Detailed Question and Answer Key GI/Neuro Med Surg. With Rationale.

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The pharmacy is delayed in supplying the client’s next container of TPN. Which of the following fluids should the nurse infuse until the next container arrives? A. Dextrose 5% in water Rationale: TPN contains high concentrations of certain nutrients. Infusing dextrose 5% in water could cause rapid shifts in serum levels of some substances. B. 0.9% sodium chloride Rationale: TPN contains high concentrations of certain nutrients. Infusing 0.9% sodium chloride could cause rapid shifts in serum levels of some substances. C. Dextrose 10% in water Rationale: TPN contains high concentrations of dextrose and proteins. To avoid hypoglycemia, the nurse should infuse dextrose 10% or 20% in water until the next container of TPN solution arrives. D. Lactated Ringer’s solution Rationale: TPN contains high concentrations of certain nutrients. Infusing lactated Ringer’s solution could cause rapid shifts in serum levels of some substances. 2. A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements by the nurse is appropriate? A. “You should decrease your caloric intake when abdominal pain is present.” Rationale: Clients who have chronic pancreatitis are at risk for malnutrition and should increase their caloric intake in order to maintain weight. B. “You should increase your daily intake of protein.” Rationale: Clients who have chronic pancreatitis should consume a diet that is high in protein. C. “You should increase fat intake when experiencing loose stools.” Rationale: Clients who have chronic pancreatitis should consume a low-fat diet to prevent stimulation of the pancreas and steatorrhea. D. “You should limit alcohol intake to 2-3 drinks per week.” Rationale: Clients who have chronic pancreatitis should avoid alcohol intake to prevent stimulation of the pancreas. 3. A nurse monitors for increased intracranial pressure (ICP) on a client who has a leaking cerebral aneurysm. If the client manifests increased intracranial pressure, which of the following findings should the nurse expect? (Select all that apply) A. Violent headache B. Neck pain and stiffness C. Slurred speech D. Projectile vomiting E. Rapid loss of consciousness Rationale: Violent headache is correct. The client who manifests ICP should display a violent headache Neck pain and stiffness is incorrect. The client who manifests ICP should not display neck pain and stiffness Slurred speech is correct. The client who manifests ICP may display slurred speech. Projectile vomiting is correct. The client who manifests ICP may display sudden onset of projectile vomiting. Rapid loss of consciousness is correct. The client who manifests ICP may display a sudden rapid loss of consciousness. 4. A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache Rationale: The nurse should find as a sign of meningococcal meningitis severe headache due to meningeal inflammation. B. Bradycardia Rationale: The nurse should find as a sign of meningococcal meningitis tachycardia not bradycardia. C. Increased muscle tone Rationale: The nurse should find as a sign of meningococcal meningitis decreased not increased muscle tone. D. Oriented to time, person, place Rationale: The nurse should find as a sign of meningococcal meningitis disorientation not orientation to time, person, and place. 5. A nurse admits a client who has a concussion for overnight observation. Alert and oriented on admission, the client reports a headache along with neck pain and generalized muscle aches. The nurse knows that a manifestation considered an early indication of increased intracranial pressure (ICP) is A. bradycardia. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. B. ipsilateral pupil dilation. Rationale: Ipsilateral or bilateral pupil dilation occurs when increasing intracranial pressure displaces the brain against the optic nerve, but pupil dilation is not an early sign of increased ICP. C. widening pulse pressure. Rationale: Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia may be later signs of increased ICP. D. lethargy. Rationale: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. An early sign of increasing ICP is lethargy. 6. A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed? A. NPO until dysphagia subsides Rationale: Making the client NPO provides no nutritional support and will not likely be prescribed. B. Supplements via nasogastric tube Rationale: Supplements via nasogastric tube provide enteral nutrition for clients who are at risk for aspiration caused by a diminished gag reflex or difficulty swallowing. This nutritional therapy will likely be prescribed. C. Initiation of total parenteral nutrition Rationale: Total parenteral nutrition is initiated when the GI tract cannot be used for the ingestion, digestion, and absorption of essential nutrients. This nutritional therapy will not likely be prescribed. D. Soft residue diet Rationale: A soft residue diet would place the client at risk for aspiration due to difficulty swallowing solids; therefore, this nutritional therapy will not likely be prescribed. 