1. Nurse Tristan is assigned to care for a group of clients.

On review of the clients medical records, the nurse determines that which client is at risk for deficient fluid volume? a. A client with a colostomy b. A client with congestive heart failure c. A client with decreased kidney function d. A client receiving frequent wound irrigation 1. Answer A. Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume. 2. Nurse Lorena caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition? a. Lung congestion b. Decrease hematocrit c. Increased blood pressure d. Decrease central venous pressure (CVP) 2. Answer D. Assessment findings in a client with a deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. 3. Nurse George is assigned to care for a group of clients. On review of the clients medical records, the nurse determines that which client is at risk for excess fluid volume? a. The client taking diuretics b. The client with renal failure c. The client with an ileostomy d. The client who requires gastrointestinal suctioning 3. Answer B. The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume. 6. 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) hyperparathroidism d) excessive ingestion of vitamin D 6) A- 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 hyperthyroidism are causative factors associated with hypercalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypercalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. 4. Nurse Levy is caring for a client with congestive heart failure. On assessment the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss b. Flat neck and hand veins c. An increase in blood pressure d. A decreased central venous pressure (CVP) 4. Answer C. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. 5. Nurse Faye is preparing to care for a client with a potassium deficit. The nurse reviews the client was at risk for developing the potassium deficit because the client: a. Has renal failure b. Requires nasogastric suction

c. Has a history of Addison s disease d. Is taking a potassium-sparing diuretic 5. Answer B. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with renal failure or Addison s disease and the client taking a potassium-sparing diuretic are at risk for hyperkalemia. 7. Tanya, a nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium? a. Obtaining a cotrolled IV infusion pump b. Monitoring urine output during administration c. Diluting in appropriate amount of normal saline d. Preparing the medication for bolus administration 7. Answer D. Potassium chloride administered intravenously must always be diluted in IV fluid and infused via a pump or controller. The usual concentration of IV potassium chloride is 20 to 40 mEq/L. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. Dilution in normal saline is recommended, but dextrose solution is avoided because this type of solution increases intracellular potassium shifting. The IV bag containing the potassium chloride is always gently agitated before hanging. The IV site is monitored closely because potassium chloride is irritating to the veins and the risk of phlebitis exists. The nurse monitors urinary output during administration and contacts the physician if the urinary output is less than 30 mL/hr. 11. Nurse Princess 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 muscles 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. Decrease urinary output c. Hyperactive bowel sounds d. Increased specific gravity of the urine 11. Answer C. Hyperactive bowel sounds indicate hyponatremia. Options A, B, and D 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. 13. Nurse Editha 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 13. Answer A. 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. 16. Nurse Danny 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 16. Answer A. 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 magnesium-based antacids. Malnutrition is associated with alcoholism. Hypoparathyroidism, tumor lysis syndrome, and renal insufficiency are causative factors of hyperphosphatemia. 22. A female 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, nurse Daniel 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

22. Answer B. 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. 11. 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 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 11) D - 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 A reflects a respiratory acidosis condition. Option B reflects a respiratory alkalosis condition. Option C reflects a metabolic acidosis condition. 12. 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 12) D - 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. Option A, B, and C are incorrect. 13. A nurse reviews the blood gas results of client with Guillain-Barre 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, Pco2 28 mm Hg 13) A - 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 B identifies normal values. Option C identifies an alkalosis condition. Option D identifies respiratory alkalosis. 14. A nurse reviews the arterial blood gas results of client and notes the following: pH 7.45, Pco2 of 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 acidosis, uncompensated d) respiratory alkalosis, uncompensated 14) B - the normal pH is 7.35 to 7.45. In respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is at high end of the normal value and Pco2 is low. In alkalosis 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 normal range at the high end, compensation has occurred. 33. A 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/dlL b) 0.5 mg/dL c) 1.9 mg/dL d) 3.5 mg/dL 33) C- the normal serum creatinine level foadults is 0.6 to 1.3 mg/dL. The client with a mild degree of renal insufficiency would have a slight elevated level. A creatinie level of 0.2 mg/dL is low, and a level of 0.5 mg/dL is just below normal. A creeatinie level of 3.5 mg/dL may be associated with acute or chronic renal failure. 16. 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 16) C - the normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin level. 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. 17. 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 leafy vegetables 17) D - 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. 18. 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 18) B - 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. 19. A client receiving parenteral nutrition (PN) complains of 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 19) C - the client's sign 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. 20. 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 20) D - 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 A), air embolism (option B), and hyperglycemia (option C). 21. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 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 21) D - 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 A and B are associated with hyperglycemia. Option C is likely to be noted in deficient fluid volume. 23. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, repalce immediate blood loss, and increase blood pressure? a) 0.45% sodium chloride b) 0.33% sodium chloride c) 0.225% sodium chloride d) lactated ringer's solution 23) D - the goal of therapy with this client is to expand intravascular volume as quickly as possible. Lactated ringer's (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in option A, B, and C would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis. 22. A nurse is caring for a group of adult clients on an acute care medical-surgical unit. The nurse understands that which of the following clients would be the least likely candidate for parenteral nutrition (PN)? a) a 66-year old client with extensive burns b) a 42-year old client who has an open cholecystectomy c) a 27-year old client with severe exacerbation of Crohn's disease d) a 35-year old client with persistent nausea and vomiting from chemotherapy. 22) B - parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods. Examples of these conditions include those of the clients identified in option A, C, and D. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or AIDS. The client with the open cholecystectomy is not a candidate because this client would resume regular diet within few days following surgery 24. The nurse is making initial rounds on the nursing unit to assess the conditon of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client? a) infection b) phlebitis c) infiltration d) thrombosis 24) C - an infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. The other three options are likely to be accompanied by warmth at the site, not coolness. 27. The nurse hears an attending physician asking an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe? a) 5% dextrose in water b) 10% dextrose in water c) 0.45% sodium chloride d) 5% dextrose in 0.9% sodium chloride 27) C - hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D5W) is isotonic. Solutions of 10% dextrose in water (D10W) and 5% dextrose in 0.9% sodium chloride are hypertonic solutions.

28. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The nurse takes the client's blood pressure and it is 90/50 mm Hg, from a baseline of 125/78 mm Hg. The client's temperature is 100.8F orally, from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? a) septicemia b) hyperkalemia b) circulatory overload d) delayed transfusion reaction 28) A - septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after transfusion. Signs include fever, mild jaundice, and decreased hematocrit level. 29. The nurse is told by a physician that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving an order to transfuse which product? a) albumin b) platelets c) cryoprecipitate d) packed red blood cells 29) A - albumin may be used as plasma expander. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hrmophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Packed RBC replace erythrocytes and not a plasma expander. 30. A physician tells a client that the client needs a blood transfusion and that the blood sample must be drawn first for blood typing and crossmatching. After the physician leaves, the client asks the nurse, "What exactly is blood type, anyway?" The nurse responds with which of the following statements? a) the blood type represents an antigen found on the surface of the red blood cells b) the blood type represents an antibody found on the surface of the red blood cells c) the blood type represents an antibody that normally circulates in the blood plasma d) the blood type represents an antigen that normally circulates in the blood plasma 30) A - the major blood types are A, B, AB, and O. The blood type indicates an antigen found on the surface of the red blood cell. Acute hemolytic transfusion reaction (ABO incompatibility) can occur if a client receives blood that is not compatible with his or her blood type. Acute hemolytic reaction is the most serious adverse reaction to a blood transfusion. 31. The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that his client most likely is experiencing which complication of blood transfusion therapy? a) bacteremia b) hypovolemia c) fluid overload d) transfusion reaction 31) C - with fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and generalized rash. Hypovolemia is not a complication of blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. 32. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most form this therapy if the client exhibits which of the following? a) increased hematocrit level b) increased hemoglobin level c) decline of elevated temperature to normal d) decreased oozing of blood from puncture sites and gums 32) D - platelet are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites,

wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body. 33. The nurse listening to morning reports learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion? a) hematocrit level b) erythrocytes count c) hemoglobin level d) white blood cell count 33) D - the client who has neutropenia may receive a transfusion of granulocytes or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed RBC. 34. A client is brought to the emergency room having experienced blood loss related to an arterial laceration. Fresh frozen plasma (FFP) is ordered and transfused to replace fluid and blood loss. The nurse understands that he rationale for transfusing FFP in this client is to: a) treat the loss of platelets b) promote rapid volume expansion c) that the transfusion must be done slowly d) that it will increase the hemoglobin and hematocrit levels 34) B - fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfuse quickly. It will not specifically increase the hemoglobin and hematocrit level. 35. A nurse obtains an order from a physician to restrain a client by using a jacket restraint and instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse indicates inappropriate application of the restraint by the nursing assistant? a) a safety knot in the restraint straps b) restraint straps that are safely secured to the side rails c) jacket restraint straps that do not tighten when force is applied against them d) jacket restraint secured so that two fingers can slide easily between the restraint and th client's skin 35) B - the restraint straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and it allows quick and easy removal of the restraint in case of an emergency. The jacket restraint should be secure, and one to two fingers should slide easily between the restraint and the client's skin. 36. A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a) red, hard skin b) serous drainage c) purulent drainage d) warm, tender skin

36) B
- serous drainage is expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique and a contaminated wound before surgical exploration. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. 38. A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify that which of he following medications should be given to the client and not withheld? a) ferrous sulfate b) prednisone (deltasone) c) cyclobenzaprine (flexeril) d) conjugated estrogen (premarin)

