparing to measure central venous pressure (CVP). Mark the spot on the torso indicating the location for leveling the transducer. NA 23. A client has had a pulmonary artery catheter inserted. In performing Downloaded by: Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? 1. Cardiac output. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Right atrial blood flow. 3. Left end-diastolic pressure. 4. Cardiac index. 24. After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation. 25. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth. 26. The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food.- does not affect absorption. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.– not necessary. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 27. Which client is at greatest risk for coronary artery disease? 1. A32-year-old female with mitral valve prolapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L). 3. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin. 4. A65-year-old female who is obese with an LDL of 188 (10.4 mmol/L). 28. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and Creactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse? 1. “The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.” 2. “The triglycerides are elevated and will not return to normal without these medications.” 3. “The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed.” 4. “These medications will reduce the risk of type 2 diabetes.” 29. The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective? 1. Decreased chest pain. 2. Increased blood pressure. 3. Decreased blood pressure. 4. Decreased heart rate. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 30. If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the risk factor behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior. 31. Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery. 32.After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds. Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t- Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material PA frequently receive heparin to prevent closure of the artery after administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material CN: Reduction of risk potential; CL: Analyze 33. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia. 34. Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking. 35. A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 36. Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4. Fluid-filled alveoli. 37. A68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness. 38. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following? 1. Left ventricular atrophy. 2. Irregular heartbeats. 3. Peripheral vascular occlusion. 4. Pacemaker placement. In older adults who are less active and do not exercise the heart muscle, Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress. 39. Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem? 1. Climb the steps early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down after climbing the stairs. 40. The client who experiences angina has been told to follow a low cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk. 41. The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea (GLIPAZIDE, GLYBURIDE) that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4. Disulfiram (Antabuse)–like symptoms. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 42. Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? 1. Cigarette smoking. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. High-cholesterol diet. 3. Obesity. 4. Hypertension. 43. Which of the following indicates a potential complication of diabetes mellitus? 1. Inflamed, painful joints. 2. Blood pressure of 160/100 mm Hg. 3. Stooped appearance. 4. Hemoglobin of 9 g/dL (90 g/L). 44. The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? 1. 59 mg/dL (3.3 mmol/L). 2. 75 mg/dL (4.2 mmol/L). 3. 108 mg/dL (6 mmol/L). 4. 119 mg/dL (6.6 mmol/L). 45. Assessment of the diabetic client for common complications should include examination of the: 1. Abdomen. 2. Lymph glands. 3. Pharynx. 4. Eyes.- Diabetic retinopathy, cataracts, and glaucoma are common complications. Feet should also be examined at each encounter. 46. The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material greatest risk of hypoglycemia will occur at about what time? 1. 11AM, shortly before lunch. 2. 1 PM, shortly after lunch. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. 6 PM, shortly after dinner. 4. 1AM, while sleeping. – eat a bedtime snack to help prevent hypoglycemia while sleeping. 47. Anurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? 1. Arms. 2. Legs. 3. Abdomen. 4. Iliac crest. 48. Aclient with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection. 49. The best indicator that the client has learned how to give an insulin self-injection correctly is when the client can: 1. Perform the procedure safely and correctly. 2. Critique the nurse's performance of the procedure. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Explain all steps of the procedure correctly. 4. Correctly answer a posttest about the procedure. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units? 32 units. 51. Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: 1. Chronic obstructive pulmonary disease (COPD). 2. Pancreatic cancer. 3. Renal failure. –ACEI increase renal blood flow and are effective in decreasing diabetic neuropathy. 4. Cerebrovascular accident. 52. The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia? 1. Nervousness. + weakness, perspiration, confusion, hunger, tachycardia, blurred vision, incoherent speech. 