Reduction of Risk – Flashcards
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To reduce the risk of developing a complication following balloon angioplasty, the nurse should implement which measure? Select all that apply: 1. Monitor cardiac rhythm 2. Assess the puncture site every 8 hours 3. Measure urinary output hourly 4. Prevent flexion of the affected leg 5. Avoid lifting buttocks off the bed
answer
Monitor cardiac rhythm Measure urinary output hourly Prevent flexion of the affected leg Avoid lifting buttocks off the bed
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Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 ml one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer high flow oxygen per mask. 2. Lower the head of the bed in order to raise BP. 3. Give the ordered Lasix to increase urinary output. 4. Re-check the BP in the other arm.
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Administer high flow oxygen per mask.
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A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply: 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.
answer
Administer furosemide. Weigh daily. Measure urine output every 30 - 60 minutes.
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A nurse is caring for a client admitted to the hospital for a total hip replacement. In preparing the post-operative plan of care for this client, the nurse recognizes which goal as the highest priority? 1. Prevent complications of shock. 2. Prevent dislocation of prosthesis. 3. Prevent respiratory complications. 4. Prevent contractures by early ambulation.
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Prevent respiratory complications.
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After artificial rupture of membranes (AROM), the baseline fetal heart rate tracking begins to show sharp decreases with a rapid recovery with and between contractions. Which of the following actions by the RN has priority? 1. Position the client on her left side 2. Increase the IV fluid rate 3. Place the client in the knee-chest position 4. Administer oxygen per tight face mask
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Place the client in the knee-chest position
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A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? 1. Ecchymosis of incision 2. Tenderness over the kidney 3. Frequent polyuria 4. Subnormal temperature
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Tenderness over the kidney
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A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider? 1. Midabdominal pain radiating to the shoulder 2. Nausea and vomiting periodically for several hours 3. Abdominal rigidity with pain in the left lower quadrant 4. Elimination pattern of constipation alternating with diarrhea
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Abdominal rigidity with pain in the left lower quadrant
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Which nursing intervention represents secondary prevention level? 1. Teaching the effects of alcohol to elementary school children. 2. Providing care for abused women in a shelter. 3. Leading a group of adolescents in drug rehabilitation. 4. Ensuring medication compliance in a client with schizophrenia.
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Providing care for abused women in a shelter.
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The high school nurse is teaching her students about proper food storage and preparation. What instructions should be given in the teaching plan to prevent exposure to the potentially fatal botulism pathogen? 1. Make sure that you heat food or drink to 212 degrees Fahrenheit for 10 minutes. 2. Consume home canned foods with caution. 3. Heat all foods to an internal temperature of 140 degrees Fahrenheit for one minute. 4. Don't consume home canned products.
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Make sure that you heat food or drink to 212 degrees Fahrenheit for 10 minutes.
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The Emergency Department triage nurse encounters a client who says that he has received exposure to a liquid hazardous chemical at work. He reports that he is only one of about 20 people. What should the nurse do? Select all that apply: 1. Call the supervisor and inform of the possibility of contamination of surrounding space. 2. Obtain vital signs immediately. 3. Call personnel trained in containment and decontamination immediately. 4. Direct the individual to a bed space immediately. 5. Instruct the client to remove clothing and put on disposable hospital gown.
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*Call the supervisor and inform of the possibility of contamination of surrounding space. *Call personnel trained in containment and decontamination immediately.
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The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms
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Clear urine
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A client's membranes spontaneously rupture at 10 cm dilation and -2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 1. Emergency cesarean delivery 2. Immediate high forceps delivery 3. Equipment for immediate suctioning of the newborn 4. Administration of IV oxytocin
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Equipment for immediate suctioning of the newborn
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A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? Select all that apply: 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD.
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*Avoid magnets directly over the site. *Notify primary healthcare provider whenever a shock is delivered by the ICD.
