1. An IV solution of 0.9% sodium chloride is the most 1. An IV solution of 0.9% sodium chloride is the most appropriate initial IV fluid for this client, because it is an appropriate initial IV fluid for this client, because it is an isotonic solution that will act as a volume expander to isotonic solution that will act as a volume expander to quickly replace volume losses and promote physiological quickly replace volume losses and promote physiological stabilization. 3% sodium chloride, is a high concentration stabilization. 3% sodium chloride, is a high concentration (hypertonic) electrolyte solution; it would only be used in a (hypertonic) electrolyte solution; it would only be used in a client with hyponatremia and must be closely monitored client with hyponatremia and must be closely monitored during infusion. 5% dextrose and 0.9% sodium chloride and during infusion. 5% dextrose and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be appropriate fluids 5% dextrose and lactated Ringer's may be appropriate fluids to infuse after 0.9% sodium chloride.to infuse after 0.9% sodium chloride.

Test-Taking Tip: Become familiar with reading questions on aTest-Taking Tip: Become familiar with reading questions on a computer screen. Familiarity reduces anxiety and decreases computer screen. Familiarity reduces anxiety and decreases errors.errors.

2. Patient care assistants can make occupied and 2. Patient care assistants can make occupied and unoccupied beds. Taking routine vital signs is within the unoccupied beds. Taking routine vital signs is within the scope of practice of patient care assistants. Answering call scope of practice of patient care assistants. Answering call lights and meeting clients' basic safety, hygiene, and lights and meeting clients' basic safety, hygiene, and comfort needs are within the scope of practice of patient comfort needs are within the scope of practice of patient care assistants. Watching a client take oral medications is care assistants. Watching a client take oral medications is part of procedure for administration of medications, which part of procedure for administration of medications, which requires a professional license. Emptying a closed chest requires a professional license. Emptying a closed chest drainage system for intake and output is inappropriate; a drainage system for intake and output is inappropriate; a closed chest drainage system is not emptied for intake and closed chest drainage system is not emptied for intake and output. Documentation is indicated on the outside of the output. Documentation is indicated on the outside of the drainage collection chamber.drainage collection chamber.

3. The nurse filling out an incident or variance report needs 3. The nurse filling out an incident or variance report needs to state only the objective facts surrounding the incident, no to state only the objective facts surrounding the incident, no opinion or speculation. In an incident report fault or blame is opinion or speculation. In an incident report fault or blame is subjective and should not be implied. It is not necessary to subjective and should not be implied. It is not necessary to include names except for those of witnesses. Speculations orinclude names except for those of witnesses. Speculations or opinions as to the reason why the ordered restraints were opinions as to the reason why the ordered restraints were not on the client are subjective and not appropriate to not on the client are subjective and not appropriate to include in an incident or variance report.include in an incident or variance report.

4. 4. Primary preventionPrimary prevention activities are directed toward activities are directed toward promoting healthful lifestyles and increasing the level of promoting healthful lifestyles and increasing the level of

well-being. Performing yearly physical examinations is a well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum rehabilitating individuals and restoring them to an optimum level of functioning.level of functioning.

5. Clients who are mentally competent have the right to 5. Clients who are mentally competent have the right to refuse treatment; the nurse must respect this right. Client's refuse treatment; the nurse must respect this right. Client's questions must always be answered truthfully. The health questions must always be answered truthfully. The health care provider should be notified when a client refuses an care provider should be notified when a client refuses an intervention so that an alternate treatment plan can be intervention so that an alternate treatment plan can be formulated. This is done after the nurse explores the client's formulated. This is done after the nurse explores the client's reasons for refusal. The client had a discussion with the reasons for refusal. The client had a discussion with the nurse that indicated that the client had sufficient informationnurse that indicated that the client had sufficient information to make the decision to refuse the medication. The client hasto make the decision to refuse the medication. The client has a right to refuse treatment; this right takes precedence over a right to refuse treatment; this right takes precedence over the health care provider's prescription.the health care provider's prescription.

6. To facilitate visualization of the rectum and the sigmoid 6. To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before colon, the lower colon must be emptied immediately before the procedure. A fleet or tap water enema should be used. the procedure. A fleet or tap water enema should be used. The client will be kept NPO for at least 8 hours before the The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not medication before a sigmoidoscopy. Restraints are not typically used during the procedure.typically used during the procedure.

7. Because of fluid overload in the intravascular space, the 7. Because of fluid overload in the intravascular space, the neck veinsneck veins become visibly distended. Rapid, thready pulse become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is sodium causes fluid retention, its concentration is unchanged; if fluid is retained independently of sodium, its unchanged; if fluid is retained independently of sodium, its concentration is decreased.concentration is decreased.

8. The generativity versus stagnation stage precedes 8. The generativity versus stagnation stage precedes integrity versus despair; integrity versus despair; EriksonErikson theorized that how well theorized that how well people adapt to a present stage depends on how well they people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versusadapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity childhood; it precedes initiative versus guilt, not integrity versus despair.versus despair.

9. The client is exhibiting the freedom to make a personal 9. The client is exhibiting the freedom to make a personal decision, and this reflects the concept of autonomy. Justice decision, and this reflects the concept of autonomy. Justice refers to fairness. Veracity refers to truthfulness. refers to fairness. Veracity refers to truthfulness. Beneficence refers to implementing actions that benefit Beneficence refers to implementing actions that benefit others.others.

10. Some state boards of nursing identify specific activities 10. Some state boards of nursing identify specific activities that may be that may be delegateddelegated to NAP, such as obtaining routine to NAP, such as obtaining routine vital signs on stable clients, feeding or assisting clients at vital signs on stable clients, feeding or assisting clients at mealtimes, ambulating stable clients, and helping clients mealtimes, ambulating stable clients, and helping clients with bathing and hygiene. However, nursing interventions with bathing and hygiene. However, nursing interventions that require independent nursing knowledge, skill, or that require independent nursing knowledge, skill, or judgment, such as assessment, client teaching, and judgment, such as assessment, client teaching, and evaluation of care cannot be delegated. Although LPNs and evaluation of care cannot be delegated. Although LPNs and LVNs may change dressings, evaluation of wounds must be LVNs may change dressings, evaluation of wounds must be done by the registered nurse (RN). Clients who have low done by the registered nurse (RN). Clients who have low oxygen saturation levels and telemetry readings must be oxygen saturation levels and telemetry readings must be evaluated by the RN.evaluated by the RN.

11. 11. An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. _ gtts/min A:31

12. The nurse should remove and dispose of the patch in a 12. The nurse should remove and dispose of the patch in a manner that protects self and others from exposure to the manner that protects self and others from exposure to the fentanyl. Having the family remove and dispose of the patch fentanyl. Having the family remove and dispose of the patch or having the mortician remove the patch are not the or having the mortician remove the patch are not the responsibility of nonprofessionals because they do not know responsibility of nonprofessionals because they do not know how to protect themselves and others from exposure to the how to protect themselves and others from exposure to the fentanyl. It is unnecessary to return a used fentanyl patch.fentanyl. It is unnecessary to return a used fentanyl patch.

13. Allowing the denial and being available to discuss the 13. Allowing the denial and being available to discuss the situation with the client does not remove the client's only situation with the client does not remove the client's only way of copingway of coping, and it permits future movement through the , and it permits future movement through the grieving process when the client is ready. Reassuring the grieving process when the client is ready. Reassuring the client that everything will be all right is false reassurance. client that everything will be all right is false reassurance. The client must not be abandoned; the nurse's presence is a The client must not be abandoned; the nurse's presence is a form of emotional support. The client's denial should be form of emotional support. The client's denial should be neither encouraged nor removed; encouraging denial is a neither encouraged nor removed; encouraging denial is a form of false reassurance.form of false reassurance.

14. Conscious sedation is administered by direct intravenous14. Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid oradministered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves theAn epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for exit the spinal cord. Epidural blocks are not used for moderate sedation. The oral route of drug administration is moderate sedation. The oral route of drug administration is commonly used for pediatric clients, not adults.commonly used for pediatric clients, not adults.

15. The reporting of possible child abuse is required by law, 15. The reporting of possible child abuse is required by law, and the nurse's identity can remain confidential. The nurse isand the nurse's identity can remain confidential. The nurse is functioning in a professional capacity and therefore can be functioning in a professional capacity and therefore can be held accountable. Although the Good Samaritan Act protects held accountable. Although the Good Samaritan Act protects health professionals, the nurse is still responsible for acting health professionals, the nurse is still responsible for acting as any reasonably prudent nurse would in a similar situation.as any reasonably prudent nurse would in a similar situation.

