HESI EXIT COMPREHENSIVE REVIEW A (100 Q & A) (New, 2020) (100% Correct)(SATISFACTION GUARANTEED, Check REVIEWS of my 1000 Plus Clients) - €16,68   In winkelwagen

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HESI EXIT COMPREHENSIVE REVIEW A (100 Q & A) (New, 2020) (100% Correct)(SATISFACTION GUARANTEED, Check REVIEWS of my 1000 Plus Clients)

HESI EXIT COMPREHENSIVE REVIEW A 1. The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours Rationale: Nifedipine is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose. 2. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A. An adolescent who was readmitted to the hospital because of a postoperative infection B. A woman with a new colostomy who requires discharge teaching C. A woman who had a hip replacement and may be transferred to the home care unit D. A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction Rationale: A hip replacement is considered a clean case, and transferring the client to another unit is likely to involve physically moving the client and her belongings. The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs. The adolescent client is infected, and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit. This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support. This may require skills beyond the level of this UAP. 3. A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A. Encourage staff to participate in online in-service education. B. Assign staff to make sure that all equipment is thoroughly cleaned. C. Ask which staff members would like to go home for the remainder of the day. D. Notify the supervisor that the staff needs additional assignments. Rationale: Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census. Option B is not the responsibility of the nursing staff. Option C is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary. 4. When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A. Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B. Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C. Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D. Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear. Rationale: Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients. Option A is too authoritarian and does not permit education to play a role in reducing fears. Option C is likely to be intrusive to the family member. Arbitrary staffing without education does not reduce staff fears, even with the provision of peer counseling. 5. The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A. Parents of children with spina bifida B. High school girls in a health class C. Class of people interested in having children D. Postpartum women attending a baby care class Rationale: Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is option C. Parents with children who already have a neural tube defect such as spina bifida are not as invested in the content as option C. High school age students may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than option C. Option D may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period. 6. Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A. Team 1: RN team leader, PN; team 2: PN team leader, UAP B. Team 1: RN team leader, UAP; team 2: PN team leader, PN C. Team 1: PN team leader, PN; team 2: RN team leader, UAP D. Team 1: PN team leader, UAP; team 2: RN team leader, PN Rationale: Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN. Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. Options B, C, and D do not use the expertise of the nursing staff for the high-risk clients. 7. A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take? A. Encourage foods high in vitamin B6 such as meat or liver. B. Teach client to change positions slowly. C. Instruct client to take at the same time as prescribed beta blocker. D. Notify client that development of a rash is a common side effect. Rationale: Amantadine can cause postural hypotension, so sudden position changes should be avoided. Options A and C are contraindicated with this drug, and option D is a sign of a possible allergic reaction, not a common side effect. 8. A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A. The client's usual sleeping pattern B. Whether the client smokes C. How much liquid the client consumes before bedtime D. The amount of caffeine that the client consumes during the day Rationale: The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia. Options B, C, and D provide additional information after option A is ascertained. 9. A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A. The respiratory settings on the ventilator B. Only the client's spontaneous respirations C. The ventilator-assisted respirations minus the client's independent breaths D. The ventilator setting for respiratory rate and the client-initiated respirations Rationale: The nurse should count the client's respirations and document both the respiratory rate set by the ventilator and the client's independent respiratory rate. Never rely strictly on option A. Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client. 10. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes. Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis. 11. A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A. As women age, they often become rounder in the middle because they do not exercise properly. B. Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C. With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D. Because there is no evidence of a diseased colon, there is no need to worry about abdominal size. Rationale: With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation. Option A is not the primary reason for the changes in body structure. Option B is not indicated because loss of muscle tone and constipation are age-related changes. Option D dismisses the client's concerns and does not help her understand the changes that she is experiencing. 12. A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A. "Is your son's short stature a social embarrassment to him or the family?" B. "What types of foods do both your children eat now and what did they eat when they were infants?" C. "Did any significant trauma occur with the birth of your son?" D. "Did your daughter also start her menstrual period at 12 years of age?" Rationale: Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins. Option A is not appropriate at this time. The mother is worried that something is wrong with her son physically. Option B has less to do with stature than growth and development. Option C is not related to growth hormone deficiencies, which are idiopathic (without known causes). 13. Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa? A. "Has your child been swimming recently?" B. "Has you child had a recent sore thorat?" C. "Does your child drink from a sippy cup?" D. "Is anyone else in the home ill?" Rationale: Otits externa is an external ear infection and often due to swimming and the retention of fluid in the ear. Options B and C are not relative to otitis. Otitis externa is not contagious, so option D is not relevant. 14. Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A. Assess the client's ability to swallow liquids. B. Obtain applesauce in which to mix the medication. C. Determine the client's food likes and dislikes. D. Auscultate the client's breath sounds. Rationale: An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used. If a food product is used to thicken the liquid, option C would be beneficial. Option D may also be warranted, but only if the client is at risk for aspiration, determined by option A. 15. On conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A. "Have you ever been told that you have hardening of the arteries?" B. "Do you frequently experience eye pain?" C. "Do you have high blood pressure or kidney problems?" D. "Does anyone in your family have glaucoma?" Rationale: Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member. Options A and C are not related to glaucoma. Glaucoma rarely causes pain, which is why screening is so important. 16. Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A. The color of the dialysate outflow is opaque yellow. B. The dialysate outflow is greater than the inflow. C. The inflow dialysate feels warm to the touch. D. The inflow dialysate contains potassium chloride. Rationale: Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia. 17. Which client is best to assign to a graduate PN who is being oriented to a renal unit? A. A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B. A client who is receiving continuous ambulatory peritoneal dialysis C. A client with continuous bladder irrigation for hematuria D. A client with renal calculi whose urine needs to be strained Rationale: The client with renal calculi (kidney stones) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. Options A, B, and C require careful assessment from an experienced nurse because of the potential for significant complications. 18. A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A. Perform a digital evaluation for fecal impaction. B. Administer a PRN dose of psyllium. C. Obtain a stool specimen for culture and sensitivity. D. Instruct the UAP to obtain incontinent pads for the client. Rationale: Long-term use of levofloxacin can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen. Impaction is unlikely, so option A is of less priority and may not be necessary. Option B is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort are important interventions but of less priority than determining the cause of the client's diarrhea. 19. When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A. Encourage the client to turn from side to side every 2 hours. B. Elevate the foot of the client's bed at least 6 inches. C. Encourage the client to ambulate every 3 hours. D. Teach the client how to perform leg exercises while in bed. Rationale: Ambulation is the best way to increase peripheral vascular activity. Options A, B, and D will increase peripheral vascular activity but are not as effective as ambulation. 20. A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity. Rationale: The nurse should instruct the client to save the next urine sample for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated. Option C is only necessary if a calculus (stone) is suspected. Option D is not indicated by this client's symptoms. 21. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A. "It sounds like you're feeling very sad." B. "Tell me more about how you're feeling." C. "How often do you have crying spells?" D. "Do you want to talk about these feelings?" Rationale: It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings. Option A is a leading response, and the client may not be feeling sad. Options C and D are closed-ended questions that do not facilitate communication. 22. The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A. Obtain the remainder of the preoperative admission information. B. Check the vomiting client for signs of tube feeding aspiration. C. Position the client who has vomited on his side and obtain vital signs. D. Teach the preoperative client coughing and deep breathing exercises. Rationale: The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs. Options A and B involve assessment, which should be performed by a nurse. Option D involves initial client teaching, which should be performed by the nurse. 23. The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A. Tachypnea B. Guaiac-positive stool C. Multiple small abdominal bruises D. Dependent pitting edema Rationale: Dalteparin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding such as guaiac-positive stool while receiving an anticoagulant, the medication should be held and coagulation studies completed. Option A is not an indication to hold the medication unless accompanied by signs of bleeding. Option C is an expected result. Option D is related to fluid volume, rather than anticoagulant therapy. 24. Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A. Inspection of the skin B. Breath sound auscultation C. Pain scale measurement D. Mobility limitations Rationale: Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority. Options A, B, and D are part of the complete assessment but do not have the priority of option C for this client. 25. The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received. Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel. 26. A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A. Administer oxygen per nasal cannula at 2 L/min. B. Plan to check his vital signs again in 30 minutes. C. Notify the health care provider of the change in mental status. D. Ask the client why he thinks there are bugs in the bed. Rationale: One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status. It is important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation is normal, the administration of oxygen is not the top priority. Vital signs should be monitored frequently, but the client's confusion should be reported immediately. Option D is not a useful intervention. 27. A five year old is in Bryant's traction for intervention for a fractured femur. Which finding by the nurse would require intervention? A. The parents are at the bedside reading a book with the child. B. The child's hips are in 90-degree flexion. C. The child's hips are gently resting on the bed. D. The child is consuming 120 mL of grape juice. Rationale: The In Bryant's traction, the buttocks should be elevated off the bed not resting on the mattress. Drinking grape juice with a volume of 120 mL is acceptable and the family should be incorporated into the child's plan of care. 28. The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A. A client with an admitting diagnosis of menorrhagia who is now 24 hours' post–vaginal hysterectomy B. A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C. A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D. A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet Rationale: Option C requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one-on-one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic, and careful assessment is essential. Options A, B, and D could all be cared for by a PN under the supervision of the RN. 29. Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A. A stage III sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B. Pneumonia, with a sputum culture of gram-negative bacteria C. Urinary tract infection, with positive blood cultures D. Culture of a diabetic foot ulcer shows gram-positive cocci Rationale: The client with colonized MRSA is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy, which makes recovery very difficult. Positive blood cultures indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer at high risk for poor healing and bone infection. 30. The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A. 42 B. 83 C. 125 D. 250 Rationale: Use the following calculation: 1000 mL of LR with oxytocin 30 mg/4 hours = 250 ml/hr x 20 gtt/60 = 83.3 or 83 ml/hr 31. A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? . A. Pain scale B. Vital signs C. Breath sounds D. Level of consciousness Rationale: Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds. Options A, B, and D are important assessment data but are not specifically related to insertion of a central venous catheter 32. When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A. Keep the residual limb elevated during positioning. B. Instruct the client to grasp the overhead trapeze bar. C. Maintain alignment with an abduction pillow. D. Use pillow support to prevent turning to a prone position. Rationale: The client will gain upper body strength and independence by using the overhead trapeze bar for positioning. Elevation of the residual limb is controversial because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. Option C is used for alignment following some hip surgeries. A prone position should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip. 33. The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A. Serum digoxin level is 1.5 ng/mL B. Blood pressure is 104/68 mm Hg C. Serum potassium level is 2.5 mEq/L D. Apical pulse is 68/min Rationale: Hypokalemia can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥ 2 ng/mL); Option A is within this range. Option B would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is < 60/min. 34. Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.) A. Record wet diapers. B. Assess for sunken fontanels C. Examine skin turgor. D. Observe mucous membranes. E. Record dietary intake Rationale: All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, D, E), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age. 35. The nurse should encourage a laboring client to begin pushing at which point? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable Rationale: Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson reflex). 36. The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A. Hearing acuity B. Immunization history C. Weight and length D. Head circumference Rationale: The Centers for Disease Control and Prevention indicates that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of options A, C, and D provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity. 37. A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A. Check the client's blood pressure. B. Teach her to elevate her feet when sitting. C. Obtain a 24-hour diet history to evaluate for the intake of salty foods. D. Assess the fetal heart rate. Rationale: The blood pressure should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and who have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. Options B, C, and D can be done if the blood pressure is normal. 38. Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department. Rationale: Past medical records must be "secured" and "reasonably protected" from inadvertent viewing. A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without his or her diagnosis or treatment) is not considered confidential or PHI. Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous, but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions. 39. The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A. Increased oxygen saturation B. Increased urinary output C. Decreased apical pulse rate D. Decreased blood pressure Rationale: Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation. Options B, C, and D do not indicate the desired effect of a bronchodilator. 40. A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A. The client is noncompliant with his medications. B. The client recently consumed large quantities of pears or nuts. C. The client's renal function has affected his potassium level. D. The client needs to be started on a potassium supplement. Rationale: The client has a normalized potassium level despite diuretic use. The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment. Pears and nuts do not affect the serum potassium level. There is no need for a potassium supplement because the client's potassium level is within the normal range. 41. The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A. Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B. Apply ice packs to edematous or tender joints to reduce pain and swelling. C. Warm the child with an electric blanket prior to getting the child out of bed. D. Immobilize swollen joints during acute exacerbations until function returns. Rationale: Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. Option A on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness. Option D is contraindicated, because joints should be exercised, not immobilized. 42. A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A. Participating in telephone consultations with clients B. Identifying oneself by name and title to clients in telehealth communications C. Sending medical records to health care providers via the Internet D. Answering a client-initiated health question via electronic mail Rationale: Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred. Client confidentiality is protected by federal wiretapping laws making telephone consultation a private and protected form of communication. By stating one's name and credentials in telehealth communication, one is taking responsibility for the encounter. E-mail initiated by the client poses less risk than sending records via the Internet. 43. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A. Shave the area where the TENS will be placed. B. Obtain small needles for insertion. C. Place the TENS unit directly over or near the site of pain. D. Explain to the client that drowsiness may occur immediately after using TENS. E. Describe the use of TENS for postoperative procedures such as dressing changes. Rationale: The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D). 