A male client who has severe burns is receiving H2 receptor antagonist therapy.

The nurse Incharge knows the purpose of this therapy is to:

A.Block prostaglandin synthesis B.Prevent stress ulcer C.Facilitate protein synthesis. D.Enhance gas exchange
Curlings ulcer occurs as a generalized stress response in burn patients. This results in a decreased production of mucus and increased secretion of gastric acid. The best treatment for this prophylactic use of antacids and H2 receptor blockers.

The nurse is assessing a 48-year-old client who has come to the physicians office for his annual physical exam. One of the first physical signs of aging is:
A.Having more frequent aches and pains. B.Accepting limitations while developing assets. C.Failing eyesight, especially close vision. D.Increasing loss of muscle tone.
Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increase in loss of muscle tone occurs in later years (age 80 and older).

A newly admitted female client was diagnosed with deep vein thrombosis. Which nursing diagnosis should receive the highest priority?
A.Impaired gas exchange related to increased blood flow. B.Excess fluid volume related to peripheral vascular disease. C.Ineffective peripheral tissue perfusion related to venous congestion D.Risk for injury related to edema.
Explanation
Ineffective peripheral tissue perfusion related to venous congestion takes the highest priority because venous inflammation and clot formation impede blood flow in a client with deep vein thrombosis.

Which of the following theory addresses the four modes of adaptation?

A.Madeleine Leininger B.Jean Watson C.Sr. Callista Roy(Your Answer) D.Florence Nightingale
Explanation
Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode.

The physician prescribes a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?
A.Hyperkalemia B.Hypokalemia C.Hypernatremia D.Hypervolemia
A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.

The doctor orders hourly urine output measurement for a postoperative male client. The nurse Trish records the following amounts of output for 2 consecutive hours: 8 a.m.: 50 ml; 9 a.m.: 60 ml. Based on these amounts, which action should the nurse take?
A.Irrigate the indwelling urinary catheter B.Increase the I.V. fluid infusion rate C.Continue to monitor and record hourly urine output(Your Answer) D.Notify the physician
Explanation
Normal urine output for an adult is approximately 1 ml/minute (60 ml/hour). Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a stroke. The client has right sided arm and leg weakness. The nurse would suggest that the client use which of the following assistive devices that would provide the best stability for ambulating?
A.Crutches B.Quad cane(Missed) C.Walker(Your Answer) D.Single straight-legged cane
Explanation
Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for client with weakness of the arm and leg on one side. However, the quad cane would provide the most stability because of the structure of the cane and because a quad cane has four legs.

A male client is receiving total parenteral nutrition suddenly demonstrates signs and symptoms of an air embolism. What is the priority action by the nurse?
A.Place the client on the left side in the Trendelenburg position. (Missed) B.Place the client in high-Fowlers position. C.Stop the total parenteral nutrition.(Your Answer) D.Notify the physician.
Explanation
Lying on the left side may prevent air from flowing into the pulmonary veins. The Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during aspiration.

A male client is being transferred to the nursing unit for admission after receiving a radium implant for bladder cancer. The nurse in-charge would take which priority action in the care of this client?
A.Encourage the client to take frequent rest periods. B.Admit the client into a private room.(Missed) C.Encourage family and friends to visit.

D.Place client on reverse isolation.(Your Answer)

Explanation
The client who has a radiation implant is placed in a private room and has a limited number of visitors. This reduces the exposure of others to the radiation.