16. In this situation being aware that a client is 16. In this situation being aware that a client is overmedicating and taking no action can be considered an overmedicating and taking no action can be considered an act of euthanasia on the part of the home care nurse. act of euthanasia on the part of the home care nurse. Implementing a "do not resuscitate" order, abiding by the Implementing a "do not resuscitate" order, abiding by the decision of a living will signed by the client's family, and decision of a living will signed by the client's family, and encouraging the client to consult an attorney are all encouraging the client to consult an attorney are all appropriate actions for a home care nurse.appropriate actions for a home care nurse.

17. Before suctioning, regardless of the means, oxygen 17. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to endotracheal tube may not be able to follow commands to take deep breaths, cough, or have the strength to do either, take deep breaths, cough, or have the strength to do either, which is why manual bagging is preferred. A new sterile which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not suctioned, but the suction tubing and equipment need not be changed.be changed.

18. The most important side effect to monitor in a client who18. The most important side effect to monitor in a client who has received epidural anesthesia is hypotension due to has received epidural anesthesia is hypotension due to autonomic nervous system blockade. Therefore, in the autonomic nervous system blockade. Therefore, in the immediate postoperative recovery period, the blood immediate postoperative recovery period, the blood pressure should be assessed frequently. Other side effects pressure should be assessed frequently. Other side effects include bradycardia, nausea, and vomiting. Increased oral include bradycardia, nausea, and vomiting. Increased oral temperature and unequal bilateral breath sounds are not temperature and unequal bilateral breath sounds are not effects associated with epidural anesthesia. Diminished effects associated with epidural anesthesia. Diminished peripheral pulses may result from hypotension, although peripheral pulses may result from hypotension, although they are not the most common side effects.they are not the most common side effects.

19. Acetazolamide is a carbonic anhydrase inhibitor that 19. Acetazolamide is a carbonic anhydrase inhibitor that decreases inflow of aqueous humor and controls intraocular decreases inflow of aqueous humor and controls intraocular pressure in acute angle-closure glaucoma attack. pressure in acute angle-closure glaucoma attack. Chlorothiazide and bendroflumethiazide have no effect on Chlorothiazide and bendroflumethiazide have no effect on the eye. Demecarium bromide does not affect production of the eye. Demecarium bromide does not affect production of aqueous humor.aqueous humor.

20. 20. Skin elasticitySkin elasticity will decrease because of a decrease in will decrease because of a decrease in interstitial fluid. The pulse rate will increase to oxygenate theinterstitial fluid. The pulse rate will increase to oxygenate the body's cells. Specific gravity will increase because of the body's cells. Specific gravity will increase because of the greater concentration of waste particles in the decreased greater concentration of waste particles in the decreased amount of urine. The temperature will increase, not amount of urine. The temperature will increase, not decrease.decrease.

21. Papules are superficial and elevated up to 0.5 cm. 21. Papules are superficial and elevated up to 0.5 cm. Nodules and tumors are masses similar to papules but are Nodules and tumors are masses similar to papules but are elevated more than 0.5 cm and may infiltrate deeper into elevated more than 0.5 cm and may infiltrate deeper into tissues. Erosions are characterized as loss of the epidermis tissues. Erosions are characterized as loss of the epidermis layer; macules are nonpalpable, flat changes in skin color layer; macules are nonpalpable, flat changes in skin color less than 1 cm in diameter; and vesicles are usually less than 1 cm in diameter; and vesicles are usually transparent, filled with serous fluid, and are a blisterlike transparent, filled with serous fluid, and are a blisterlike elevation. elevation.

22. The Nurse Practice Act states that the nurse will do 22. The Nurse Practice Act states that the nurse will do health teaching and administer nursing care supportive to health teaching and administer nursing care supportive to life and well-being. The teaching was essential before life and well-being. The teaching was essential before discharge. The client is responsible for self-care. Health discharge. The client is responsible for self-care. Health teaching is an independent nursing function.teaching is an independent nursing function.

Test-Taking Tip: Avoid taking a wild guess at an answer. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure youincorrect, and reread the information given to make sure you understand the intent of the question. This approach understand the intent of the question. This approach increases your chances of randomly selecting the correct increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on computer will adapt the next question accordingly based on your knowledge and skill performance on the examination upyour knowledge and skill performance on the examination up to that pointto that point

23. Of the choices provided, the potential complication of 23. Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration highest risk for a client with an NG tube is aspiration

pneumonia. Care should be taken to prevent dislodging of pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler's or NG tube would include supine or side-lying, semi-Fowler's or higher. Skin breakdown in a client with an NG tube may higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility.unrelated or a result of an enteral feeding incompatibility.

24. The prayer cloth has 24. The prayer cloth has religious significancereligious significance for the client for the client and should be preserved as is. Making a new prayer cloth and should be preserved as is. Making a new prayer cloth disregards what the prayer cloth means to the client. The disregards what the prayer cloth means to the client. The prayer cloth is the property of the client and should not be prayer cloth is the property of the client and should not be discarded. Washing the prayer cloth with a detergent discarded. Washing the prayer cloth with a detergent disregards what the prayer cloth means to the client; this disregards what the prayer cloth means to the client; this never should be done without the client's permissionnever should be done without the client's permission

25. Hyperventilation causes excessive loss of carbon dioxide,25. Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation cannot occur; the pH is increased. Excess oxygen saturation cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.usual oxygen saturation of hemoglobin is 95% to 98%.

26. Toxicity can result because the action of calcium ions is 26. Toxicity can result because the action of calcium ions is similar to that of digoxin. Calcium gluconate cannot be similar to that of digoxin. Calcium gluconate cannot be added to a solution containing carbonate or phosphate added to a solution containing carbonate or phosphate because a dangerous precipitation will occur. Calcium because a dangerous precipitation will occur. Calcium gluconate can be added to the IV solution the client is gluconate can be added to the IV solution the client is receiving. If calcium infiltrates, sloughing of tissue will result.receiving. If calcium infiltrates, sloughing of tissue will result.

27. Shearing force is the pressure exerted on the skin when 27. Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the subcutaneous tissue and bone slide in the direction of the

body movements, causing a tearing of the skin. Using a body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supportingrepositioning the client at least every 2 hours and supporting with pillows and at least once every 8 hours, and performing with pillows and at least once every 8 hours, and performing passive range-of-motion exercises of all extremities are all passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.using a drawsheet in prevention of shearing force.

28. Prayer is an alternative therapy that may relax the client 28. Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an regimen for pain relief, so they are not considered an alternative therapyalternative therapy

29. Clients adapting to illness frequently feel afraid and 29. Clients adapting to illness frequently feel afraid and helpless and strike out at health team members as a way of helpless and strike out at health team members as a way of maintaining control or denying their fear. There is no maintaining control or denying their fear. There is no evidence that the client denies the existence of the health evidence that the client denies the existence of the health problem. Although disorders such as brain attacks and problem. Although disorders such as brain attacks and atherosclerosis, which are associated with hypertension, atherosclerosis, which are associated with hypertension, may lead to cerebral anoxia, there is insufficient evidence to may lead to cerebral anoxia, there is insufficient evidence to support this conclusion. Captopril (an antihypertensive) is a support this conclusion. Captopril (an antihypertensive) is a renin-angiotensin antagonist that reduces blood pressure renin-angiotensin antagonist that reduces blood pressure and does not cause behavioral changes; alprazolam is and does not cause behavioral changes; alprazolam is prescribed to reduce anxiety.prescribed to reduce anxiety.

30. The hospital is threatening to keep the infant; therefore 30. The hospital is threatening to keep the infant; therefore false imprisonment is threatened. False imprisonment is false imprisonment is threatened. False imprisonment is restraining or confining a person without a clinical reason. restraining or confining a person without a clinical reason. False threat may be a term to describe false imprisonment; False threat may be a term to describe false imprisonment;

however it is inaccurate in this situation. Assault and battery however it is inaccurate in this situation. Assault and battery legally means to threaten violence and the physical act of legally means to threaten violence and the physical act of violence. Breach of confidentiality is a disclosure to a third violence. Breach of confidentiality is a disclosure to a third party, without client consent or court order of private party, without client consent or court order of private information.information.

31. 31. DehydrationDehydration is measured most readily and accurately by is measured most readily and accurately by serial assessments of body weight; 1 L of fluid weighs 2.2 lb. serial assessments of body weight; 1 L of fluid weighs 2.2 lb. Although dry skin may be associated with dehydration, it Although dry skin may be associated with dehydration, it also is associated with aging and some disorders (e.g., also is associated with aging and some disorders (e.g., hypothyroidism). Although hypovolemia eventually will resulthypothyroidism). Although hypovolemia eventually will result in a decrease in blood pressure, it is not an accurate, reliablein a decrease in blood pressure, it is not an accurate, reliable measure because there are many other causes of measure because there are many other causes of hypotension. Altered appearance is too general and not an hypotension. Altered appearance is too general and not an objective determination of fluid volume deficit.objective determination of fluid volume deficit.