7. A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following is an appropriate response by the nurse? A. "Incorporate nonverbal cues in the conversation." Rationale: Nonverbal cues enhance the client’s ability to comprehend and use language. B. "Ask multiple choice questions as part of the conversation." Rationale: Simple questions requiring yes/no responses are better understood by the client. C. "Use a higher-pitched tone of voice when speaking." Rationale: Tone of voice is understood by clients with aphasia, unless they have a hearing impairment. D. "Use simple child-like statements when speaking." Rationale: It is important to respect the client and use age-appropriate communication. 8. A nurse is caring for a client in liver failure with ascites who is receiving spironolactone (Aldactone). Which of the following outcomes should the nurse expect from this client’s medication therapy? A. Increased sodium excretion Rationale: The primary action of spironolactone is to increase sodium excretion in the urines. B. Decreased urinary output Rationale: Spironolactone is a diuretic, thus it should increase urine output. C. Increased potassium excretion Rationale: Spironolactone is potassium-sparing. D. Decreased chloride excretion Rationale: Spironolactone promotes the excretion of chloride in the urine. 9. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? A. Dehydration Rationale: Dehydration is not considered a complication of the hypothermia blanket therapy. B. Seizures Rationale: Seizures are not considered a complication of the hypothermia blanket therapy. C. Burns Rationale: Burns are associated with the improper use of heating pads, not a hypothermia blanket. D. Shivering Rationale: The hypothermia (cooling) blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. 10. An acute care nurse is caring for an adult client who is undergoing evaluation for a possible brain tumor. When performing a neurological examination, which of following is the most reliable indicator of cerebral status? A. Pupil response Rationale: The nurse should include pupil response as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. B. Deep tendon reflexes Rationale: The nurse should include deep tendon reflexes as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. C. Muscle strength Rationale: The nurse should include muscle strength as part of a neurological examination; however, it is not the most reliable indicator of cerebral status. D. Level of consciousness Rationale: The nurse should examine the client’s level of consciousness as the most reliable indicator of cerebral status. 11. A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy- induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa Rationale: Placenta previa occurs with painless vaginal bleeding. B. Prolapsed cord Rationale: With a prolapsed umbilical cord, there is no bleeding or pain. There may be changes in the fetal heart tracing, and the cord might also become visible. C. Ruptured ovarian cysts Rationale: A rupture of an ovarian cyst can cause sudden pelvic pain, but it does not commonly cause vaginal bleeding. D. Abruptio placentae Rationale: The cardinal signs and symptoms of abruptio placentae include a rigid board-like abdomen, severe pain, and heavy vaginal bleeding. 12. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? A. Measure the circumference of both upper arms. Rationale: The first action to take if the client's arm appears to be swollen is to measure the arm and compare it to the circumference of the other arm. If the arm is swollen, it is appropriate to notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site. B. Notify the provider who inserted the PICC line. Rationale: It may be necessary to notify the provider, but this is not the first action the nurse should take. C. Remove the PICC line. Rationale: It may be necessary to remove the PICC line, but this is not the first action the nurse should take. D. Apply a cold pack to the client's upper arm. Rationale: It may be necessary to apply a cold pack to the client's upper arm, but this is not the first action the nurse should take. 13. A nurse is planning care for a client who has a GI bleed. Which of the following actions should the nurse take first? A. Assess orthostatic blood pressure. Rationale: The first action the nurse should take using the nursing process is to assess the client; therefore, assessing the orthostatic blood pressure is the first priority to determine if the client is hypovolemic. B. Explain the procedure for an upper GI series. Rationale: The nurse should explain the procedure for an upper GI series, but this is not the priority. C. Administer pain medication. Rationale: The nurse should administer pain medication as needed, but this is not the priority. D. Test the emesis for blood. Rationale: The nurse should test the emesis for blood if the client vomits, but this is not the priority. 14. A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat- soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following? A. Vitamin A Rationale: The nurse should instruct the client that fat-soluble vitamins include vitamins A, D, E, and K. B. Vitamin B1 Rationale: itamin B1 is not a fat-soluble vitamin. C. Vitamin C Rationale: Vitamin C is not a fat-soluble vitamin. D. Vitamin B12 Rationale: Vitamin B12 is not a fat-soluble vitamin. 