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An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and his vital signs are unstable. What should the nurse do first? 1. Decrease rate of IV fluids. 8 2. Neurovascular checks of affected leg. 3. Elevate the head of the bed. 4. Call the active response team.
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Call the active response team.
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To promote rapid diuresis in a client in acute pulmonary edema, which prescription should the nurse administer first? 1. Furosemide 40 mg IVP 2. Dopamine 15 mcg/kg/min 3. Hydrochlorothiazide 25 mg PO 4. Captopril 25 mg PO
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Furosemide 40 mg IVP
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A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? 1. Surgical cannulation of the bile duct is causing spasm and pain. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage.
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Carbon dioxide used intraperitoneally is irritating the phrenic nerve.
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A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to do what? 1. Remove air from the pleural space 2. Create access for irrigating the chest cavity 3. Evacuate secretions from the bronchioles and alveoli 4. Drain blood and fluid from the pleural space
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Remove air from the pleural space
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A client is admitted to the medical unit with persistent vomiting. The client complains of weakness and leg cramps. The wife states that he is irritable. The primary healthcare provider has prescribed lab work and blood gases. Based on this assessment the nurse anticipates which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
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Metabolic alkalosis
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A client asked a nurse, "What could have caused me to develop right sided congestive heart failure?" What would be the best response by the nurse? "Other than left sided heart failure, the most common cause of right sided heart failure is.. 1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta.
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High blood pressure in the lungs.
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The lactation consultant is preparing to make rounds on the breastfeeding clients on the LDRP. Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good; she has to wake him for each feeding.
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The mother who stated that her baby was so good; she has to wake him for each feeding.
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The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the night before the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.
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I'll have to drink contrast while x-rays are taken
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After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? 1. How the client tolerated the procedure. 2. The length and intactness of the central line catheter. 3. The amount of fluid left in the IV solution container. 4. That a dressing was applied to the insertion site.
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The length and intactness of the central line catheter.
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A client who needs to have a stool specimen for an occult blood test (Hemocult II) is instructed by the nurse to avoid which substances two hours prior to testing? Select all that apply: 1. Baked liver and onions 2. Lettuce and tomato salad 3. Ibuprofen 4. Sardines 5. Oranges
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*Baked liver and onions *Ibuprofen *Sardines *Oranges
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The nurse is caring for an oncology client with a WBC-5.5 x 103 /mm3, Hgb-12g/dL, PLT-90 x 103 /mm3. Which measure should be instituted? 1. Protective isolation 2. Oxygen therapy 3. Bleeding precautions 4. Strict intake and output
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Bleeding precautions
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A nurse working in a locked psychiatric unit is caring for a client diagnosed with paranoia. The client becomes very agitated and shouts, "I am not going to my session today!" What action by the nurse would be most appropriate? 1. Sit with the client and say a prayer 2. Send the client to the session after explaining that shouting is not allowed 3. Escort the client to an easel and canvas in order for the client to paint 4. Call for assistance and put the client in seclusion
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Escort the client to an easel and canvas in order for the client to paint
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Which assessment findings would the nurse expect to see in a client diagnosed with idiopathic thrombocytopenic purpura (ITP)? Select all that apply: 1. Ecchymoses 2. Bleeding gums 3. Palpable spleen 4. Pain 5. Petechiae
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*Ecchymoses *Bleeding gums *Palpable spleen *Petechiae
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A client arrives in the emergency department after severely lacerating the left hand with a knife. HR 96, BP 150/88, R36. The client is extremely anxious and crying uncontrollably. Based on this assessment, the nurse should anticipate that this client is likely in which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
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Respiratory alkalosis
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Which food selections would need to be removed by the nurse, if on a tray for a client recovering from thyroidectomy? 1. Fresh apple 2. V8 juice 3. Mustard greens 4. Ice cream
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Fresh apple
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The client had a thoracentesis with removal of 2500 mL of fluid from the chest cavity. What is the priority nursing assessment for this client? 1. Vital signs 2. Pain 3. O2 sat 4. Signs of infection
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Vital signs
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The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities? 1. Ask the client to lie down and place the stockings on the legs. 2. Ask the client to sit on the bedside and place the stockings on the legs. 3. Tell the client that the nurse will return later to assist with the application. 4. Elevate the extremities in bed for 30 minutes before application.