2. Anorexia. = HYPERglycemia/Ketoacidosis 3. Kussmauls respirations.= HYPERglycemia/Ketoacidosis 4. Bradycardia. 53. The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? 1. Aspirin. 2. Steroids.= affects carbohydrate metabolism causes hyperglyemia Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Sulfonylureas. 4. Angiotensin-converting enzyme (ACE) inhibitors. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 54. Aclient with type 1 diabetes mellitus has influenza. The nurse should instruct the client to: 1. Increase the frequency of self-monitoring (blood glucose testing). 2. Reduce food intake to diminish nausea. 3. Discontinue that dose of insulin if unable to eat. 4. Take half of the normal dose of insulin. 55. Which of the following is a priority goal for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? 1. Obtaining adequate food intake. 2. Managing own health. 3. Relieving pain. 4. Increasingactivity. 56. Aclient with diabetes begins to cry and says, “I just cannot stand the thought of having to give myself a shot every day.” Which of the following would be the best response by the nurse? 1. “If you do not give yourself your insulin shots, you will die.” 2. “We can teach your daughter to give the shots so you will not have to do it.” 3. “I can arrange to have a home care nurse give you the shots every day.” 4. “What is it about giving yourself the insulin shots that bothers you?” The Client with PituitaryAdenoma 57. A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the: 1. Back of the mouth. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Nose. 3. Sinus channel below the right eye. 4. Upper gingival mucosa in the space between the upper gums and lip. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 58. To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to: 1. Use incentive spirometry. 2. Turn in bed. 3. Take deep breaths. 4. Cough. 59. Following a transsphenoidal hypophysectomy, the nurse should assess the client for: 1. Cerebrospinal fluid (CSF) leak. 2. Fluctuating blood glucose levels. 3. Cushing's syndrome. 4. Cardiac arrhythmias. 60. A male client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy? 1. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility. 2. Potency will be restored, but the client will remain infertile. 3. Fertility will be restored, but impotence and decreased libido will persist. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Exogenous hormones will be needed to restore erectile function after the adenoma is removed. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 61. The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care? 1. Assess the oral cavity each time mouth care is given and record observations. 2. Use a soft toothbrush to brush the client's teeth after each meal. 3. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. 4. Rinse the client's mouth with mouthwash several times a day. 62. The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information? 1. Areview in the Cochrane Library. 2. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL). 3. An online nursing textbook. 4. The policy and procedure manual at the health care agency. 63. The nurse in the intensive care unit is giving a report to the nurse in the post surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to: 1. Give the report face to face with both nurses in a quiet room. 2. Audiotape the report for future reference and documentation. 3. Use a printed checklist with information individualized for the client. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Document essential transfer information in the client's electronic health record. 64. Aclient reports vomiting every hour for the past 8 to 10 hours. The nurse Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material should assess the client for risk of which of the following? Select all that apply. 1. Metabolic acidosis. 2. Metabolic alkalosis. = loss of acids 3. Hypokalemia. = gastric acid contains substantial amounts of potassium 4. Hyperkalemia. 5. Hyponatremia. 65. The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy? 1. “Your biopsy will be performed before the aspiration because enough tissue may be obtained so that you won't have to go through the aspiration.” 2. “You will feel a pressure sensation when the biopsy is taken but should not feel actual pain; if you do, tell the doctor so that you can be given extra numbing medicine.” 3. “You may hear a crunch as the needle passes through the bone, but when the biopsy is taken, you will feel a suction-type pain that will last for just a moment.” 4. “You will be shaved and cleaned with an antiseptic agent, after which the doctor will inject a needle without making an incision to aspirate out the bone marrow.” 66. Aclient with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal of nursing care at this time is to: Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. Reduce the client's fear of pain. 2. Support the client's wish to discontinue further therapy. 3. Prevent feelings of isolation. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Help the client overcome feelings of social inadequacy. 67. The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates the client needs additional information? 1. “Regular screening is very important for me.” 2. “The survivor rate is directly proportional to the incidence of second malignancy.” 3. “The survivor rate is indirectly proportional to the incidence of second malignancy.” 4. “It is important for survivors to know the stage of the disease and their current treatment plan.” 68. Which of the following is the most important goal of nursing care for a client who is in shock? 