32. HIV, which is the virus that causes AIDS, is transmitted 32. HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other is not spread casually. Although HIV may be found in other body secretions, including feces, urine, sweat, tears, saliva, body secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.sufficient enough to be transmitted.

33. Additional fluid from surrounding tissues will be drawn 33. Additional fluid from surrounding tissues will be drawn into the lung because of the high osmotic pressure exerted into the lung because of the high osmotic pressure exerted by the salt content of the aspirated ocean water; this results by the salt content of the aspirated ocean water; this results in pulmonary edema. Hypoxia and acidosis may occur after ain pulmonary edema. Hypoxia and acidosis may occur after a near-drowning. Renal failure is not a sequela of near-near-drowning. Renal failure is not a sequela of near-drowning. Hypovolemia occurs because fluid is drawn into drowning. Hypovolemia occurs because fluid is drawn into the lungs by the hypertonic saltwater.the lungs by the hypertonic saltwater.

34. Assessing the client's knowledge to delineate baseline 34. Assessing the client's knowledge to delineate baseline information should be done before planning appropriate information should be done before planning appropriate health teaching. Providing written material without knowing health teaching. Providing written material without knowing the client's ability to read is inappropriate; also, it limits the the client's ability to read is inappropriate; also, it limits the nurse's personal involvement in the teaching process. nurse's personal involvement in the teaching process. Having the client talk with the health care provider avoids Having the client talk with the health care provider avoids carrying out the nurse's responsibility to provide teaching carrying out the nurse's responsibility to provide teaching about a prescribed medication regimen. Health teaching about a prescribed medication regimen. Health teaching

about medication is the responsibility of the registered about medication is the responsibility of the registered professional nurse.professional nurse.

35. Beneficence commonly is referred to as "doing of good"; 35. Beneficence commonly is referred to as "doing of good"; it is related to the nurse's duty to help clients further their it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety. legitimate interest within the boundaries of safety. Unfortunately in this situation the client's priority is relief Unfortunately in this situation the client's priority is relief from pain and the nurse should be working with other health from pain and the nurse should be working with other health team members to achieve this objective. Veracity is defined team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, meansas telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are that the nurse respects the client and the choices that are made. Paternalism occurs if the nurse interferes with the made. Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices.individual's autonomy by disregarding the client's choices.

36. 36. Denial includes feelingsDenial includes feelings that the health care provider has that the health care provider has made a mistake, so the client seeks additional opinions. made a mistake, so the client seeks additional opinions. Anger follows denial; behavior will be hostile and critical. Anger follows denial; behavior will be hostile and critical. Bargaining occurs after anger; the client verbally or secretly Bargaining occurs after anger; the client verbally or secretly may promise something in return for wellness or a prolongedmay promise something in return for wellness or a prolonged life. Depression occurs after bargaining; the client feels life. Depression occurs after bargaining; the client feels sadness and despair and may be withdrawn.sadness and despair and may be withdrawn.

37. This behavior is a sign of hypersomnia and the client 37. This behavior is a sign of hypersomnia and the client needs a medical assessment; it frequently is caused by needs a medical assessment; it frequently is caused by central nervous system damage or certain kidney, liver, or central nervous system damage or certain kidney, liver, or metabolic disorders. Exercise is appropriate for a client metabolic disorders. Exercise is appropriate for a client experiencing insomnia, not hypersomnia. This behavior is a experiencing insomnia, not hypersomnia. This behavior is a sign of hypersomnia and medical causes should be ruled out sign of hypersomnia and medical causes should be ruled out before attributing it to a psychogenic cause. Narcolepsy before attributing it to a psychogenic cause. Narcolepsy consists of recurrent sudden waves of overwhelming consists of recurrent sudden waves of overwhelming sleepiness that occur during the day, even during activities sleepiness that occur during the day, even during activities such as eating or conversing.such as eating or conversing.

Study Tip: Determine whether you are a “lark” or an “owl.” Study Tip: Determine whether you are a “lark” or an “owl.” Larks, day people, do best getting up early and studying Larks, day people, do best getting up early and studying during daylight hours. Owls, night people, are more alert during daylight hours. Owls, night people, are more alert after dark and can remain up late at night studying, catchingafter dark and can remain up late at night studying, catching up on needed sleep during daylight hours. It is better to workup on needed sleep during daylight hours. It is better to work with natural biorhythms than to try to conform to an with natural biorhythms than to try to conform to an

arbitrary schedule. You will absorb material more quickly andarbitrary schedule. You will absorb material more quickly and retain it better if you use your most alert periods of each dayretain it better if you use your most alert periods of each day for study. Of course, it is necessary to work around class andfor study. Of course, it is necessary to work around class and clinical schedules. Owls should attempt to register in clinical schedules. Owls should attempt to register in afternoon or evening lectures and clinical sections; larks do afternoon or evening lectures and clinical sections; larks do better with morning lectures and day clinical sections.better with morning lectures and day clinical sections.

38. The Z-track method seals the puncture at the 38. The Z-track method seals the puncture at the intramuscular level, preventing seepage of injected intramuscular level, preventing seepage of injected medication up the needle track and thereby avoiding injury medication up the needle track and thereby avoiding injury to subcutaneous tissue and skin. The Z-track technique is to subcutaneous tissue and skin. The Z-track technique is unrelated to the volume of medication to be administered. unrelated to the volume of medication to be administered. When the volume of medication is large, it should be When the volume of medication is large, it should be administered into a large muscle or divided into two administered into a large muscle or divided into two syringes. Massage is avoided with the Z-track technique to syringes. Massage is avoided with the Z-track technique to help prevent the injected medication from flowing back up help prevent the injected medication from flowing back up the needle track. Administration of a small air bubble at the the needle track. Administration of a small air bubble at the completion of injection of medication into a muscle (air-lock completion of injection of medication into a muscle (air-lock technique) is no longer recommended because it does not technique) is no longer recommended because it does not increase the likelihood that medication will remain in the increase the likelihood that medication will remain in the muscle without flowing back up the needle track.muscle without flowing back up the needle track.

39. Contact precautions should be used for direct client or 39. Contact precautions should be used for direct client or environmental contact with blood or body fluids from an environmental contact with blood or body fluids from an infected client. This includes colonization of infection with infected client. This includes colonization of infection with multidrug-resistant organisms (MDRO) such as MRSA, stool multidrug-resistant organisms (MDRO) such as MRSA, stool infected with Clostridium difficle, draining wounds where infected with Clostridium difficle, draining wounds where secretions are not contained, or scabies. Airborne secretions are not contained, or scabies. Airborne precautions are used for infected droplets smaller then 5 precautions are used for infected droplets smaller then 5 mcg, such as measles, chickenpox (varicella), or pulmonary mcg, such as measles, chickenpox (varicella), or pulmonary TB. Droplet precautions are used for droplets larger than 5 TB. Droplet precautions are used for droplets larger than 5 mcg and being within 3 feet of the client, such as mcg and being within 3 feet of the client, such as streptococcal pharyngitis, mumps, and influenza. Protective streptococcal pharyngitis, mumps, and influenza. Protective environment focuses on clients with a compromised immuneenvironment focuses on clients with a compromised immune system to protect them from incoming pathogens.system to protect them from incoming pathogens.

40. Prostaglandins accumulate at the site of an injury, 40. Prostaglandins accumulate at the site of an injury, causing pain; NSAIDs inhibit COX-1 and COX-2 (both are causing pain; NSAIDs inhibit COX-1 and COX-2 (both are isoforms of the enzyme cyclooxygenase), which inhibit the isoforms of the enzyme cyclooxygenase), which inhibit the

production of prostaglandins, thereby contributing to production of prostaglandins, thereby contributing to analgesia. NSAIDs inhibit COX-2, which is associated with analgesia. NSAIDs inhibit COX-2, which is associated with fever, thereby causing antipyresis. NSAIDs inhibit COX-2, fever, thereby causing antipyresis. NSAIDs inhibit COX-2, which is associated with inflammation, thereby reducing which is associated with inflammation, thereby reducing inflammation. NSAIDs do not cause diuresis; reversible renal inflammation. NSAIDs do not cause diuresis; reversible renal ischemia and renal insufficiency in clients with heart failure, ischemia and renal insufficiency in clients with heart failure, cirrhosis, or hypovolemia can be potential cirrhosis, or hypovolemia can be potential adverse effects of adverse effects of NSAIDsNSAIDs. NSAIDs do not cause bronchodilation. . NSAIDs do not cause bronchodilation. Anticoagulation is an adverse effect, not a desired outcome; Anticoagulation is an adverse effect, not a desired outcome; NSAIDs can impair platelet function by inhibiting NSAIDs can impair platelet function by inhibiting thromboxane, an aggregating agent, resulting in bleeding.thromboxane, an aggregating agent, resulting in bleeding.