15. A nurse is caring for a client who has acute pancreatitis. After the client's pain has been addressed, which of the following is the next intervention to include in the plan of care? A. Monitor respiratory status every 8 hr. Rationale: Monitoring respiratory status is an appropriate intervention, but it is not the next intervention. B. Encourage a side-lying position with knees flexed. Rationale: Encouraging a side-lying position with knees flexed status is an appropriate intervention, but it is not the next intervention. C. Provide frequent oral hygiene. Rationale: Providing frequent oral hygiene status is an appropriate intervention, but it is not the next intervention. D. Maintain NPO status. Rationale: To rest the pancreas and reduce secretion of pancreatic enzymes, oral fluids and food are withheld during the acute phase of pancreatitis. This is the next intervention to be included in the plan of care. 16. A nurse is caring for a client at a rehabilitation center 3 weeks after a cerebrovascular accident (CVA). Because the client's CVA affected the left side of the brain, which of the following goals should the nurse anticipate including in the client's rehabilitation program? A. Establish the ability to communicate effectively. Rationale: A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication. B. Have a regular, formed stool at least every other day. Rationale: This goal is not specific to the client's impairment. C. Learn to control impulsive behavior. Rationale: A client with a right-side lesion is likely to be impulsive. Clients with left-side lesions are typically cautious. D. Improve left-side motor function. Rationale: A client with a left-side lesion will demonstrate hemiplegia of the right side due to the fact that the pyramidal pathway crosses over at the base of the brain. 17. A client comes to the emergency department reporting nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see if the client has acute pancreatitis? A. Decreased WBC Rationale: With acute pancreatitis, WBC is generally elevated. B. Increased serum amylase Rationale: With acute pancreatitis, serum amylase rises within 24 hr of the start of the client’s symptoms. C. Decreased serum lipase Rationale: With acute pancreatitis, serum lipase is generally elevated. D. Increased serum calcium Rationale: Hypocalcemia is common with acute pancreatitis. 18. A nurse is caring for a client who has an acute respiratory illness. The nurse should monitor the client for which of the following manifestations of impending airway obstruction. (Select all that apply.) A. Tachycardia B. Nausea C. Retractions D. Muscle tremors E. Restlessness Rationale: Tachycardia is correct. Increases in pulse and respiratory rates are indications of impending airway obstruction. Nausea is incorrect. Gastrointestinal upset is not an indication of impending airway obstruction. Retractions is correct. Substernal, suprasternal, and intercostal retractions and flaring nares are indications of impending airway obstruction. Muscle tremors is incorrect. Muscle tremors are not an indication of impending airway obstruction. Restlessness is correct. Restlessness is an indication of impending airway obstruction. 19. A nurse is assessing a client who has meningitis and notes when passively flexing the client’s neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig’s sign Rationale: The client who displays the Kernig’s sign is unable to extend the leg completely when the thigh is flexed on the abdomen, which is not the condition manifested but is a common sign of meningitis. B. Nuchal rigidity Rationale: The client who displays nuchal rigidity has a stiff painful neck when the head is flexed, which is not the condition manifested but is a common sign of meningitis. C. Brudzinski sign Rationale: The client was manifesting Brudzinski sign, flexes hips and knees when neck is flexed, a common sign of meningitis. D. Bradykinesia Rationale: The client who displays bradykinesia, slow or no movement of extremities is a sign of Parkinson disease. 20. A nurse is caring for a client who has a history of pancreatitis. Which of the following food choices should the client avoid? A. Noodles Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Noodles are low in fat and are therefore an appropriate food choice for clients with pancreatitis. B. Vegetable soup Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Vegetable soup is low in fat and is therefore an appropriate food choice for clients with pancreatitis. C. Baked fish Rationale: Clients who have a history of pancreatitis should avoid foods high in fat. Baked fish is low in fat and is therefore an appropriate food choice for clients with pancreatitis. D. Cheddar cheese Rationale: Clients who have pancreatitis should avoid foods high in fat. Cheddar cheese is high in fat content and the client should avoid this food choice. 21. A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate in the client’s history? A. Gallstones Rationale: The client’s history may reveal biliary obstruction from a gallstone causing bile to inflame the pancreas. B. Hypolipidemia Rationale: The client’s history may reveal hyperlipidemia, not hypolipidemia, a metabolic disturbance causing an inflamed pancreas. C. COPD Rationale: The client’s history of COPD would not cause pancreatitis. D. Diabetes mellitus Rationale: The client’s history of diabetes mellitus may be a result of pancreatitis, not cause the disorder. 