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1. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 4. Weakness and decreased central venous pressure (CVP) Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough , dyspnea , crackles , tachypnea , tachycardia , elevated blood pressure , bounding pulse , elevated CVP , weight gain, edema , neck and hand vein distention , altered level of consciousness , and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit. 2. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client’s record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison’s disease 4. Uric acid level of 9.4 mg/dL (559 μmol/L) Rationale: The n ormal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison’s disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (0.16 to 0.43 mmol/L) and for a male is 4.0 to 8. mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia. 3. The nurse reviews a client’s electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2. mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. 3. An increase in blood pressure and increased respirations
1. U waves
- Absent P waves
- Widened QRS complex Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/ L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life- threatening. Electrocardiographic changes include shallow , flat or inverted T waves ; ST segment depression ; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia. 4. Potassium chloride intravenously is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.
- Prepare the medication for bolus administration. Rationale: Potassium chloride administered intravenously must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). Giving potassium chloride by IV push can result in cardiac arrest. The nurse should ensure that the potassium is diluted in the appropriate amount of diluent or fluid. The IV bag containing the potassium chloride should always be labeled with the volume of potassium it contains. The IV site is monitored closely because potassium chloride is irritating to the veins and there is risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors urinary output during administration and contacts the health care provider if the urinary output is less than 30 mL/hour. 5. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.
- Peas **3. Inverted T waves
- Depressed ST segment
- Obtain an intravenous (IV) infusion pump.
- Monitor urine output during administration.
- Monitor the IV site for signs of infiltration or phlebitis.
- Ensure that the medication is diluted in the appropriate volume of fluid.
- Ensure that the bag is labeled so that it reads the volume of potassium in the solution.
- Raisins
- Potatoes**
Rationale: The normal serum calcium level is 9 to 10. mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.
9. The nurse reviews the electrolyte results of an assigned client and notes that the potassium levelis 5. mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. 1. ST depression 2. Prominent U wave 4. Prolonged ST segment Rationale: The normal potassium level is 3.5 to 5.0 mEq/L (3. to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves , prolonged PR intervals , widened QRS complexes , and tall peaked T waves. ST depression and a prominent U wave occurs in hypokalemia. A prolonged ST segment occurs in hypocalcemia. 10. Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? 2. The client with hyperaldosteronism 3. The client with Cushing’s syndrome 4. The client who is taking corticosteroids Rationale: The normal serum sodium level is 135 to 145 mEq/ L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing’s syndrome are at risk for hypernatremia. 3. Tall peaked T waves 5. Widened QRS complexes 1. The client who is taking diuretics
11. The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output , and decreased specific gravity of the urine would be noted. 12. The nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus (phosphate) level is 1. mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide– based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia. 13. The nurse is reading a health care provider’s (HCP’s) progress notes in the client’s record and reads that the HCP has documented “insensible fluid loss of approximately 800 mL daily.” The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The gastrointestinal tract Rationale: Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination , wound drainage, and gastrointestinal tract losses.
heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.
17. Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? 1. The client with colitis 2. The client with Cushing’s syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn Rationale: T he normal potassium level is 3.5 to 5.0 mEq/L (3. to 5.0 mmol/L). A serum potassium level higher than 5. mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing’s syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.
IMMUNE DISORDERS
Rationale: An anaphylactic reaction requires immediate action, starting with quickly assessing the client’s respiratory status. Although the HCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV of normal saline is started and infused per HCP prescription. D ocumentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client’s blood pressure is normal.
4. The nurse is conducting a teaching session with a client on their diagnosis of pemphigus. Which statement by the client indicates that the client understands the diagnosis? 1. “My skin will have tiny red vesicles.” 2. “The presence of the skin vesicles is caused by a virus.” 4. “The presence of red, raised papules and large plaques covered by silvery scales will be present on my skin.” Rationale: Pemphigus is an autoimmune disease that causes blistering in the epidermis. The client has large flaccid blisters (bullae). Because the blisters are in the epidermis, they have a thin covering of skin and break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. Option 1 describes eczema, option 2 describes herpes zoster, and option 4 describes psoriasis. 5. The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? 1. Protecting the client from infection 2. Providing emotional support to decrease fear 3. Encouraging discussion about lifestyle changes 4. Identifying factors that decreased the immune function Rationale: The client with immunodeficiency has inadequate or absence of immune bodies and is at risk for infection. The priority nursing intervention would be to protect the client from infection. Options 2, 3, and 4 may be components of care but are not the priority 6. A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client’s neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? 1. Advise the client to soak the site in hydrogen peroxide. 3. “I have an autoimmune disease that causes blistering in the epidermis.”