41. Noisy, increased respirations and increased pulse are 41. Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear thesigns that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratoryairway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then assessment should be performed. After suctioning, then performing a respiratory assessment, further problem performing a respiratory assessment, further problem solving may require readjustment of the tracheostomy tube solving may require readjustment of the tracheostomy tube and ties or a physician changing the tracheostomy tube.and ties or a physician changing the tracheostomy tube.

42. The gamma-globulin fraction in the plasma is the fraction42. The gamma-globulin fraction in the plasma is the fraction that includes the antibodies. Albumin helps regulate fluid that includes the antibodies. Albumin helps regulate fluid shifts by maintaining plasma oncotic pressure. Thrombin is shifts by maintaining plasma oncotic pressure. Thrombin is involved with clotting. Hemoglobin carries oxygen.involved with clotting. Hemoglobin carries oxygen.

43. The impaired skin integrity is physiologically a result of 43. The impaired skin integrity is physiologically a result of unrelieved pressure and shearing force. This is supported by unrelieved pressure and shearing force. This is supported by the data provided that the client is non-ambulatory and has the data provided that the client is non-ambulatory and has a reddened sacrum. Risk for pressure ulcer is not an a reddened sacrum. Risk for pressure ulcer is not an approved NANDA-I nursing diagnosis. The client's problem is approved NANDA-I nursing diagnosis. The client's problem is not being "at risk" because the client already has an actual not being "at risk" because the client already has an actual problem. Not enough information is provided to make the problem. Not enough information is provided to make the assumption that the impaired skin integrity is related to assumption that the impaired skin integrity is related to infrequent turning and repositioning.infrequent turning and repositioning.

44. Increased respirations blow off carbon dioxide (CO44. Increased respirations blow off carbon dioxide (CO22), ), which decreases the hydrogen ion concentration and the pH which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in COincreases (less acidity). Decreased respirations result in CO22 buildup, which increases hydrogen ion concentration and thebuildup, which increases hydrogen ion concentration and the

pH falls (more acidity). The kidneys either conserve or pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to excrete bicarbonate and hydrogen ions, which helps to adjust the adjust the body's pHbody's pH. The buffering capacity of the renal . The buffering capacity of the renal system is greater than that of the pulmonary system, but thesystem is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.interact with the urinary system to regulate plasma pH.

45. The client has the right to make this decision, and the 45. The client has the right to make this decision, and the staff should accept the client's wishes. The client is a doctor, staff should accept the client's wishes. The client is a doctor, and the nurse's statement attacks the client's self-concept. and the nurse's statement attacks the client's self-concept. The informality of using first names is not encouraged unlessThe informality of using first names is not encouraged unless it is the client's choice. The nurse can and should honor the it is the client's choice. The nurse can and should honor the client's request.client's request.

46. Socialization, values, and role definition are learned 46. Socialization, values, and role definition are learned within the family and help develop a sense of self. Once within the family and help develop a sense of self. Once established in the family, the child can move more easily established in the family, the child can move more easily into society. Although important, providing rewards and into society. Although important, providing rewards and punishments, supporting the child's development, and punishments, supporting the child's development, and reflecting the mores of society are just one aspect of the reflecting the mores of society are just one aspect of the family's influence and are not as important as identity and family's influence and are not as important as identity and roles in relation to emotional development.roles in relation to emotional development.

47. Dependent edema around the area of feet and ankles 47. Dependent edema around the area of feet and ankles often indicates right sided heart failure or venous often indicates right sided heart failure or venous insufficiency. The nurse should assess for pitting edema by insufficiency. The nurse should assess for pitting edema by pressing firmly for several seconds then release to assess forpressing firmly for several seconds then release to assess for any any depressiondepression left on the skin. The grading of 1+ to 4+ left on the skin. The grading of 1+ to 4+ characterizes the severity of the edema. A grade of grade of characterizes the severity of the edema. A grade of grade of 4+ indicates an 8 mm depression. A grade of 1+ indicates a 4+ indicates an 8 mm depression. A grade of 1+ indicates a 2 mm depression. A grade of 2 + indicates a 4 mm 2 mm depression. A grade of 2 + indicates a 4 mm depression. A grade of 3+ indicates a 6 mm depression.depression. A grade of 3+ indicates a 6 mm depression.

48.48. An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The

tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min A: 38

49. Because of the profound effect of paralysis on body 49. Because of the profound effect of paralysis on body image, the nurse should foster an environment that permits image, the nurse should foster an environment that permits exploration of feelings without judgment, punishment, or exploration of feelings without judgment, punishment, or rejection. Attempts to distract the client may be interpreted rejection. Attempts to distract the client may be interpreted as denial of the client's feelings and will not resolve the as denial of the client's feelings and will not resolve the underlying problem. Including the client in decision making underlying problem. Including the client in decision making and helping the client to problem-solve personal issues are and helping the client to problem-solve personal issues are an important part of nursing care, but they are not related toan important part of nursing care, but they are not related to the client's feelings.the client's feelings.

50. Ibuprofen irritates the gastrointestinal (GI) mucosa and 50. Ibuprofen irritates the gastrointestinal (GI) mucosa and can cause mucosal erosion, resulting in bleeding; blood in can cause mucosal erosion, resulting in bleeding; blood in the stool (melena) occurs as the digestive process acts on the stool (melena) occurs as the digestive process acts on the blood in the upper GI tract. Hemoglobin, which carries the blood in the upper GI tract. Hemoglobin, which carries oxygen to body cells, is decreased with anemia; the heart oxygen to body cells, is decreased with anemia; the heart rate increases as a compensatory response to increase rate increases as a compensatory response to increase oxygen to body cells. Constipation usually is related to oxygen to body cells. Constipation usually is related to immobility, a low-fiber diet, and inadequate fluid intake, not immobility, a low-fiber diet, and inadequate fluid intake, not the data listed in this situation. Clay-colored stools are the data listed in this situation. Clay-colored stools are related to biliary problems, not GI bleeding. Painful bowel related to biliary problems, not GI bleeding. Painful bowel movements are related to hemorrhoids, not GI bleeding.movements are related to hemorrhoids, not GI bleeding.

51. The liver manufactures albumin, the major plasma 51. The liver manufactures albumin, the major plasma protein. A deficit of this protein lowers the osmotic (oncotic) protein. A deficit of this protein lowers the osmotic (oncotic) pressure in the intravascular space, leading to a fluid shift. pressure in the intravascular space, leading to a fluid shift. An enlarged liver compresses the portal system, causing An enlarged liver compresses the portal system, causing increased, rather than decreased, pressure. The kidneys are increased, rather than decreased, pressure. The kidneys are not the primary source of the pathologic condition. It is the not the primary source of the pathologic condition. It is the liver's ability to manufacture albumin that maintains the liver's ability to manufacture albumin that maintains the colloid oncotic pressure. Potassium is not produced by the colloid oncotic pressure. Potassium is not produced by the body, nor is its major function the maintenance of fluid body, nor is its major function the maintenance of fluid balance.balance.

52. Best practice guidelines indicate that non-coring needles 52. Best practice guidelines indicate that non-coring needles be changed at least every seven days to decrease risk of be changed at least every seven days to decrease risk of infection. Changing a non-coring needle every 3 to 5 days is infection. Changing a non-coring needle every 3 to 5 days is too frequent and increases the risk for infection as well as too frequent and increases the risk for infection as well as patient discomfort. Changing a non-coring needle every 9 patient discomfort. Changing a non-coring needle every 9 days increases the risk of infection due to the prolonged days increases the risk of infection due to the prolonged length of time the needle is in place.length of time the needle is in place.

53. Meta-analysis is a synthesis of evidence from associated 53. Meta-analysis is a synthesis of evidence from associated randomized controlled trials. Meta-analysis is more reliable randomized controlled trials. Meta-analysis is more reliable than a randomized controlled trial. Randomized controlled than a randomized controlled trial. Randomized controlled trials are studies where subjects randomly are assigned to a trials are studies where subjects randomly are assigned to a treatment or control group. A randomized control trial is treatment or control group. A randomized control trial is more reliable than a controlled trial without randomization. more reliable than a controlled trial without randomization. Controlled trials without randomization are studies in which Controlled trials without randomization are studies in which subjects are assigned nonrandomly to a treatment or controlsubjects are assigned nonrandomly to a treatment or control group. A controlled trial without randomization is more group. A controlled trial without randomization is more reliable than a cohort study. Cohort studies observe a group reliable than a cohort study. Cohort studies observe a group to determine the development of an outcome. Expert opinionto determine the development of an outcome. Expert opinion based on principles is not based on actual evidence; it is based on principles is not based on actual evidence; it is relied on when there is no evidence from research.relied on when there is no evidence from research.