22. A nurse is anticipating the provider’s orders for a client who has a paralytic ileus following an appendectomy. Which of the following are expected nursing actions? A. Administer antacids. Rationale: The nurse should not expect to administer an antacid to the client who has no peristaltic activity, since this may cause further nausea and vomiting. B. Provide bulk-forming agent. Rationale: The nurse should not expect to administer a bulk forming agent to the client who has no peristaltic activity since this may cause further nausea and vomiting. C. Insert nasogastric tube. Rationale: The nurse should expect to insert a nasogastric tube for the client who has no peristaltic activity to decompress the gastrointestinal system of draining fluid and flatus. D. Apply a truss. Rationale: The nurse should not expect to apply a truss to the client who has a paralytic ileus since this is used for hernia. 23. A client comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum? A. Chvostek’s sign Rationale: Chvostek’s sign is a response of facial twitching when the examiner taps the client’s face over the facial nerve. It indicates hypocalcemia, not blood in the peritoneum. B. Cullen’s sign Rationale: Cullen’s sign is a blue discoloration similar to ecchymosis around the umbilicus. It indicates hematoperitoneum, a common clinical manifestation of a ruptured ectopic pregnancy. C. Chadwick’s sign Rationale: Chadwick’s sign is a change in the color of the vagina from pink to purplish. It is a probable finding during pregnancy, not an indication of blood in the peritoneum. D. Goodell’s sign Rationale: Goodell’s sign is a softening of the cervix of the uterus. It is a probable finding during pregnancy, not an indication of blood in the peritoneum. 24. After receiving TPN at 84 ml/hr continuously for five days, a client in a state of confusion pulled out their central line. Prior to notifying the provider, the nurse should start a peripheral IV and do which of the following? A. Flush the peripheral IV line with 0.9% sodium chloride to await further instructions from the physician. Rationale: This is not the appropriate intervention for the nurse to take. B. Change the tubing and filter on the TPN. Rationale: Changing the tubing and filter is not the appropriate intervention for the nurse to take. C. Hang an infusion 10% dextrose. Rationale: The sudden withdrawal from the TPN (hypertonic solution) can cause the client to be experiencing hypoglycemia. Administering an infusion of 10% dextrose will adjust the client’s blood glucose levels. D. Notify the pharmacy. Rationale: This is not the appropriate intervention for the nurse to take. 25. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? A. Administer antibiotics when available. Rationale: The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. B. Reduce environmental stimuli. Rationale: Reducing environmental stimuli is an appropriate action by the nurse; however, this is not the priority. C. Document intake and output. Rationale: Documenting intake and output is an appropriate action by the nurse; however, this is not the priority. D. Maintain seizure precautions. Rationale: Maintaining seizure precautions is an appropriate action by the nurse; however, this is not the priority. 26. A nurse is caring for a client whose total parenteral nutrition (TPN) was stopped for an hour by mistake. After restarting the infusion pump, the nurse should watch the client carefully for the development of A. excessive thirst and urination. Rationale: Excessive thirst and urination are manifestations of hyperglycemia, which is a complication of TPN related to the high proportion of glucose in the infusion. Hyperglycemia would not occur secondary to an interruption in the TPN administration. B. shakiness and diaphoresis. Rationale: When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia. C. fever and chills. Rationale: Fever and chills are manifestations of infection. D. hypertension and crackles. Rationale: Hypertension and crackles are manifestations of fluid overload, which is a complication of TPN related to the fluid infusion rate. 27. A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. Rationale: Allowing the child to ambulate in his room alone does not increase the child’s safety risk appreciably and has other benefits for the client. B. Limit contact with other pediatric clients. Rationale: Contact with other clients on the pediatric unit does not increase the child’s safety risk appreciably and has other benefits for the client. C. Initiate seizure precautions for the child. Rationale: A client who has a brain tumor is at risk for seizures. It is imperative for the nurse to implement seizure precautions for this client. D. Have the child use a wheelchair for all out-of-bed activities. Rationale: Having the child use a wheelchair is unnecessary and does not ensure the child’s safety. 28. A client has right-sided paralysis from a cerebral vascular accident (CVA). Which of the following interventions should the nurse implement to prevent foot-drop? A. Place sandbags to maintain right plantar flexion. Rationale: Sandbags can be used to support the foot in a dorsiflexion position. Plantar flexion positions the foot with toes down, contributing to foot-drop. B. Position soft pillows against the bottom of the feet. Rationale: Placing firm pillows against the bottom of the feet will help to maintain a position of dorsiflexion. Soft pillows will not provide a firm enough surface to prevent foot-drop. C. Support the right foot in dorsiflexion with a footboard. Rationale: The foot should be positioned in a dorsiflexion position using a firm surface, such as a footboard. When foot-drop occurs, the foot is permanently fixed in plantar flexion with toes pointing downward. D. Splint the right lower extremity to maintain proper alignment. Rationale: The leg should not be splinted. Support the foot in dorsiflexion with ankle-foot orthotic or high-top tennis shoes. 