38) B - prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These other three medications may be withheld before surgery without undue effects on the client. 39. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? a) sodium, 141 mEq/L b) hemoglobing, 8.0 g/dL c) platelets, 210,000 mm3 d) serum creatinine, 0.8 mg/dL 39) B - routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. 40. A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? a) urinary output of 20 ml/hr b) temperature of 37.6 C (99.6F) c) blood pressure of 100/70 mmHg d) serous drainage on he surgical dressing 40) A - urine output should be maintained at a minimum of 30 ml/hr for an adult. An output of less than 30 ml for each of 2 consecutive hours should be reported to the physician. A temperature higher than 37.7C (100F) or lower than 36.1C (97F) and a falling systolic blood pressure, lower than 90 mmHg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. 2. A preoperative client expresses anxiety to a nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? 1. "I will be happy to explain the entire surgical procedure to you." 2. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate." 3. "If it's any help, everyone is nervous before surgery." 4. "Can you share with me what you've been told about your surgery?" 2.4 Rationale: Explanations should begin with the information that the client knows. By providing the client with individualized explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia better and experience fewer postoperative complications. Options 1, 2, and 3 will produce anxiety in the client.

4. A nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week's time. The client has a history of arthritis and has been taking acetylsalicylic acid (aspirin, ASA). The nurse determines that the client needs additional teaching if the client states: 1. "I need to continue to take the aspirin as prescribed until the day of surgery." 2. "Aspirin can cause bleeding after surgery." 3. "Aspirin can cause my ability to clot blood to be abnormal." 4. "I need to discontinue the aspirin 48 hours before the scheduled surgery." 4.1 Rationale: Anticoagulants alter normal clotting factors and increase the risk of bleeding after surgery. Aspirin has properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery.

10. A client is admitted to a surgical unit postoperatively with a wound drain in place. Which action would the nurse avoid in the care of the drain? 1. Check the drain for patency

2. Curl the drain tightly and tape firmly to body 3. Maintain aseptic technique when emptying the drain 4. Observe for bright red bloody drainage 10. 2 Rationale: A postoperative drain should not be curled tightly or obstructed in any way. This could prevent the drain from functioning properly. The tube]drain should be checked for patency to provide an exit for the fluid]blood to promote healing. Aseptic technique must be used for emptying the drainage container or changing the dressing, to avoid contamination of the wound. Usually the drainage from the wound is pale, red, and watery. Active bleeding will be bright red.

19. A nurse is monitoring a postoperative client after abdominal surgery for signs of complications. The nurse assesses the client for the presence of Homans' sign and determines that this sign is positive if which of the following is noted? 1. Pain with dorsiflexion of the foot 2. Incisional pain 3. Absent bowel sounds 4. Crackles on auscultation of the lungs 19. 1 Rationale: To elicit Homans' sign, the nurse would dorsiflex the client's foot and assess the client for pain in the calf area. If pain is present, a positive Homans' sign is present, which is an indication of thrombophlebitis. Incisional pain is an expected occurrence after abdominal surgery. Absent bowel sounds may occur in the immediate postoperative period. Crackles on auscultation of the lungs may be an indication of a respiratory complication.

3. A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer in the postoperative period. The nurse would include which piece of information in discussions with the client? 1. Keep a loose seal between the lips and the mouthpiece 2. Inhale as rapidly as possible 3. After maximum inspiration, hold the breath for 10 seconds and exhale 4. The best results are achieved when sitting at least half-way or fully upright 3.4 Rationale: For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high-Fowier's position. The mouthpiece should be covered completely and tightly while the client inhales slowly with a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly.

57. A nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents and checks the contents for pH. The nurse verifies correct tube placement if which pH value is noted? a) 3.5 b) 7.0 c) 7.35 d) 7.5 57) A - if the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. Option B indicates a slightly acidic pH. Option C indicates a neutral pH. Option D indicates an alkaline pH.f 3. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the adult client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician. b. Continue to monitor the client. c. Reinforce the occlusive dressing. d. Encourage the client to deep-breathe. 3. Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.

7. A nurse is caring for a male client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate of 24 breaths/min

7. Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician. 32. 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 32) B - the normal blood urea nitrogen level is 8 to 25 mg/dL. Values such as those in options C and D reflect continued dehydration. Option A reflects a lower than normal value, which may occur with fluid volume overload, among other conditions. 39. 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 39) A - 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 sufficiency below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. Options B, C, and D are normal values. 54. A client who is 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 54) A - 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. 55. 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 55) A - the client with cirrhosis needs to consume foods high in thiamine. Thiamine is present in a variety of foods of plants and animal origin. Pork products are especially rich in this vitamin. Other good food sources include nuts, whole grain cereals, and legumes. Milk contains vitamin A, D, and B2. Poultry contains niacin. Broccoli contains vitamin C, E and K and folic acid.

34. 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, strawberries, orange juice 34) A - the diet for a client with renal failure who is receiving hemodialysis should include controlled amounts of sodium, phosphorus, calcium, potassium, and fluids. Option B, C, and D are high in sodium, phosphorus, and potassium.