54. Assigning one staff member to approach the client 54. Assigning one staff member to approach the client regularly and interact with the client provides continuity and regularly and interact with the client provides continuity and demonstrates to the client that the nursing staff is demonstrates to the client that the nursing staff is concerned; frequent contact should reduce the client's need concerned; frequent contact should reduce the client's need to call the staff for reassurance. Closing the door to the roomto call the staff for reassurance. Closing the door to the room so that the client cannot see the staff members as they pass so that the client cannot see the staff members as they pass by may increase the client's anxiety and the need for by may increase the client's anxiety and the need for contact with staff. Telling the client is not the same as doing contact with staff. Telling the client is not the same as doing it; the client may not believe that staff will come in it; the client may not believe that staff will come in frequently. Arranging for a variety of staff members to take frequently. Arranging for a variety of staff members to take turns going into the room to see whether the client has any turns going into the room to see whether the client has any requests will not facilitate the development of a therapeutic requests will not facilitate the development of a therapeutic relationship with a staff member.relationship with a staff member.

55. Refocusing the conversation on the client's fears, 55. Refocusing the conversation on the client's fears, frustrations, and anger about the condition provides an frustrations, and anger about the condition provides an opportunity for the client to verbalize the feelings underlyingopportunity for the client to verbalize the feelings underlying

the behavior. Describing the purpose of different hospital the behavior. Describing the purpose of different hospital therapies will have no effect on decreasing the client's therapies will have no effect on decreasing the client's anxiety or on allowing ventilation of feelings. Explaining that anxiety or on allowing ventilation of feelings. Explaining that becoming so upset dangerously blocks the need for rest will becoming so upset dangerously blocks the need for rest will not decrease anxiety so that the client can rest. Although not decrease anxiety so that the client can rest. Although allowing release of feelings is therapeutic, leaving denies theallowing release of feelings is therapeutic, leaving denies the client the opportunity for verbalization and discussion.client the opportunity for verbalization and discussion.

56. The first step in the problem-solving process is data 56. The first step in the problem-solving process is data collection so that client needs can be identified. During the collection so that client needs can be identified. During the initial interview a direct approach obtains specific initial interview a direct approach obtains specific information, such as allergies, current medications, and information, such as allergies, current medications, and health history. The exploratory approach is too broad health history. The exploratory approach is too broad because in a nondirective interview the client controls the because in a nondirective interview the client controls the subject matter. Problem solving and information giving are subject matter. Problem solving and information giving are premature at the initial visit.premature at the initial visit.

57. Tetanus antitoxin provides antibodies, which confer 57. Tetanus antitoxin provides antibodies, which confer immediate passive immunity. Antitoxin does not stimulate immediate passive immunity. Antitoxin does not stimulate production of antibodies. It provides passive, not active, production of antibodies. It provides passive, not active, immunity. Passive immunity, by definition, is not long-immunity. Passive immunity, by definition, is not long-lasting.lasting.

58. Rehabilitation refers to a process that assists clients to 58. Rehabilitation refers to a process that assists clients to obtain optimal functioning. Care should be initiated obtain optimal functioning. Care should be initiated immediately when a health problem exists to avoid immediately when a health problem exists to avoid complications and facilitate recuperation. All resources that complications and facilitate recuperation. All resources that can be beneficial to client rehabilitation, including the can be beneficial to client rehabilitation, including the private health care provider and acute care facilities, should private health care provider and acute care facilities, should be used. Rehabilitation is a commonality in all areas of be used. Rehabilitation is a commonality in all areas of nursing practice. Rehabilitation is necessary to help clients nursing practice. Rehabilitation is necessary to help clients return to a previous or optimal level of functioning.return to a previous or optimal level of functioning.

59.59. At the beginning of the shift at 7 AM, a client has 650 mL of normal saline solution left in the intravenous bag, which is infusing at 125 mL/hr. At 9:30 AM the health care provider changes the IV solution to Ringer's lactate, which is to infuse at 100

mL/hr. What total amount of intravenous solution should the client have received by the end of the eight-hour shift? Record your answer using a whole number. ___ mL A: 863

The client will have absorbed 313 mL of solution before the The client will have absorbed 313 mL of solution before the health care provider changes the prescription (2½ hours × health care provider changes the prescription (2½ hours × 125 mL/hour = 312.5, rounded up to 313); for the remaining 125 mL/hour = 312.5, rounded up to 313); for the remaining 5½ hours of the shift, the client will have received 550 mL 5½ hours of the shift, the client will have received 550 mL (5½ hours × 100 mL/hour), for a total of 863 mL.(5½ hours × 100 mL/hour), for a total of 863 mL.

60. Tachypnea occurs with 60. Tachypnea occurs with Addisonian crisisAddisonian crisis because of because of inadequate circulating glucocorticoids and inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.with Addisonian crisis.

Study Tip: The old standbys of enough sleep and adequate Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.puts the brain at a disadvantage.

61. Clients receiving TPN require monitoring of blood glucose61. Clients receiving TPN require monitoring of blood glucose because the TPN solution contains a high concentration of because the TPN solution contains a high concentration of dextrose. In response to the high-dextrose TPN solution, the dextrose. In response to the high-dextrose TPN solution, the pancreas increases production of insulin to meet the glucosepancreas increases production of insulin to meet the glucose demands. In this situation, the current TPN infusion is demands. In this situation, the current TPN infusion is completed, and the nurse should infuse 10% dextrose to completed, and the nurse should infuse 10% dextrose to compensate for the loss while the next TPN bag is being compensate for the loss while the next TPN bag is being prepared. If this action is not taken, the client could prepared. If this action is not taken, the client could experience a profound hypoglycemic reaction. After experience a profound hypoglycemic reaction. After beginning an infusion of 10% dextrose, the nurse may beginning an infusion of 10% dextrose, the nurse may perform a fingerstick glucose test and notify the physician if perform a fingerstick glucose test and notify the physician if

the results are abnormal. Discontinuing the infusion and the results are abnormal. Discontinuing the infusion and flushing the line until the next TPN bag is ready is not flushing the line until the next TPN bag is ready is not recommended. Starting an infusion of 5% dextrose at KVO recommended. Starting an infusion of 5% dextrose at KVO until the next TPN is ready may not prevent hypoglycemia; until the next TPN is ready may not prevent hypoglycemia; the nurse manager does not need to be involved unless the nurse manager does not need to be involved unless there is a negative patient outcome that results.there is a negative patient outcome that results.

62. False imprisonment is a wrong committed by one person 62. False imprisonment is a wrong committed by one person against another in a willful, intentional way without just against another in a willful, intentional way without just cause or excuse. Negligence is an cause or excuse. Negligence is an unintentional tortunintentional tort. . Malpractice, which is professional negligence, is classified as Malpractice, which is professional negligence, is classified as an unintentional tort. Breach of duty is an unintentional tort.an unintentional tort. Breach of duty is an unintentional tort.

63. PTU can cause depression of leukocytes and platelets. 63. PTU can cause depression of leukocytes and platelets. Propylthiouracil and potassium iodide should be given with Propylthiouracil and potassium iodide should be given with milk, juice, or food to prevent gastric irritation. Drug therapy milk, juice, or food to prevent gastric irritation. Drug therapy decreases the risk of postoperative hemorrhage because thisdecreases the risk of postoperative hemorrhage because this drug regimen decreases the size and vascularity of the drug regimen decreases the size and vascularity of the thyroid gland. Drug therapy is continued for at least six to thyroid gland. Drug therapy is continued for at least six to eight weeks, even if the client's temperature and pulse eight weeks, even if the client's temperature and pulse return to the expected range.return to the expected range.

64. A neurovascular assessment involves evaluation of nerve64. A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of apupillary response, and respiratory rate are components of a neurological assessment.neurological assessment.

65. The voltage or current is adjusted on the basis of the 65. The voltage or current is adjusted on the basis of the degree of pain relief experienced by the client. Maintaining degree of pain relief experienced by the client. Maintaining the settings programmed by the health care provider may the settings programmed by the health care provider may provide too little or too much stimulation to achieve the provide too little or too much stimulation to achieve the desired response. Pain suppressor desired response. Pain suppressor TENSTENS units must be units must be turned on several times a day for 10 to 20 minutes, not the turned on several times a day for 10 to 20 minutes, not the conventional unit. The electrodes should be applied either onconventional unit. The electrodes should be applied either on the painful area or immediately below or above the area.the painful area or immediately below or above the area.