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Elevate the extremities in bed for 30 minutes before application.
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Which factor would most likely predispose a client to developing shock following a fracture of the femur? 1. Pooling of the blood in the lower leg 2. Generalized vasoconstriction in the lower extremities 3. Loss of blood into soft tissues surrounding the fracture 4. Depression of the adrenal gland by toxins released at the injury
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Loss of blood into soft tissues surrounding the fracture
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A client, hospitalized with possible acute pancreatitis secondary to chronic cholecystitis, has severe abdominal pain and nausea. The client is kept NPO, an NG tube is inserted, and IV fluids are being administered. What is the rationale for the client being NPO with an NG tube to low suction? 1. Relieve nausea 2. Reduce pancreatic secretions 3. Control fluid and electrolyte imbalance 4. Remove the precipitating irritants
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Reduce pancreatic secretions
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A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? Select all that apply: 1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. 4. Positioning you with your affected lung down. 5. Palpating around the incision site for air under the skin.
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*Checking your vital signs frequently. *Examining the dressing for bleeding. *Listening to and percussing your lungs. *Palpating around the incision site for air under the skin.
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A nurse is providing care to a post-operative parathyroidectomy client. Which occurrence takes highest priority? 1. Psychoses 2. Renal calculi 3. Positive Trousseau's sign 4. Laryngospasm
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Laryngospasm
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A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? Select all that apply: 1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. 4. Position upright with head tilted slightly backwards. 5. Provide meals one hour prior to administering cholinesterase inhibitor meds.
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1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids.
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A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection, if chosen by the client, would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries
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Popcorn
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A nurse is planning to conduct parenting classes for first time parents in an attempt to decrease child abuse in the community. This is an example of: 1. Primary prevention 2. Secondary prevention 3. Tertiary prevention 4. Case management
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Primary prevention
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A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.
answer
Notify the primary healthcare provider.
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The nurse is preparing to make initial shift rounds. Which primapara client should the nurse see first? 1. 39 weeks with a board like abdomen and scant dark red bleeding. 2. 38 weeks gestation with blood streaked vaginal discharge 3. 40 weeks gestation reporting urinary frequency 4. 36 weeks gestation with pitting pedal edema
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39 weeks with a board like abdomen and scant dark red bleeding.
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A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? 1. Assess the wounds for drainage. 2. Give ice chips sparingly. 3. Maintain the patency of the NG tube. 4. Monitor for the return of peristalsis.
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Maintain the patency of the NG tube.
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Which interventions decrease risk of infection or damage to delicate tissue when the nurse is changing a wound dressing? Select all that apply: 1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 3. Use cotton balls to clean the suture site. 4. Use sterile gauze squares to dry the wound before applying the dressing. 5. Use sterile forceps when cleaning the wound.
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1. Warm cleansing solutions to body temperature. 2. Clean the wound when there is drainage present. 5. Use sterile forceps when cleaning the wound.
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A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? 1. Apply a wet to dry dressing for debridement. 2. Wrap each digit individually to prevent webbing. 3. Open blisters to allow drainage prior to dressing. 4. Allow the client to do as much of the dressing change as possible.
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Wrap each digit individually to prevent webbing.
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Which task would be appropriate for the LDRP charge nurse to assign to an LPN/VN? 1. Administering IV pain medication to a client three days post op cesarean section. 2. Drawing a trough vancomycin level on a client one week postpartum with mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Drawing routine admission labs on a client admitted to the observation room in early labor.
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Reinforce how to perform perineal care to a primipara who is four hours postpartum.