29. A nurse is collaborating on care for a client following a cerebrovascular accident (CVA). Which of the following should be addressed by an occupational therapist? A. Using assistive devices Rationale: As a member of the interdisciplinary team, the physical therapist would help the client achieve gross mobility skills, such as facilitating ambulation and teaching the client to use a walker or crutches. The physical therapist also may assist with ADLs, such as transferring from bed to chair, ambulating, and toileting. B. Completing self-care Rationale: As a member of the interdisciplinary team, the occupational therapist works with the client to develop fine motor skills and coordination, such as improving hand strength and hand movements. The occupational therapist focuses on self-management of ADLs, such as skills needed for eating, hygiene, and dressing. Occupational therapists also can teach clients to perform other independent living skills, such as cooking and shopping. C. Thickening clear liquids Rationale: As a member of the interdisciplinary team, the speech-language pathologist would provide screening for clients who have dysphagia. The speech-language pathologist evaluates and retrains clients who have speech, language, or swallowing problems. If the client has a problem with swallowing, appropriate food and feeding techniques would be recommended. Thickening clear liquids would reduce the risk of aspiration in a client who has dysphagia by increasing the liquid’s viscosity and making it easier to swallow. D. Transferring from chair to bed Rationale: As a member of the interdisciplinary team, the physical therapist would help the client achieve gross mobility skills, such as facilitating ambulation and teaching the client to use a walker or crutches. The physical therapist also assists with ADLs, such as moving in and out of the bed, ambulating, and toileting. 30. A nurse is caring for a conscious client who has an airway obstruction. Which of the following is an appropriate intervention? A. Tilt the head and lift the chin. Rationale: Tilting the head and lifting the chin is an appropriate intervention to open the airway if the client loses consciousness. B. Begin the Heimlich maneuver. Rationale: The nurse should immediately begin the Heimlich maneuver on a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness. C. Turn the client to the side. Rationale: Turning the client to the side is an appropriate intervention if the client is unconscious and breathing. D. Perform a blind finger sweep. Rationale: Performing a blind finger sweep creates a risk of worsening the obstruction. 31. A nurse is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the nurse recognize as a complication of this therapy? A. Polyuria Rationale: TPN is prescribed when extensive nutritional support for prolonged periods of time is required. It is delivered through a central venous access device, usually via the internal jugular or subclavian vein. TPN contains a high concentration of dextrose, which can result in hyperglycemia. Clinical manifestations of hyperglycemia include polydipsia, polyphagia, and polyuria. Frequent glucose monitoring should be implemented in clients receiving TPN. Administering regular insulin according to a sliding scale will help control glucose levels. B. Aspiration Rationale: Aspiration is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. One of the complications of TEN is pulmonary aspiration. This can occur if the tube is not placed correctly (e.g., in the lungs instead of the stomach) or if feedings are administered too rapidly or in too large a volume. Ensuring the tube is placed correctly and maintaining the client in a Fowler’s position will minimize this risk. Because TPN is not administered via the GI tract, aspiration is not a complication. C. Diarrhea Rationale: Diarrhea is a complication of total enteral nutrition (TEN). During TEN, a tube is placed in the client’s GI tract, often via the nasal passage. Diarrhea can occur if the feedings are delivered too rapidly. Feedings should be started slowly and advanced as tolerated. Because TPN is not administered via the GI tract, diarrhea is not a complication. D. Stomatitis Rationale: Although mouth care is important for clients who are receiving supplemental nutrition, stomatitis is not expected. Stomatitis is an inflammation of the lining of the mouth that may include the inside of the cheeks, gums, and tongue. It can be caused by chemotherapy. It is not caused by TPN. 32. A nurse is caring for an adolescent client in the emergency department who sustained a head injury. The nurse notes the client’s IV fluids are infusing at 125 mL/hour. Which of the following is an appropriate action by the nurse? A. Slow the rate to 20 mL/hr. Rationale: The nurse who slows the IV rate to 20mL/hr may compromise volume resuscitation and cause hypotension. B. Continue the rate at 125 mL/hr. Rationale: The nurse who continues the IV rate at 125 mL/hr may worsen the client’s condition by rapidly expanding the client’s plasma volume. C. Slow the rate to 50 mL/hr. Rationale: The nurse should decrease the rate to 50 mL/hr to minimize cerebral edema and prevent increased intracranial pressure. D. Increase the rate to 250 mL/hr. Rationale: The nurse who continues the IV rate at 250 mL/hr may worsen the client’s condition by rapidly expanding the client’s plasma volume and causing increased intracranial pressure. 