- Tell the client to call an ambulance for transport to the emergency department.
- Tell the client not to worry about the sting unless difficulty with breathing occurs. Rationale: In some types of allergies, a reaction occurs only on second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he 9. A client presents at the health care provider’s office with complaints of a ring-like rash on his upper leg. Which question should the nurse ask first?
- “Do you have any cats in your home?” 2. “Have you been camping in the last month?”
- “Have you or close contacts had any flu-like
- symptoms within the last few weeks?”
- “Have you been in physical contact with anyone who has the same type of rash?” ever experienced a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told “not to worry.” 7. The community health nurse is conducting a research study and is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1. Hairdressers
- The homeless
- Children in day care centers
- Individuals living in a group home Rationale: Individuals most at risk for developing a latex allergy include health care workers; individuals who work in the rubber industry ; or those who have had multiple surgeries , have spina bifida , wear gloves frequently (such as food handlers, hairdressers, and auto mechanics), or are a llergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts. 8. Which interventions apply in the care of a client at high risk for an allergic response to a latex allergy? Select all that apply.
- Place the client in a private room only.
- Use a blood pressure cuff from an electronic device only to measure the blood pressure. Rationale: If a client is allergic to latex and is at high risk for an allergic response, the nurse would use non latex gloves and latex safe supplies , and would keep a latex-safe supply cart available in the client’s area. Any supplies or materials that contain latex would be avoided. These include blood pressure cuffs and medication vials with rubber stoppers that require puncture with a needle. It is **not necessary to place the client in a private room.
- Ask the client if he ever sustained a bee sting in the past.
- Use nonlatex gloves.
- Use medications from glass ampules.
- Keep a latex-safe supply cart available in the client’s area.
- Avoid the use of medication vials that have rubber stoppers.**
- Tell the client that if this happens again, to never remove the tick but vigorously scrub the area with an antiseptic. Rationale: A blood test is available to detect Lyme disease; however, the test is not reliable if performed before 4 to 6 weeks following the tick bite. Antibody formation takes place in the following manner. Immunoglobulin M is detected 3 to 4 weeks after Lyme disease onset, peaks at 6 to 8 weeks , and then gradually disappears ; immunoglobulin G is detected 2 to 3 months after infection and may remain elevated for years. Areas that ticks inhabit need to be avoided. Ticks should be removed with tweezers and then the area is washed with an antiseptic. Options 1 and 5 are incorrect. 12. The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?
- “I need to bring a hat to wear during the trip.”
- “I should wear long-sleeved tops and longpants.”
- “I need to wear closed shoes and socks that can be pulled up over my pants.” Rationale: In the prevention of Lyme disease, individuals need to be instructed to use an insect repellent on the skin and clothes when in an area where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over the pant legs to prevent ticks from entering under clothing. 13. The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi’s sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding?
- Swelling in the genital area
- Swelling in the lower extremities 3. Positive punch biopsy of the cutaneous lesions
- Appearance of reddish-blue lesions noted on the skin Rationale: Kaposi’s sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. The lesions spread by metastasis through the upper body and then to the face and oral mucosa. They can move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and **biopsy of pulmonary and gastrointestinal lesions.