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The nurse is preparing to educate a group of clients on how to decrease the risk of developing recurrent renal calculi. What topics should the nurse include? Select all that apply: 1. High-purine foods to consume 2. Discuss diuretic use to prevent urinary stasis 3. Straining urine with each void 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium
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2. Discuss diuretic use to prevent urinary stasis 4. Maintaining a daily water intake of at least 2 liters 5. Foods low in calcium
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Which independent nursing actions should the nurse initiate for a client admitted with heart failure? Select all that apply: 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure 5. Administer medications as prescribed
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1. Monitor for distended neck veins 2. Measure abdominal girth 3. Evaluate urine output from diuretic therapy 4. Educate client regarding signs and symptoms of heart failure
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A client receiving 50 mL/hr of enteral feedings has a gastric residual volume of 200 mL and is complaining of nausea. The is the appropriate nursing intervention? 1. Stop the feeding and assess gastric residual volume in 1 hour. 2. Reduce the infusion rate to 25 mL/ hour and reevaluate residual volume in 4 hours. 3. Change the feeding schedule from continuous to intermittent delivery. 4. Discard the 200 mL and continue the feedings at the same rate.
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Stop the feeding and assess gastric residual volume in 1 hour.
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The lactation consultant is preparing to make rounds on the breastfeeding clients on the LDRP. Which client should the consultant see first? 1. The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. 2. The mother who stated that her newborn sucks in short bursts and has audible swallowing. 3. The mother who reported blisters on her nipples and pain whenever the newborn latches on. 4. The mother who stated that her baby was so good that she has to wake him for each feeding.
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The mother who stated that her baby was so good that she has to wake him for each feeding.
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A nurse is conducting an initial admission history on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather during this initial screening? 1. The physical assessment of the client 2. The hemoglobin and hematocrit levels 3. The amount of pain medication the client is receiving 4. The client's description of the pain
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The client's description of the pain
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A client is scheduled for plateletpheresis. When taking the client's history, which information is most significant? 1. Allergies to shellfish 2. Date last donated 3. Time of last oral intake 4. Blood type
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Date last donated
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What is the nurse's priority when preparing a client for a paracentesis? 1. Place client in the prone position. 2. Position the client flat with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs immediately prior to the procedure.
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Ask the client to empty bladder.
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The nurse is discharging the client after removing sutures from an abdominal wound. Which instructions should the nurse give the client at the time of discharge to reduce the risk of complications or infection? 1. Look at the wound daily to determine if it is red or has drainage present. 2. Assume normal activities when you go home. 3. Keep the incision covered at all times. 4. Make sure that you keep your next primary healthcare provider's appointment.
answer
Look at the wound daily to determine if it is red or has drainage present.
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After applying oxygen using bi-nasal prongs to a client who is having chest pain, the nurse should implement which intervention? 1. Have the client take slow deep breaths in through the mouth and out through the nose. 2. Post signs on the client's door and in the client's room indicating that oxygen is in use . 3. Apply Vaseline petroleum to both nares and 2 x 2 gauze around the oxygen tubing at the client's ears. 4. Encourage the client to hyperextend the neck, take a few deep breaths and cough
answer
Post signs on the client's door and in the client's room indicating that oxygen is in use .
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The labor nurse is assessing a client admitted in preterm labor. Which client finding would require a social service consult? 1. Very quiet and avoids eye contact. 2. Reports that she is not married. 3. Has injuries in various stages of healing. 4. Reports frequent arguments with her partner.
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Has injuries in various stages of healing.
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When planning post procedure care for a client who is having a barium enema, what must the nurse include? 1. Cardiac monitoring for potential arrhythmias 2. Monitoring urinary output 3. Administration of a laxative or enema after the procedure 4. Reordering the client's diet
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Administration of a laxative or enema after the procedure
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A client who is 3 days post abdominal hysterectomy reports left sided chest and back pain on inspiration. The nurse notes hemoptysis, shortness of breath, and auscultates bilateral rales. Vital signs are BP 140/90, HR 122, Resp 28, T 100°F (37.78°C) . O2 sat is 89%. Based on this assessment, what is the nurse's first action? 1. Obtain 12 lead ECG. 2. Draw arterial blood for ABGs. 3. Administer morphine for pain. 4. Notify the primary healthcare provider.
answer
Notify the primary healthcare provider.