33. A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective? A. Hct 43% Rationale: An Hct of 43% is within the expected reference range but this does not indicate the TPN therapy is effective. Clients with cancer are likely to have a low Hct due to anemia. B. WBC 8,000/uL Rationale: A WBC count of 8,000/uL is within the expected reference range but this does not indicate the TPN therapy is effective. Clients receiving TPN are at risk for developing infection. C. Albumin 4.2 g/dL Rationale: Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein. D. Calcium 9.4 mg/dL Rationale: A calcium level of 9.4 mg/dL is within the expected reference range but this does not indicate the TPN therapy is effective. Clients receiving TPN are at high risk for developing hypercalcemia. 34. A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). The nurse should know that which of the following client findings supports this suspicion? A. Cyanotic fingertips. Rationale: Cyanotic fingertips is not an indicator that a client is experiencing increased intracranial pressure. B. Nuchal rigidity. Rationale: Nuchal rigidity is not an indicator that a client is experiencing increased intracranial pressure. C. Fever. Rationale: Fever is not an indicator that a client is experiencing increased intracranial pressure. D. Diplopia. Rationale: Clients who have meningitis can be at risk for developing increased intracranial pressure (ICP). The classic triad of manifestations for increased ICP consists of headache, nausea/vomiting, and diplopia, or double vision. The client who has meningitis and reports diplopia must be carefully monitored for other manifestations of increased ICP. 35. A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemi-colectomy. Which of the following foods should the nurse instruct the client to avoid? A. Rice Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Rice is low in fiber and provides carbohydrates. B. Poached eggs Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. Poached eggs are low in fiber and a good source of protein. C. Fresh apples Rationale: Clients with dumping syndrome following a hemi-colectomy should avoid fresh fruits and choose canned or well-cooked fruits instead. D. White bread Rationale: Clients with dumping syndrome following a hemi-colectomy should include high protein, high fat, low-to-moderate carbohydrate, and low fiber foods. White bread is low in fiber and provides carbohydrates. 36. A nurse is caring for a client receiving total parenteral nutrition (TPN) therapy via an infusion pump. When assessing the client receiving this therapy, which of the following observations by the nurse is of least importance? A. IV site Rationale: It is essential that the nurse assess the IV site, regardless of the fluid delivery system. B. Height of IV pole Rationale: Since the TPN is infusing via an IV infusion pump, the height of the IV pole is irrelevant. Gravity is not an issue with an infusion pump, which controls the flow of the solution via mechanical means. C. Date on tubing Rationale: It is essential that the nurse assess the date on the IV tubing. The tubing for a TPN infusion must be changed daily. In addition, the tubing itself should be assessed thoroughly. Tubing can become kinked, leading to an obstructed flow of IV fluid. If the connections are not secure, breaks in the system are potential portals of entry for infection. D. Contents of solution bag Rationale: It is essential that the nurse verify that the solution infusing is the solution ordered. 37. A nurse is caring for a client following surgical treatment for a brain tumor near the hypothalamus. For which of the following is the client at risk? A. Inability to regulate body temperature Rationale: The nurse should be aware that the hypothalamus controls body temperature, fluid balance, particular emotions (such as pleasure and fear), sleep, and appetite. B. Bradycardia Rationale: The nurse should be aware that bradycardia results from a problem in the medulla oblongata rather than the hypothalamus. C. Visual disturbances Rationale: The nurse should be aware that the visual area is controlled by the occipital lobe rather than the hypothalamus. D. Inability to perceive sound Rationale: The nurse should be aware that the auditory center is located in the temporal lobe rather than the hypothalamus. 38. A nurse creates a plan of care for a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is within normal limits? A. Pushes the painful stimulus away. Rationale: The client who pushes the painful stimulus away is a normal response that is purposeful and appropriate. B. Extends the body part toward the stimuli. Rationale: The client who extends the body part toward the stimuli indicates increased intracranial pressure and is not a normal response. C. Shows no reaction to the painful stimuli. Rationale: The client who shows no reaction to the painful stimuli is not a normal response and may indicate flaccidity and may be neurological impaired. D. Flexes the upper and extends the lower extremities. Rationale: The client who flexes the upper and extends the lower extremities is not a normal response and indicates decorticate or decerebrate. 