- “I should not use insect repellents because it will attract the ticks.”**
14. The nurse is conducting allergy skin testing on a client. Which post procedure interventions are most appropriate? Select all that apply. 3. Estimate the size of the wheal and document the finding. 4. Tell the client to return to have the site inspected only if there is a reaction. 5. Have the client wait in the waiting room for at least 1 to 2 hours after injection. Rationale: Skin testing involves administration of an allergen to the surface of the skin or into the dermis. Site, date, and time of the test must be recorded, and the client must return at a specific date and time for a follow-up site evaluation, even if no reaction is suspected; a list of potential allergens is identified. For the follow-up evaluation, the size of the site has to be measured and not estimated. After injection, clients only need to be monitored for about 30 minutes to assess for any adverse effects. 15. The nurse is performing an assessment on a client ho has been diagnosed with an allergy to latex. In determining the client’s risk factors, the nurse should question the client about an allergy to which food item? 1. Eggs 2. Milk 3. Yogurt 4. Bananas Rationale: Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts are at risk for developing a latex allergy. This is thought to be the result of a possible cross reaction between the food and the latex allergen. Options 1 , 2 , and 3 are unrelated to latex allergy. IMMUNOLOGICAL MEDICATIONS 1. The client with acquired immunodeficiency syndrome and Pneumocystis jiroveci infection has been receiving pentamidine. The client develops a temperature of 101 °F (38.3 °C). The nurse continues to assess the client, 1. Record site, date, and time of the test. 2. Give the client a list of potential allergens if identified.
of which adverse effects of the medication? Select all that apply.
- Ototoxicity
- Palpitations
- Increased white blood cell (WBC) count Rationale: Adverse effects of sulfonamides include nephrotoxicity, bone marrow suppression, GI effects, hepatotoxicity, dermatological effects, and some neurological symptoms , including headache, dizziness, vertigo, ataxia, depression, and seizures. Options 1, 2, and 6 are unrelated to these medications. 5. The nurse is reviewing the results of serum laboratory studies drawn on a client with acquired immunodeficiency syndrome who is receiving didanosine. The nurse interprets that the client may have the medication discontinued by the health care provider if which elevated result is noted?
- Serum protein level
- Blood glucose level 3. Serum amylase level
- Serum creatinine level Rationale: Didanosine can cause pancreatitis. A serum amylase level that is increased to 1.5 to 2 times normal may signify pancreatitis in the client with acquired immunodeficiency syndrome and is potentially fatal. The medication may have to be discontinued. The medication is also hepatotoxic and can result in liver failure. 6. The nurse is caring for a postrenal transplantation client taking cyclosporine. The nurse notes an increase in one of the client’s vital signs and the client is complaining of a headache. What vital sign is most likely increased?
- Pulse
- Respirations 3. Blood pressure
- Pulse oximetry Rationale : Hypertension can occur in a client taking cyclosporine , and because this client is also complaining of a headache , the blood pressure is the vital sign to be monitored most closely. Other adverse effects include infection, nephrotoxicity, and hirsutism. Options 1, 2, and 4 are unrelated to the use of this medication. 7. Amikacin is prescribed fora client with abacterial infection. The nurse instructs the client to contact the health care provider (HCP) immediately if which occurs?
- Nausea **3. Nephrotoxicity
- Bone marrow suppression
- Gastrointestinal (GI) effects**
- Lethargy 3. Hearing loss
- Muscle aches Rationale: Amikacin is an aminoglycoside. Adverse effects of aminoglycosides include ototoxicity (hearing problems), confusion, disorientation, gastrointestinal irritation, palpitations, blood pressure changes, nephrotoxicity, and hypersensitivity. The nurse instructs the client to report hearing loss to the HCP immediately. Lethargy and muscle aches are not associated with the use of this medication. It is not necessary to contact the HCP immediately if nausea occurs. If nausea persists or results in vomiting, the HCP should be notified. 8. The nurse is assigned to care for a client with cytomegalovirus retinitis and acquired immunodeficiency syndrome who is receiving foscarnet, an antiviral medication. The nurse should monitor the results of which laboratory study while the client is taking this medication?
- CD4+ T cell count
- Lymphocyte count
- Serum albumin level 4. Serum creatinine level Rationale: Foscarnet is toxic to the kidneys. The serum creatinine level is monitored before therapy , two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency. 9. A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse should monitor which most closely while the client is taking this medication? 1. Gait
- Appetite
- Level of consciousness
- Gastrointestinal function Rationale: Stavudine is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy , and the nurse should monitor the client’s gait closely and ask the client about paresthesia. Options 2, 3, and 4 are unrelated to this medication.