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A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH-7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
answer
Respiratory alkalosis
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A client admitted with somnolence, has a history of chronic bronchitis and heart failure. Vital signs on admit are T 101.8ºF/38.8ºC, HR 106, R 26/shallow, BP 90/58. ABGs are pH 7.2, PCO2 75, HCO3 26. The nurse determines that this client has which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
answer
Respiratory acidosis
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A charge nurse is planning care for several clients on the unit. Which activities can the nurse safely delegate to an unlicensed assistive personnel (UAP)? Select all that apply: 1. Administer a nebulizer treatment to a client diagnosed with pneumonia. 2. Obtain vital signs on a postoperative client who required naloxone 5 minutes ago. 3. Report a UOP less than 50 ml/hr on a post-op client. 4. Obtain a clean catch urine sample from a client. 5. Remove an indwelling urinary catheter from a client.
answer
3. Report a UOP less than 50 ml/hr on a post-op client. 4. Obtain a clean catch urine sample from a client.
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A client with a history of increasing dyspnea over the past week comes to the emergency room. After arterial blood gases (ABGs) are drawn, which information would it be important for the nurse to document? 1. The client had not been NPO prior to the test. 2. The client was on 2 L of oxygen by nasal canula. 3. Lung sounds are wet. 4. Client is sitting in upright position.
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2. The client was on 2 L of oxygen by nasal canula.
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The nurse assesses a multigravida who is four hours postpartum. Findings include fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Assist the client up to void.
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4. Assist the client up to void.
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A client has returned to the burn unit after an escharotomy of the forearm. What is the priority nursing intervention? 1. Roll sterile q-tip over the wound 2. Elevate the affected arm 3. Ask the client to rate pain level 4. Assess bilateral radial pulses
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4. Assess bilateral radial pulses
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The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include? Select all that apply: 1. Restricting oral fluids until the gag reflex has returned 2. Encouraging early ambulation and deep breathing exercises 3. Discontinuing medicines following percutaneous intervention 4. Reporting any chest discomfort following percutaneous intervention 5. Avoid lifting more than 10 pounds until ok'd by healthcare provider
answer
4. Reporting any chest discomfort following percutaneous intervention 5. Avoid lifting more than 10 pounds until ok'd by healthcare provider
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A client asked the nurse what could have caused them to develop right sided heart failure? What would be the best response by the nurse? 1. High blood pressure in the lungs. 2. Long term hypertension. 3. The inability of the mitral valve to close properly. 4. Narrowing of the aorta.
answer
1. High blood pressure in the lungs.
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The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? Select all that apply: 1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 3. Smallpox is fatal is about 50% of cases. 4. Smallpox victims are contagious for two weeks. 5. Smallpox victims are isolated from others.
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1. People may be exposed to smallpox but not get the disease. 2. People may contract the disease by handling contaminated clothing or bedding. 5. Smallpox victims are isolated from others.
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The home care nurse visits a client who has moderate cognitive impairment and whose family provides care for the client. Which suggestions would be helpful for this family to reduce the risk of injury? Select all that apply: 1. Suggest that the family lock medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 3. Suggest that the family go out to dinner at least once per week for respite from responsibility. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
answer
1. Suggest that the family lock medications and poisons and keep the keys. 2. Encourage the family to place locks high on the door frame to make it difficult for the client to leave. 4. Suggest that the family remove knobs from stove when not in use. 5. Keep fire extinguishers present and in working order.