39. An older adult client in a long-term care facility had a cerebrovascular accident (CVA) 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A. A reddened area over the sacrum Rationale: A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage. B. Stiffness in the lower extremities Rationale: Depending on the location and extent of the CVA, varying degrees of leg stiffness are typical findings. C. Difficulty moving the upper extremities Rationale: Depending on the location and extent of the CVA, varying degrees of mobility impairment are typical findings. D. Difficulty hearing some types of sounds Rationale: Presbycusis, or age-related sensorineural hearing loss, is typical among older adults and is not a complication of immobility. 40. A nurse is caring for an older adult client who is hospitalized for a bowel obstruction and has a nasogastric (NG) tube to wall suction. Which of the following nursing interventions should be included in the postoperative plan of care? (Select all that apply.) A. Offer small amounts of clear liquids after the client's gag reflex returns. B. Maintain the client on complete bed rest for 48 hr. C. Irrigate the nasogastric tube with saline as needed. D. Place sequential compression devices on the bilateral lower extremities. E. Reposition the client from side to side every 2 hr. F. Encourage the use of an incentive spirometer every hour while the client is awake. Rationale: Offer small amounts of clear liquids after the client's gag reflex returns is incorrect. Offering of clear liquids is contraindicated in a client who has a nasogastric tube. In addition, the client's diet will not be resumed until bowel sounds, rather than the gag reflex, have returned. Irrigate the nasogastric tube with saline as needed is correct. A nasogastric tube will be in place following surgery for a bowel obstruction to provide gastric decompression. The tube should be irrigated as needed to maintain patency. Place sequential compression devices on the bilateral lower extremities is correct. Sequential compression devices improve blood flow in a client who has impaired mobility and should be in place on the lower extremities whenever the client is in bed. Reposition the client from side to side every 2 hr is correct. All clients who are postoperative should be repositioned, either alone or with assistance, every 2 hr. Encourage the use of an incentive spirometer every hour while the client is awake is correct. Use of the incentive spirometer helps to prevent the development of atelectasis. All clients who are postoperative should be encouraged to use the device 10 times each hour while awake. 41. A nurse is caring for a client who is 6 days postoperative following a craniotomy for removal of an intracerebral aneurysm. The client has been transferred from the ICU to the PACU. The nurse should assess the client for early signs of increased intracranial pressure (ICP) when the client states A. "Could you get me a bowl? I feel nauseated." Rationale: Nausea and vomiting may occur with increased ICP. The classic three symptoms of increased ICP in a conscious client are nausea, headache, and diplopia (double vision). A client report of nausea should be investigated immediately. B. "I'm so bored in here. I want to go home." Rationale: This is a statement that may be heard from many clients recovering from surgery, especially if the client has been hospitalized for nearly a week. C. "Can you assist me to the bathroom? I need to urinate." Rationale: This client will require assistance in getting to the bathroom. D. "I think I'm constipated. I haven't had a stool since before surgery." Rationale: This issue should be addressed, but this is not an early sign of increased ICP. 42. A nurse is planning care for a client who has a decreased level of consciousness from bacterial meningitis. The client is receiving continuous nourishment via gastrostomy tube (G-tube) feedings due to an inability to swallow. Which of the following is the priority action by the nurse? A. Turn and position the client every 2 hr. Rationale: This is not the priority action by the nurse. B. Elevate the head of the client's bed 30° to 45&#176. Rationale: Elevating the head of the client's bed will decrease the risk of aspiration. C. Change the client’s G-tube dressing. Rationale: This is not the priority action by the nurse. D. Place sequential compression devices (SCDs) on the client while in bed. Rationale: This is not a priority action by the nurse. 43. A nurse is admitting a client who has bacterial meningitis. The nurse notes during the physical examination that the client cannot extend his leg when his hip is flexed so that his thigh rests on his abdomen. The nurse should document this as which of the following? A. Brudzinski’s sign Rationale: Brudzinski’s sign is an involuntary, spontaneous flexion of both hips and knees when the neck is flexed. It indicates meningeal irritation. Only some clients with meningitis display this sign, however. B. Chvostek’s sign Rationale: Chvostek’s sign is a response of facial twitching when the nurse taps the client’s face over the facial nerve. It indicates hypocalcemia, not meningeal irritation. C. Goodell’s sign Rationale: Goodell’s sign is a softening of the cervix of the uterus. It is a probable finding during pregnancy. D. Kernig’s sign Rationale: Kernig’s sign is an inability to extend the leg completely when sitting or lying with the thigh flexed on the abdomen. Only some clients with meningitis display this sign, however. 