66. Early notification provides an opportunity to prepare for 66. Early notification provides an opportunity to prepare for change. The ability to decrease the client's anxiety, families change. The ability to decrease the client's anxiety, families being more relaxed and less likely to cause problems with being more relaxed and less likely to cause problems with nursing staff may be a secondary gain but are not the nursing staff may be a secondary gain but are not the primary purpose.primary purpose.

67. An infant having a seizure should receive care first 67. An infant having a seizure should receive care first because the infant is in acute distress. A person having a because the infant is in acute distress. A person having a seizure should never be left alone. The primary seizure should never be left alone. The primary responsibilities include maintaining client safety and responsibilities include maintaining client safety and observing the characteristics of the seizure. A woman havingobserving the characteristics of the seizure. A woman having acute chest pain should receive care second because chest acute chest pain should receive care second because chest pain can indicate a myocardial infarction or other potential pain can indicate a myocardial infarction or other potential fatal cardiac event. Acute pancreatitis is extremely painful fatal cardiac event. Acute pancreatitis is extremely painful and therefore this client should be medicated as soon as and therefore this client should be medicated as soon as possible after clients with life-threatening problems are possible after clients with life-threatening problems are stabilized. A child with a non-life-threatening cut and stabilized. A child with a non-life-threatening cut and needing stitches can wait until the more acute clients are needing stitches can wait until the more acute clients are attended to and stabilized. Although a blood glucose level of attended to and stabilized. Although a blood glucose level of 190 is elevated it is not life threatening; therefore, meeting 190 is elevated it is not life threatening; therefore, meeting the needs of clients with more acute problems first is the needs of clients with more acute problems first is appropriate.appropriate.

68. Blood plasma and interstitial fluid are both part of the 68. Blood plasma and interstitial fluid are both part of the extracellular fluidextracellular fluid and are of the same ionic composition. The and are of the same ionic composition. The osmotic pressure is the same. The composition is the same. osmotic pressure is the same. The composition is the same. The main cation of both extracellular fluids is sodium.The main cation of both extracellular fluids is sodium.

69. 69. Self-help groupsSelf-help groups are successful because they support a are successful because they support a basic human need for acceptance. A feeling of comfort and basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on AA meets dependency needs rather than focusing on independence, trust, and growth.independence, trust, and growth.

70. Because the client's condition is terminal, the 70. Because the client's condition is terminal, the nursingnursing  priority should be directed toward providingpriority should be directed toward providing  basic basic care and comfortcare and comfort. Although intake and output, diet and . Although intake and output, diet and

nutrition, and body mechanics and posture are important nutrition, and body mechanics and posture are important aspects of nursing care, provision of comfort is theaspects of nursing care, provision of comfort is the  priority priority when caring for a dying client.when caring for a dying client.

71. Eye contact indicates to the client that the nurse is 71. Eye contact indicates to the client that the nurse is listening and interested. Paraphrasing is an effective listening and interested. Paraphrasing is an effective interviewing technique; it indicates to the client that the interviewing technique; it indicates to the client that the message was heard and invites the client to elaborate message was heard and invites the client to elaborate further. Open-ended statements provide a milieu in which further. Open-ended statements provide a milieu in which people can verbalize their problems rather than be placed in people can verbalize their problems rather than be placed in a situation of providing a forced response. Asking "why" and a situation of providing a forced response. Asking "why" and "how" questions can be threatening to the client, who may "how" questions can be threatening to the client, who may not have the answer to these questions. False reassurance isnot have the answer to these questions. False reassurance is detrimental to the nurse-client relationship and does not detrimental to the nurse-client relationship and does not promote communication. Direct questions do not open or promote communication. Direct questions do not open or promote communication.promote communication.

72. Moving the client who is singing away from the other 72. Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doorswill not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention.use of a sedative should not be the initial intervention.

73.73. The intake and output of a client over an eight-hour period (from 0800-1600)  is as follows: 150 mL urine voided at 0800; 220 mL urine voided at 1200; 235 mL urine voided at 1600; 200 mL gastric tube formula + 50 mL water administered initially and then repeated x 2; IV had 900 mL in the bag at 0800, and 550 mL remains in the bag at 1600. What is the difference between the client’s intake and output? Record the answer using a whole number ___ mL A:495

Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 Intake: Gastric tube: 250 x 3 = 750 mL; IV: 900 - 550 = 350 mL; Intake total: 1100 mL. Output: Urinary output: 150 + mL; Intake total: 1100 mL. Output: Urinary output: 150 + 220 + 235 = 605 mL I & O difference: 1100 – 605 = 495 mL220 + 235 = 605 mL I & O difference: 1100 – 605 = 495 mL

74. Medication reconciliation involves the creation of a list of 74. Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or there is a transfer to a different setting or service, or discharge. A change in status does not require medication discharge. A change in status does not require medication reconciliation. A medication reconciliation should be reconciliation. A medication reconciliation should be completed long before entering the operating room. Total completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place before admission; medication reconciliation takes place when the client is admitted.place when the client is admitted.

75. Using long-handled forceps keeps the sealed implant 75. Using long-handled forceps keeps the sealed implant away from the nurse as the implant is retrieved and placed away from the nurse as the implant is retrieved and placed in a lead container kept in the client's room. Wearing a in a lead container kept in the client's room. Wearing a dosimeter film badge offers no protection from exposure to dosimeter film badge offers no protection from exposure to radiation; it only measures the nurse's exposure to the radiation; it only measures the nurse's exposure to the radiation. Exposure should be limited to no more than 30 radiation. Exposure should be limited to no more than 30 minutes daily. Visitors should maintain a minimum distance minutes daily. Visitors should maintain a minimum distance of 6 feet from the radiation source and visit for only 30 of 6 feet from the radiation source and visit for only 30 minutes daily.minutes daily.

76. When a sterile surface becomes wet, microorganisms 76. When a sterile surface becomes wet, microorganisms from the unsterile surface below the sterile field will be from the unsterile surface below the sterile field will be drawn up, contaminating the sterile field. The absorption of drawn up, contaminating the sterile field. The absorption of fluids by gauze results from the adhesion of water to the fluids by gauze results from the adhesion of water to the gauze threads; the surface tension of water causes gauze threads; the surface tension of water causes contraction of the fiber, pulling fluid up the threads. Dialysis contraction of the fiber, pulling fluid up the threads. Dialysis is separation of substances in solution using their differing is separation of substances in solution using their differing rates of diffusion through a membrane. Osmosis refers to rates of diffusion through a membrane. Osmosis refers to movement of water through a semipermeable membrane. movement of water through a semipermeable membrane. Diffusion is movement of molecules from a high to a low Diffusion is movement of molecules from a high to a low concentration.concentration.

77. When emotional stress overwhelms an individual's ability77. When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No This lack of concern is called la belle indifference. No

physiologic changes are involved with this unconscious physiologic changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.symptoms operates on an unconscious level.

78. The client is unconscious. Although the spouse can give 78. The client is unconscious. Although the spouse can give consent, there is no legal power to refuse a treatment for theconsent, there is no legal power to refuse a treatment for the client unless previously authorized to do so by a power of client unless previously authorized to do so by a power of attorney or a health care proxy; the court can make a attorney or a health care proxy; the court can make a decision for the client. Explanations will not be effective at decision for the client. Explanations will not be effective at this time and will not meet the client's needs. Instituting the this time and will not meet the client's needs. Instituting the prescribed blood transfusion and phoning the health care prescribed blood transfusion and phoning the health care provider for an administrative prescription are without legal provider for an administrative prescription are without legal basis, and the nurse may be held liable.basis, and the nurse may be held liable.

79. Use the “Desire over Have” formula of ratio and 79. Use the “Desire over Have” formula of ratio and proportion to solve this problem. Desire 125 mg = x mL proportion to solve this problem. Desire 125 mg = x mL Have 225 mg 1 mL 225x = 125 X = 125 ÷ 225 X = 0.55 mL. Have 225 mg 1 mL 225x = 125 X = 125 ÷ 225 X = 0.55 mL. Round the answer up to 0.6 mL (pic of a syringe) Round the answer up to 0.6 mL (pic of a syringe)

80. Perspiration is an involuntary 80. Perspiration is an involuntary physiologic responsephysiologic response. It is . It is mediated by the autonomic nervous system under a variety mediated by the autonomic nervous system under a variety of circumstances, such as rising ambient temperature, high of circumstances, such as rising ambient temperature, high humidity, stress, and pain. Crying is an emotional response humidity, stress, and pain. Crying is an emotional response that may or may not be related to pain. Splinting is a that may or may not be related to pain. Splinting is a voluntary action that may limit tension on the abdomen, voluntary action that may limit tension on the abdomen, thus reducing pain. Grimacing is a result of contraction of thus reducing pain. Grimacing is a result of contraction of the facial muscles; it may or may not be a response to pain.the facial muscles; it may or may not be a response to pain.