1. Manage fluid overload. 2. Manage increased cardiac output. 3. Manage inadequate tissue perfusion. 4. Manage vasoconstriction of vascular beds. 69. Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss? 1. Pulse rate less than 60 bpm. 2. Respiratory rate of 4 breaths/min. 3. Pupils unequally dilated. 4. Systolic blood pressure less than 90 mm Hg. Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 70. Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate? 1. Urine output not greater than 30 mL/h. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Systolic blood pressure greater than 110 mm Hg. 3. Diastolic blood pressure greater than 90 mm Hg. 4. Respiratory rate of 20 breaths/min. 71. Which of the following is a risk factor for hypovolemic shock? 1. Hemorrhage. 2. Antigen-antibody reaction. 3. Gram-negative bacteria. 4. Vasodilation. 72. Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? 1. Fluid balance. 2. Anaphylactic reaction. 3. Pain. 4. Altered level of consciousness. 73. The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, the nurse should assess the client for: 1. Increased renal and mesenteric blood flow. 2. Increased cardiac output. 3. Vasoconstriction. 4. Reduced preload and afterload. 74. Aclient is receiving dopamine hydrochloride for treatment of shock. The Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material nurse should: 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Evaluate arterial blood gases at least every 2 hours. 4. Monitor for signs of infection. 75. A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order should the nurse implement the following physician prescriptions? 4,1,2,3 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline solution. 76. When assessing a client for early septic shock, the nurse should assess the client for which of the following? 1. Cool, clammy skin. = occurs in later phase 2. Warm, flushed skin. = d/t high cardiac output + fever, restlessness, confusion, low bp, tachypnea, tachycardia, increased urine output, n/v/d. 3. Increased blood pressure. 4. Hemorrhage. 77. A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1g Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings should the nurse monitor? 1. Serum creatinine. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Spinal fluid analysis. 3. Arterial blood gases. 4. Serum osmolality. The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the Rocephin. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the physician immediately. 78. Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters. 79. Which of the following is an indication of a complication of septic shock? 1. Anaphylaxis. 2. Acute respiratory distress syndrome (ARDS). 3. Chronic obstructive pulmonary disease (COPD). 4. Mitral valve prolapse. 80. Anurse has two middle-aged clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? 1. Call for both clients' blood transfusions at the same time. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Ask another nurse to verify the compatibility of both units at the same time. 3. Call for and hang the first client's blood transfusion. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Ask another nurse to call for and hang the blood for the second client. 81. The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements? 1. “I will pace my activities with rest periods.” 2. “I can't wait to get home to my cat!” 3. “I will use warm saline gargle instead of brushing my teeth.” 4. “I must report a temperature of 100°F (37.7°C).” 82. Aclient with acute myeloid leukemia (AML) reports overhearing one of the other clients say that AML had a very poor prognosis. The client has understood that the client's physician informed the client that his physician told him that he has a good prognosis. Which is the nurse's best response? 1. “You must have misunderstood. Who did you hear that from?” 2. “AML does have a very poor prognosis for poorly differentiated cells.” 3. “AML is the most common nonlymphocytic leukemia.” 4. “Your doctor stated your prognosis based on the differentiation of your cells.” 83. The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent: 1. Cardiac arrhythmias. 2. Liver failure. 3. Renal failure. 4. Hemorrhage. 84. The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: 1. Lymphadenopathy. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 2. Hyperplasia of the gum. 3. Bone pain from expansion of marrow. 4. Shortness of breath. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 85. Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is: 1. 4 to 12 years. 2. 20 to 30 years. 3. 40 to 50 years. 4. 60 to 70 years. 86. The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should: 1. Place the client in a private room. 2. Have the client wear a mask. 3. Have staff wear gowns and gloves. 4. Restrict visitors. 87. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: 1. Enlarged, painless lymph nodes. 2. Headache. 3. Hyperplasia of the gums. 4. Unintentional weight loss. 88. The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every 4 hours while awake the client should use: 1. Lemon-glycerin swabs. 2. Acommercial mouthwash. 3. Asaline solution. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Acommercial toothpaste and brush 89. The client with acute leukemia and the health care team establish mutual client Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement? 1. Ambulating in the hallway. 2. Sitting up in a chair. 3. Lying in bed and taking deep breaths. 4. Using a stationary bicycle in the room. 90. The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation? 