A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?
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Solution
Answer B is correct. The client with serum sodium of 170meq/L has hypernatremia and might exhibit manic behavior. Answers A, C, and D are not associated with hypernatremia and are, therefore, incorrect.
When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?
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Solution
Answer A is correct. Previous radiation to the neck might have damaged the parathyroid glands, which are located on the thyroid gland, and interfered with calcium and phosphorus regulation. Answer B has no significance to this case; answers C and D are more related to calcium only, not to phosphorus regulation.
The nurse on the 3–11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
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Solution
Answer A is correct. It is the responsibility of the physician to explain and clarify the procedure to the client. Answers B, C, and D are incorrect because they are not within the nurse’s purview.
The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?
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Solution
Answer B is correct. It is most important to remove the contact lenses because leaving them in can lead to corneal drying, particularly with contact lenses that are not extended-wear lenses. Leaving in the hearing aid or artificial eye will not harm the client. Leaving the wedding ring on is also allowed; usually, the ring is covered with tape. Therefore, answers A, C, and D are incorrect.
A client is 2 days post-operative colon resection. After a coughing episode, the client’s wound eviscerates. Which nursing action is most appropriate?
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Solution
Answer C is correct. If the client eviscerates, the abdominal content should be covered with a sterile saline-soaked dressing. Reinserting the content should not be the action and will require that the client return to surgery; thus, answer A is incorrect. Answers B and D are incorrect because they are not appropriate to this case.
The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:
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Solution
Answer B is correct. Cancer in situ means that the cancer is still localized to the primary site. Cancer is graded in terms of tumor, grade, node involvement, and mestatasis. Answer A is incorrect because it is an untrue statement. Answer C is incorrect because T indicates tumor, not node involvement. Answer D is incorrect because a tumor that is in situ is not metastasized.
A client with cancer is to undergo an intravenous pyelogram. The nurse should:
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Solution
Answer B is correct. The client having an intravenous pyelogram will have orders for laxatives or enemas, so asking the client to void before the test is in order. A full bladder or bowel can obscure the visualization of the kidney ureters and urethra. In answers A, C, and D, there is no need to force fluids before the procedure, to withhold medications, or to cover the reproductive organs.
A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:
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Solution
Answer C is correct. The client with a fractured femur will be placed in Buck’s traction to realign the leg and to decrease spasms and pain. The Trendelenburg position is the wrong position for this client, so answer A is incorrect. Ice might be ordered after repair, but not for the entire extremity, so answer B is incorrect. An abduction pillow is ordered after a total hip replacement, not for a fractured femur; therefore, answer D is incorrect.
The nurse is performing an assessment on a client with possible pernicious anemia. Which data would support this diagnosis?
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Solution
Answer C is correct. A red, beefy tongue is characteristic of the client with pernicious anemia. Answer A, a weight loss of 10 pounds in 2 weeks, is abnormal but is not seen in pernicious anemia. Numbness and tingling, in answer B, can be associated with anemia but are not particular to pernicious anemia. This is more likely associated with peripheral vascular diseases involving vasculature. In answer D, the hemoglobin is low normal.
A client with suspected renal disease is to undergo a renal biopsy. The nurse plans to include which statement in the teaching session?
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Solution
Answer B is correct. Portions of the exam are painful, especially when the sample is being withdrawn, so this should be included in the session with the client. Answer A is incorrect because the client will be positioned prone, not in a sitting position, for the exam. Anesthesia is not commonly given before this test, making answer C incorrect. Answer D is incorrect because the client can eat and drink following the test.