44. The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) . A. 15 B. 31 C. 64 D. 50 Rationale: 1000 ml D5W / 8 hours = 125 ml/hr x 15 gtt/60 = 31.2 gtt/min. or 31 gtt/min 45. The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A. Assign the PNs to perform am care and assist with feeding the clients. B. Assign the UAPs to take vital signs and obtain daily weights. C. Assign the RNs to answer the call lights and administer all medications. D. Assign the PNs to assist health care providers on rounds and perform glucometer checks. Rationale: A UAP can take vital signs and daily weights on stable clients. UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN. All team members can answer call lights, and PNs can administer some of the medications, so assigning the. RN these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds, and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel. 46.The antigout medication allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A. "I take aspirin for my pain." B. "I frequently eat fruit and drink fruit juices." C. "I drink a great deal of water, so I have to get up at night to urinate." D. "I observe my skin daily to see if I have an allergic rash to the medication." Rationale: The client should be taught to avoid aspirin because the ingestion of aspirin or diuretics can precipitate an attack of gout. Options B, C, and D are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation. Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate. Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs. 47.The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy Rationale: Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse. 48.After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A. Ensure that the client receives breakfast within 30 minutes. B. Remind the client to have a midmorning snack at 1000. C. Discuss the importance of a midafternoon snack with the client. D. Explain that the client's capillary glucose will be checked at 1130. Rationale: Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction. Options B, C, and D are also important nursing actions but are of less immediacy than option A. 49.Which assessment finding indicates that nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake. Rationale: Nystatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication. 50Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A. Direct the client to sign a liability release form. B. Restrict the client’s ability to leave the unit. C. Explain the benefits of remaining in the hospital. D. Instruct the client to take medications as prescribed. E. Provide the client with names of local support groups. F. Notify the health care provider of the client’s intention. Rationale: To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client’s treatment program. 51.The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A. Remove the client's nail polish and dentures. B. Assist the client to the restroom to void. C. Obtain the client's height and weight. D. Offer the client emotional support. Rationale: By using therapeutic techniques to offer support, the nurse can determine any client concerns that need to be addressed. Options A, B, and C are all actions that can be performed by the UAP under the supervision of the nurse. 52. The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years." Rationale: Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark-skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area. 53. When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A. Speak privately with the nurse. B. Hold a staff meeting to discuss this issue. C. Review the nurse's current salary. D. Nominate the nurse for employee of the month. Rationale: The nurse-manager should speak privately with the nurse to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. Option B might become confrontational. Option C is irrelevant. Option D is not warranted. 54. A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? . A. This feeling occurs during feeding with a breast infection. B. This sensation occurs as breast milk moves to the nipple. C. The baby does not have good latch-on. D. The infant is not positioned correctly. Rationale: When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples when let-down occurs. Options A, C, and D provide inaccurate information 55. The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction? A. "I should balance my daily exercise with my dietary intake and insulin dosages." B. "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C. "I should inject my insulin into a different site to reduce the development of scar tissue." D. "I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials." Rationale: Aspiration is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. Option C helps minimize tissue atrophy, which can affect the absorption of the insulin. Options A and D are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure tight serum glucose level control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin. 56. The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A. Advise the client that food from the meal tray should not be shared with others. B. Leave the room and discuss the incident privately with the staff member. C. Objectively document the situation as observed on a variance report. D. Call the nurse-manager to the client's room immediately. Rationale: Discussing the incident privately promotes open communication between the charge nurse and staff member. The client is free to share unwanted food with family or friends, but the employee should not ask for the client's food. Option C is not necessary, and the charge nurse can respond to this situation without implementing option D. 57. A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A. Advocate for the rights of the staff to watch television once their assignments are complete. B. Confront the administrator about making a decision that will negatively affect the residents. C. Offer to develop an alternate solution so that the residents can continue to watch television. D. Remind the administrator that watching television helps the night shift staff remain awake. Rationale: The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise. The staff do not have the right to watch television while being paid to work. Option B challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. Option D is not a sound rationale for the use of the television. 58. The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A. Ask the UAP to check for the advanced directive while the nurse completes the assessment. B. Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C. Check the medical record for the advanced directive and then complete the client assessment. D. Call for the charge nurse to check the advanced directive while continuing to assess the client. Rationale: Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated. 59. The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A. 50 mg/dL B. 80 mg/dL C. 110 mg/dL D. 140 mg/dL Rationale: The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL, requires the most immediate intervention to prevent loss of consciousness. Normal (such as 80 mg/dL) and slightly elevated levels, such as 110 or 140 mg/dL, do not require immediate intervention. 60. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A. Allow the client to discuss the seriousness of the illness. B. Ensure that the client is provided with information about medications. C. Encourage as much independence in decision making as possible. D. Include the client in planning the course of treatment. Rationale: Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible helps reduce stress experienced with repeated hospitalization. Options A, B, and D are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand and participate in the hospitalized plan of care. 61. A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A. Reduced peripheral edema B. Urinary output of at least 70 mL/hr C. Decrease in urine osmolarity D. Serum sodium level of 137 mEq/L Rationale: Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema, but the higher priority outcome is the effect on serum electrolyte levels. Although options B and C are findings associated with resolving SIADH, they do not have the priority of option D. 62. A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A. "I will avoid coughing, sneezing, and forceful nose blowing." B. "Swimming can begin on the tenth postoperative day." C. "Any mild discomfort can be managed with acetaminophen." D. "Drainage from my ears is expected after the surgery." Rationale: The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims or allows water to enter the external ear. Options A, C, and D reflect correct responses. 63. A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited. Rationale: HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Nystatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated. 64.The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A. Inspect the dressing over the puncture site and under the client for bleeding. B. Take the vital signs to determine the client's response for a potential blood loss. C. Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D. Assess the client's pain level to determine the need for analgesic medication. Rationale: After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure. Although options A, C, and D should be implemented after the procedure, the first action is to obtain a baseline assessment. 65. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care–associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished. Rationale: A priority goal for the client with infectious diarrhea caused by C. difficile is infection control precautions and the prevention of health care–associated infection (HAI) transmission. Options A and C are goals dependent on the return of the client's normal bowel pattern. 66.A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A. Failure to collect all urine specimens during the period of the study will invalidate the test. B. Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C. Dialysis is started when the GFR is lower than 5 mL/min. D. Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours. Rationale: Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results will be inaccurate. As renal function decreases, the creatinine level will decrease in the urine. Dialysis is usually started when the GFR is 12 mL/min. There is no need to record the frequency and amount of each voiding during the time span of urine collection. 67. A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A. Flex the hips and knees and align the knees with the client's knees for safety. B. Allow the client to sit on the side of the bed for a few minutes before transferring. C. Place the client's weight-bearing or strong leg forward and the weak foot back. D. Grasp the transfer belt at the client's sides to provide movement of the client. Rationale: A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt provides a secure hold to prevent sudden falls. 68. The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A. Perform range-of-motion exercises on the lower extremities every 4 hours. B. Place a small firm pillow under the upper back to flex the lumbar spine gently. C. Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D. Position in reverse Trendelenburg with the feet firmly against the foot of the bed. Rationale: Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles. Range-of-motion exercises can result in paravertebral muscle spasms and increased pain. Bending the knees, rather than option B, reduces stress on the lower back. Option D places stress on the lower back and increases the client's pain. 69. A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical-surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines. Rationale: The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical. 70. A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today. Rationale: The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test. 71. A client with hepatic failure tells the nurse about recent use of acetaminophen. How should the nurse respond to this client's statement? A. Bleeding precautions should be implemented. B. Tylenol is indicated for minor aches and pains. C. Acetaminophen reduces inflammation. D. The drug is hepatotoxic and contraindicated. Rationale: Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated. Although bleeding is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although option B is an indicated use for this drug, it remains contraindicated in clients with hepatic failure. Option C is inaccurate. 72. Which physiologic finding in an older adult contributes to an adverse drug reaction? A. Reduced renal excretion B. Reduced gastrointestinal motility C. Increased hepatic metabolism D. Increased risk of autoimmune disorders Rationale: During the aging process, reduced renal function is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not option C, predisposes an older adult to an increase in adverse drug reactions. Option B may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders is not increased, nor does it affect drug pharmacotherapeutics. 73. Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A. Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B. Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C. Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D. Opioids suppress respirations, which increases PCO2and contributes to an elevated ICP. Rationale: The greatest risk associated with opioids such as morphine is respiratory depression that causes an increase in PCO2, which increases ICP and masks the early signs of intracranial bleeding in head injury. Options A, B, and C do not support the risks associated with opioid use in a client with increased ICP. 74. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler position without a pillow behind the head B. Semi-Fowler position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table Rationale: Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic

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