1. “Combination chemotherapy is used to interrupt cell growth cycle at different points.” 2. “Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.” 3. “Combination chemotherapy is used to decrease resistance.” 4. “Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent.” 91. In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site? 1. Biliary system. 2. Gastrointestinal tract. 3. Brain and meninges. 4. Pulmonary system. 92. The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms: Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 1. To the client from sources outside the client's environment. 2. From the client to health care personnel, visitors, and other clients. 3. By using special techniques to dispose of contaminated materials. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. By using special techniques to handle the client's linens and personal items. The Client with Lymphoma 93. Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease? 1. Difficulty swallowing. 2. Painless, enlarged cervical lymph nodes. 3. Difficulty breathing. 4. Afeeling of fullness over the liver. 94. Aclient with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. The nurse should make sure that personnel involved with the procedure do which of the following when obtaining the lymph node biopsy specimen for histologic examination for this client? 1. Maintain sterile technique. 2. Use a mask, gloves, and a gown when assisting with the procedure. 3. Send the specimen to the laboratory when someone is available to take it. 4. Ensure that all instruments used are placed in a sealed and labeled container. 95. The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first? 1. Vital signs. 2. The incision. 3. The airway. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 4. Neurologic signs. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 96. When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following findings? 1. Herpes zoster infections. 2. Discolored teeth. 3. Hemorrhage. 4. Hypercellular immunity. 97. The client with Hodgkin's disease develops B symptoms. These manifestations indicate which of the following? 1. The client has a low-grade fever (temperature lower than 100°F [37.8°C]). 2. The client has a weight loss of 5% or less of body weight. 3. The client has night sweats. 4. The client probably has not progressed to an advanced stage. 98. The nurse is developing a discharge plan about home care with a client who has lymphoma. The nurse should emphasize which of the following? 1. Use analgesics as needed. 2. Take a shower with perfumed shower gel. 3. Wear a mask when outside of the home. 4. Take an antipyretic every morning. 99. The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material disease? 1. Involvement of a single lymph node. 2. Involvement of two or more lymph nodes on the same side of the diaphragm. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material 3. Involvement of lymph node regions on both sides of the diaphragm. 4. Diffuse disease of one or more extralymphatic organs. 100. Aclient is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client and two upset family members handle anxiety during the procedure? 1. Allow the client's family to stay as long as possible. 2. Stay with the client without speaking. 3. Encourage the client to take slow, deep breaths to relax. 4. Allow the client time to express feelings. Answers 1. 4. An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history. CN: Physiological adaptation; CL:Analyze 2. 2. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained. CN: Reduction of risk potential; CL: Analyze 3. 1, 2, 3, 5. Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body. CN: Health promotion and maintenance; CL: Synthesize 4. 3: Weakness, dizziness, and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. CN: Pharmacological and parenteral therapies; CL: Evaluate 5. 3. Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. “Aches and pains” does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body. CN: Pharmacological and parenteral therapies; CL: Evaluate 6. 1. Decreased blood flow is a common characteristic of all PVD. When the Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels. Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material CN: Reduction of risk potential; CL: Apply 7. 1. Aclient with PVD and heart failure will experience decreased blood flow. In this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less importance than the disease processes. CN: Reduction of risk potential; CL: Synthesize 8. 4. In PVD, decreased blood flow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, resulting in edema. Valves often become incompetent with PVD. Blood volume is not decreased in this condition. Decreased muscular action would contribute to the formation of edema in the lower extremities. CN: Reduction of risk potential; CL: Analyze 9. 4. The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse. CN: Reduction of risk potential; CL: Analyze 10. 2. Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic activity, and choosing a diet low in saturated fats can reduce the risk of Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material developing atherosclerosis. CN: Health promotion and maintenance; CL: Apply 11. 2, 4. Reduction of blood flow to a specific area results in decreased oxygen and Downloaded by: JawTestacademics | Distribution of this document is illegal Want to earn $103 per month? S - The Marketplace to Buy and Sell your Study Material nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities. CN: Health promotion and maintenance; CL: Analyze 12. 3. When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Dop