81. Vitamin C (ascorbic acid) plays a major role in81. Vitamin C (ascorbic acid) plays a major role in  wound wound healinghealing. It is necessary for the maintenance and formation of. It is necessary for the maintenance and formation of collagen, the major protein of most connective tissues. collagen, the major protein of most connective tissues. Vitamin A is important for the healing process; however, Vitamin A is important for the healing process; however, vitamin C is the priority because it cements the ground vitamin C is the priority because it cements the ground substance of supportive tissue. Cyanocobalamin is a vitamin substance of supportive tissue. Cyanocobalamin is a vitamin BB1212  preparation needed for red blood cell synthesis and a preparation needed for red blood cell synthesis and a healthy nervous system. Phytonadione is vitamin K, which healthy nervous system. Phytonadione is vitamin K, which plays a major role in blood coagulation.plays a major role in blood coagulation.

82. The high pH and low carbon dioxide level are consistent 82. The high pH and low carbon dioxide level are consistent with with respiratory alkalosisrespiratory alkalosis, which can be caused by , which can be caused by mechanical ventilation that is too aggressive. Airway mechanical ventilation that is too aggressive. Airway obstruction causes carbon dioxide buildup, which leads to obstruction causes carbon dioxide buildup, which leads to respiratory acidosis. Inadequate nutrition causes excess respiratory acidosis. Inadequate nutrition causes excess ketones, which can lead to metabolic acidosis. Prolonged ketones, which can lead to metabolic acidosis. Prolonged gastric suction causes loss of hydrochloric acid, which can gastric suction causes loss of hydrochloric acid, which can lead to metabolic alkalosis.lead to metabolic alkalosis.

83.83. Advance directivesAdvance directives allow clients to designate another allow clients to designate another person to consent to procedures if they are unable to do so. person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No Advance directives are not related to insurance. No information suggests the client cannot consent to treatment.information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated Directions for distribution of belongings should be stipulated in a will, not in an advance directive.in a will, not in an advance directive.

84. The 2-year-old child will be at higher risk for fluid and 84. The 2-year-old child will be at higher risk for fluid and electrolyte imbalance due to higher fluid content of the bodyelectrolyte imbalance due to higher fluid content of the body and decreased ability to regulate fluid balance that put this and decreased ability to regulate fluid balance that put this client in a life-threatening situation. Care of the 35-year-old client in a life-threatening situation. Care of the 35-year-old client with nausea is not a priority because the client's body client with nausea is not a priority because the client's body has higher ability to regulate fluid and electrolyte balance has higher ability to regulate fluid and electrolyte balance compared to the child. Care of the 83-year-old female havingcompared to the child. Care of the 83-year-old female having difficulty moving her bowels is not a nursing priority becausedifficulty moving her bowels is not a nursing priority because it is not a life-threatening situation. Care of the 40-year-old it is not a life-threatening situation. Care of the 40-year-old female with vomiting is not a nursing priority because this female with vomiting is not a nursing priority because this client has a higher ability to regulate fluid and electrolyte client has a higher ability to regulate fluid and electrolyte balance comparing to the child.balance comparing to the child.

85. The pulse oximeter measures the oxygen saturation of 85. The pulse oximeter measures the oxygen saturation of blood by determining the percentage of hemoglobin-carryingblood by determining the percentage of hemoglobin-carrying oxygen. A pulse oximeter does not interpret the amount of oxygen. A pulse oximeter does not interpret the amount of oxygen or carbon dioxide carried in the blood, nor does it oxygen or carbon dioxide carried in the blood, nor does it measure respiratory rate.measure respiratory rate.

86. A person is legally unable to sign a consent until the age 86. A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of adolescent. Although the adolescent may be capable of

intelligent choices, 18 is the intelligent choices, 18 is the legal age of consentlegal age of consent unless the unless the client is emancipated or married. Parents or guardians are client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.situation unless they are legally emancipated or married.

87. A common side effect of vincristine is a 87. A common side effect of vincristine is a paralytic ileusparalytic ileus that results in constipation. Preventative measures include that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum high-fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and thereby promoting evacuation. Low in fat, high in iron, and low in residue dietary plans will not provide the roughage low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated and fluids needed to minimize the constipation associated with vincristine.with vincristine.

88. Clean gloves should be worn to check the IV site because88. Clean gloves should be worn to check the IV site because there is a risk of coming into contact with the client's blood. there is a risk of coming into contact with the client's blood. Ensuring that the medication is mixed is important. Rotating Ensuring that the medication is mixed is important. Rotating the bag is one way, although there are others. Because IV the bag is one way, although there are others. Because IV solutions enter the body's internal environment, all solutions solutions enter the body's internal environment, all solutions and medications using this route must be sterile to prevent and medications using this route must be sterile to prevent the introduction of microbes. The amount and type of the introduction of microbes. The amount and type of solution depend on the medication. The insertion site does solution depend on the medication. The insertion site does not have to be flushed with an infusing IV. The not have to be flushed with an infusing IV. The IVPBIVPB should should be hung higher, not lower, than the existing bag.be hung higher, not lower, than the existing bag.

89. The etiology, or cause, of the problem provides direction 89. The etiology, or cause, of the problem provides direction for selection of nursing interventions. It is important to for selection of nursing interventions. It is important to remember that gathering the "S" comes first in the remember that gathering the "S" comes first in the diagnostic process, even though the format is described as diagnostic process, even though the format is described as PES. Collaborative problems are potential or actual PES. Collaborative problems are potential or actual complications, diseases, or treatment that nurses treat most complications, diseases, or treatment that nurses treat most frequently with other health care providers. A wellness frequently with other health care providers. A wellness diagnosis may be identified when an individual is in diagnosis may be identified when an individual is in transition from a specific level of wellness to a higher level oftransition from a specific level of wellness to a higher level of wellness. This diagnosis begins with "Readiness for wellness. This diagnosis begins with "Readiness for enhanced," followed by the higher level of wellness desired.enhanced," followed by the higher level of wellness desired.

90. The TURP procedure is performed by insertion of a scope90. The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being therefore the client statement about an incision being painful after surgery warrants further evaluation and painful after surgery warrants further evaluation and teaching by the nurse. The client is demonstrating correct teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.will need to increase fluid intake.

91. Evidenced-based nursing care uses information gleaned 91. Evidenced-based nursing care uses information gleaned from theory, research, expert opinion, client history and from theory, research, expert opinion, client history and physical examination, client preferences and values, and thephysical examination, client preferences and values, and the clinical expertise of the nurse. Time/motion studies are not clinical expertise of the nurse. Time/motion studies are not used as a basis of evidenced-based practice. Accepted used as a basis of evidenced-based practice. Accepted nursing rituals are not used as a basis of evidenced-based nursing rituals are not used as a basis of evidenced-based practice.practice.

92. In the stage of acceptance, the client frequently 92. In the stage of acceptance, the client frequently detaches from the environment and may become indifferent detaches from the environment and may become indifferent to family members. In addition, the family may take longer to family members. In addition, the family may take longer to accept the inevitable death than does the client. Althoughto accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same exhibited by the client and family members at the same time. During depression, the family often is able to offer time. During depression, the family often is able to offer emotional support, which meets their needs.emotional support, which meets their needs.

93. Gamma globulin, which is an immune globulin, contains 93. Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen frominjected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody antibody production. It does not affect antigen-antibody function.function.

94. Turning the client to the side promotes drainage of 94. Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is inforward, preventing it from occluding the airway when it is in

the relaxed state. The risk for aspiration is increased when the relaxed state. The risk for aspiration is increased when the supine position is assumed by a semi-alert client. High the supine position is assumed by a semi-alert client. High Fowler position may cause the neck to flex in a client who is Fowler position may cause the neck to flex in a client who is not alert, interfering with respirations. Trendelenburg not alert, interfering with respirations. Trendelenburg position is not used for a postoperative client because it position is not used for a postoperative client because it interferes with breathing.interferes with breathing.

95. Because the plasma COP is the major force drawing fluid 95. Because the plasma COP is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop infrom the interstitial spaces back into the capillaries, a drop in COP caused by albuminuria results in COP caused by albuminuria results in edemaedema. Hydrostatic . Hydrostatic tissue pressure is unaffected by alteration of protein levels; tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.osmotic pressure of tissues is unchanged.