44. A nurse is assessing a client who has obstruction of the common bile duct due to cholelithiasis. Which of the following is an expected finding? A. Fatty stools Rationale: An expected client finding is fatty stools due to biliary obstruction causing a lack of bile for the absorption of fats in the intestines B. Straw-colored urine Rationale: Chronic cholecystitis may result in dark urine not straw-colored urine due to biliary obstruction. C. Tenderness in the left upper abdomen Rationale: Chronic cholecystitis may result in tenderness in the right upper abdomen due to biliary obstruction and inflamed gallbladder. D. Ecchymosis of the extremities Rationale: Chronic cholecystitis may result in jaundice due to biliary obstruction. 45. A nurse is caring for a client who is one day post-operative from an appendectomy and is HIV positive. Which of the following actions requires the nurse to wear a gown as personal protection equipment? A. Talking to the client at the bedside. Rationale: Standard precautions does not require the nurse to wear personal protective equipment while being in the room of a client who is HIV positive. B. Administering an IV piggyback medication. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. There is no risk to the nurse to be in contact with body fluids while administering an IV piggyback medication. C. Completing a dressing change. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. While performing a dressing change on a client who is HIV positive, the nurse should wear appropriate personal protective equipment, which includes a gown. D. Administering an IM injection. Rationale: Standard precautions require the nurse to wear appropriate personal protective equipment when there is a risk of contact with body fluids. The nurse should wear gloves when administering an IM injection to this client. 46. A nurse on the pediatric unit is notified that a child is being admitting following an appendectomy and is to be placed in a room with another client. The nurse should plan to place the child with which of the following clients? A. A child with sickle cell crisis. Rationale: he greatest risks to the child with sickle cell crisis are from inadequate rest and pain management. The nurse should not place another client in the room of a child with sickle cell crisis due to the frequent assessments and interventions required when caring for the client with an appendectomy. B. A child with tonsillitis. Rationale: The greatest risk to the client following surgery is from infection. Placing the postoperative client in the room of a child with an infection is not appropriate. C. A child with head injury. Rationale: The greatest risks to the client following head injury are from stimulation and inadequate pain management. The nurse should not place another client in the room of a child with head injury due to the frequent interruptions that will occur when providing care during the postoperative period. D. A child with type 1 diabetes. Rationale: he greatest risk to the client following surgery is from infection. Placing this client in the room of a child with diabetes is appropriate since this child requires monitoring and teaching. 47. A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following statements indicates the nurse understands the rationale for using this solution? A. Reduce edema of the brain. Rationale: An osmotic diuretic is used to decrease intracranial pressure by moving fluid out of the ventricles into the bloodstream. B. Provide fluid hydration. Rationale: An osmotic diuretic is used to rapidly reduce intracranial edema and is not used to provide fluid hydration. C. Increase cell size in the brain. Rationale: An osmotic diuretic is used to rapidly reduce brain size, not increase the cell size of the brain. D. Expand extracellular fluid volume. Rationale: An osmotic diuretic is used to rapidly reduce extracellular fluid volume to decrease brain edema. 48. A nurse is caring for a 5-month-old undergoing a lumbar puncture to rule out meningitis. The nurse who is planning to assist with the procedure should A. utilize a papoose board to restrain limbs. Rationale: A papoose board would be used for a procedure done on the anterior side of the body, but it would not be appropriate for visualizing or accessing the lower spine. B. position the infant seated on the side of table. Rationale: This might be an option for an adolescent or adult, but not an infant. C. have several other nurses help hold the infant. Rationale: One nurse is usually able to assist with this procedure. D. hold the infant's chin to his chest and knees to his abdomen. Rationale: The client is positioned on the side in a fetal position (knees curled to abdomen and chin tucked to chest). 49. A nurse is planning care for a 6-year-old client who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Place the client in semi-Fowler's position. Rationale: Semi-Fowler's position, with the head of bed elevated 30 to 45 degrees, will help to reduce edema in the brain. B. Admit the client to a private room. Rationale: Isolation for the first 24 hours of a client who has bacterial meningitis is indicated due to the highly contagious nature of some types of bacterial meningitis. Decreasing the environmental stimuli is an important action in the care of a client with meningitis. C. Measure head circumference every shift. Rationale: The head circumference of a 6-year-old can't increase since the fontanels and sutures have all been closed since the child was 18 months old. Therefore, it would be unnecessary to measure the client&