96. Restraint of a client, whether physical or chemical, is 96. Restraint of a client, whether physical or chemical, is considered a high-risk procedure requiring a valid health considered a high-risk procedure requiring a valid health care provider's prescription and intensive monitoring for care provider's prescription and intensive monitoring for safety and meeting the client's needs. A nurse who does not safety and meeting the client's needs. A nurse who does not follow correct procedures regarding restraints can legally be follow correct procedures regarding restraints can legally be charged with assault and battery. Laws regarding restraint charged with assault and battery. Laws regarding restraint orders may differ from state to state and in different orders may differ from state to state and in different settings. A felony is a severe offense or crime such as settings. A felony is a severe offense or crime such as murder, rape, or burglary and is commonly punished by murder, rape, or burglary and is commonly punished by imprisonment. Nurses have a professional obligation to imprisonment. Nurses have a professional obligation to report institutional misuse of restraints since this may report institutional misuse of restraints since this may constitute false imprisonment and abuse.constitute false imprisonment and abuse.

97.97. Paralytic ileus Paralytic ileus occurs when neurologic impulses are occurs when neurologic impulses are diminished as a result of anesthesia, infection, or surgery. diminished as a result of anesthesia, infection, or surgery. Interference in blood supply will result in necrosis of the Interference in blood supply will result in necrosis of the bowel. Perforation of the bowel will result in pain and bowel. Perforation of the bowel will result in pain and peritonitis. Obstruction of the bowel initially will cause peritonitis. Obstruction of the bowel initially will cause increased peristalsis and bowel sounds.increased peristalsis and bowel sounds.

98. Abduction means to move the limb away from the 98. Abduction means to move the limb away from the median plane, or axis, of the body. In care of the client with median plane, or axis, of the body. In care of the client with a fractured hip, the legs and hip must be aligned in an a fractured hip, the legs and hip must be aligned in an

abducted position to prevent internal rotation, reduce the abducted position to prevent internal rotation, reduce the risk of dislocation, and decrease pain. In a client with a risk of dislocation, and decrease pain. In a client with a fractured hip, adduction of the limb, traction, and elevation fractured hip, adduction of the limb, traction, and elevation are not appropriate procedures. Adduction means to move are not appropriate procedures. Adduction means to move the limbs toward the medial plane, or axis, of the body, and the limbs toward the medial plane, or axis, of the body, and traction involves the process of applying a pulling force in traction involves the process of applying a pulling force in opposite directions using weights.opposite directions using weights.

99. Immunization programs prevent the occurrence of 99. Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is aconsidered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.is a tertiary intervention.

100. Weakened muscles supporting the bladder in women 100. Weakened muscles supporting the bladder in women and enlargement of the prostate gland in men commonly and enlargement of the prostate gland in men commonly cause urinary urgency and frequency in older adults. Skin cause urinary urgency and frequency in older adults. Skin elasticity decreases in older adults because of a decline in elasticity decreases in older adults because of a decline in subcutaneous fat and collagen fibers, as well as thinning of subcutaneous fat and collagen fibers, as well as thinning of the epidermis. Swallowing difficulties result from a decrease the epidermis. Swallowing difficulties result from a decrease in salivary gland secretions. With aging, an increase in in salivary gland secretions. With aging, an increase in systolic blood pressure and a slight increase in diastolic systolic blood pressure and a slight increase in diastolic blood pressure occur. A decrease in subcutaneous fat resultsblood pressure occur. A decrease in subcutaneous fat results in a decreased body warmth.in a decreased body warmth.

101. Regional perfusion therapy permits relative isolation of 101. Regional perfusion therapy permits relative isolation of the tumor area and saturation with the drug(s) selected. Thisthe tumor area and saturation with the drug(s) selected. This method of drug administration requires medical and nursing method of drug administration requires medical and nursing supervision. Although toxic effects are confined mainly to supervision. Although toxic effects are confined mainly to the treated area, some migration may still occur. the treated area, some migration may still occur. Combinations of chemotherapeutic drugs are administered Combinations of chemotherapeutic drugs are administered via intravenous or oral routes, not via regional perfusion.via intravenous or oral routes, not via regional perfusion.

102.102. Albuterol'sAlbuterol's sympathomimetic effect causes central sympathomimetic effect causes central nervous stimulation, precipitating tremors, restlessness, and nervous stimulation, precipitating tremors, restlessness, and anxiety. Albuterol's sympathomimetic effect causes cardiac anxiety. Albuterol's sympathomimetic effect causes cardiac stimulation that may result in tachycardia and palpitations. stimulation that may result in tachycardia and palpitations.

Albuterol may cause restlessness, irritability, and tremors, Albuterol may cause restlessness, irritability, and tremors, not lethargy. Albuterol may cause dizziness, not visual not lethargy. Albuterol may cause dizziness, not visual disturbances. Albuterol will cause tachycardia, not disturbances. Albuterol will cause tachycardia, not bradycardia.bradycardia.

103. Certain diagnostic tests (e.g., CBC, urinalysis, chest x-103. Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by involved with surgery. Feelings will not be dispelled by telling the client not to worry; it also blocks further telling the client not to worry; it also blocks further communication. Surgery poses a risk despite test results. communication. Surgery poses a risk despite test results. Lack of knowledge without a statement of plans to obtain theLack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse.information suggests incompetence on the part of the nurse.

Study Tip: The old standbys of enough sleep and adequate Study Tip: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage.puts the brain at a disadvantage.

104. These are signs of digitalis toxicity, which is more likely 104. These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia. Although to occur in the presence of hypokalemia. Although furosemide mostfurosemide most  likely contributed to the hypokalemia, the likely contributed to the hypokalemia, the client's symptoms are consistent with digitalis toxicity. client's symptoms are consistent with digitalis toxicity. Although propranolol can cause nausea, vomiting, and Although propranolol can cause nausea, vomiting, and blurred vision, the presence of hypokalemia and yellow blurred vision, the presence of hypokalemia and yellow vision are more suggestive of digitalis toxicity. A side effect vision are more suggestive of digitalis toxicity. A side effect of spironolactone is hyperkalemia, not hypokalemia.of spironolactone is hyperkalemia, not hypokalemia.

105. Maintaining functional alignment of the head prevents 105. Maintaining functional alignment of the head prevents flexion and hyperextension of the neck, both of which place flexion and hyperextension of the neck, both of which place tension on the suture line; tension on the suture line can tension on the suture line; tension on the suture line can precipitate precipitate wound dehiscencewound dehiscence. The cervical vertebrae are . The cervical vertebrae are designed to flex and hyperextend; there should be no ill designed to flex and hyperextend; there should be no ill effects. Flexion and hyperextension of the neck do not causeeffects. Flexion and hyperextension of the neck do not cause laryngeal spasms. Flexion and hyperextension of the neck dolaryngeal spasms. Flexion and hyperextension of the neck do not cause laryngeal edema.not cause laryngeal edema.

106. Human tetanus antitoxin (tetanus immune globulin 106. Human tetanus antitoxin (tetanus immune globulin [TIG]) provides antibodies against tetanus; it is used for the [TIG]) provides antibodies against tetanus; it is used for the individual who may be infected and never has received individual who may be infected and never has received tetanus toxoid or has not received it for more than 10 years. tetanus toxoid or has not received it for more than 10 years. It confers passive immunity. Administration of the Td will It confers passive immunity. Administration of the Td will produce active, not passive, immunity. Although equine produce active, not passive, immunity. Although equine tetanus antitoxin provides passive immunity, the risk for a tetanus antitoxin provides passive immunity, the risk for a hypersensitivity reaction is high and therefore TIG is hypersensitivity reaction is high and therefore TIG is preferred. DTaP vaccine produces active, not passive, preferred. DTaP vaccine produces active, not passive, immunity; in addition, DTaP usually is not given to adults.immunity; in addition, DTaP usually is not given to adults.

107. Tetany is caused by hypocalcemia. Seizures caused by 107. Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias.weakness, and cardiac dysrhythmias.

108. Cooling blankets and antipyretic medications can 108. Cooling blankets and antipyretic medications can induce hypothermia thus decreasing brain metabolism. This induce hypothermia thus decreasing brain metabolism. This in turn makes the brain less vulnerable by decreasing the in turn makes the brain less vulnerable by decreasing the need for oxygen. The integrity of intracerebral neurons and need for oxygen. The integrity of intracerebral neurons and osmotic pressure equalization depend on an adequate osmotic pressure equalization depend on an adequate supply of oxygen, carbon dioxide, and glucose, and may supply of oxygen, carbon dioxide, and glucose, and may occur as a result of decreased cerebral metabolism and occur as a result of decreased cerebral metabolism and hypoxia. Diaphoresis does not cause hypoxia. Antipyretic hypoxia. Diaphoresis does not cause hypoxia. Antipyretic medications may cause diaphoresis as vasodilation occurs.medications may cause diaphoresis as vasodilation occurs.