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The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.7 mEq/L (2.7 mmol/L) this morning. How should the nurse proceed? 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for signs of hypokalemia.
answer
1. Notify the primary healthcare provider of the potassium level immediately.
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Which client should the nurse recognize as being at greatest risk for the development of cancer? 1. Smoker for 30 plus years 2. Body builder taking steroids and using tanning salons 3. Newborn with multiple birth defects 4. Older individual with acquired immunodeficiency syndrome
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4. Older individual with acquired immunodeficiency syndrome
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While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and black collection of blood. What is the nurse's next action? 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.
answer
3. Gently remove the debris and re-dress the wound.
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A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? 1. Moist, shiny, soft hair 2. Resting heart rate of 120 3. Adheres to the prescribed low sodium diet 4. An absence of corneal irritation
answer
4. An absence of corneal irritation
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The nurse is removing sutures from a large surgical incision. The risk of dehiscence is present due to the length and placement of the incision. What should the nurse do after cleaning the sutures with an antimicrobial solution? 1. Remove the sutures two at a time as the sutures are very close together. 2. Remove the sutures sequentially and inspect for complete removal. 3. Remove every other suture and if intact, continue removing the alternating one. 4. Remove two sutures and then apply steri-strips to reinforce site.
answer
3. Remove every other suture and if intact, continue removing the alternating one.
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The nurse is caring for a burn victim with a skin graft to the hand. The area is pale and mottled,but has good capillary refill. What is the nurse's best action at this time? 1. Warm the room. 2. Submerge the hand in warm water. 3. Order a K pad and apply to hand. 4. Have the client exercise the fingers to increase blood flow.
answer
1. Warm the room.
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What would be the nurse's priority for a child who has arrived at the emergency department after sustaining a severe burn? 1. Start intravenous fluids. 2. Provide pain relief. 3. Establish airway. 4. Place an indwelling catheter.
answer
3. Establish airway.
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A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action? 1. Inspect the catheter tubing for kinks. 2. Irrigate the catheter with a large piston syringe. 3. Notify the primary healthcare provider. 4. Stop the irrigation flow.
answer
4. Correct: The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent further bladder distention. Bladder distention is one of the main causes of hemorrhage in the fresh post op period.
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A client is admitted to the Labor & Delivery Unit with severe preeclampsia. Which nursing intervention does the nurse include in the plan of care for this client? Select all that apply: 1. Monitor for headache 2. Place client in left recumbent position 3. Insert indwelling urinary catheter 4. Administer propranolol for BP > 100 diastolic 5. Initiate external fetal heart monitoring
answer
1., 2., 3., & 5. Correct: Headache is a sign of increasing BP, and increasing ICP. The left recumbent position moves the fetus off the mom's aorta and will help decrease the BP. This client needs to have UOP closely monitored, so an indwelling urinary catheter is needed. Fetus needs to be monitored for complications. FHR should be 120-160/minute.
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The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? 1. Tracheostomy set 2. Clamps 3. Surgical scissors 4. Tourniquet
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3. Correct: Yes, if the tube gets dislodged and occludes the airway, the balloon must be cut and the tube removed to allow the client to breathe.
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The nurse is caring for a burn client 48 hours after the burn occurred. What would be the nurse's priority assessment? 1. Measure the abdominal girth. 2. Administer pain medication. 3. Auscultate the lungs every 2 hours. 4. Inspect the burn for infection.
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3 Correct: After 48 hours, the fluid in the interstitial spaces will begin to shift back into the vascular space and can lead to fluid volume excess. Excess fluid can back up into the lungs, which takes priority.
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An adult client has just returned to the nursing care unit following a gastroscopy. Which intervention should the nurse include on the nursing care plan? Select all that apply: 1. Vital sign checks every 15 min x 4 2. Supine position for 6 hours 3. NPO until return of gag reflex 4. Irrigate NG tube every 2 hours 5. Raise four siderails
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1., & 3. Correct: Vital signs post procedure are important. VS are checked frequently for the first hour post procedure. Any client who has a scope inserted down the throat and has received numbing medication in the back of the throat to depress the gag reflex needs to be NPO until the gag reflex returns.
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The nurse is caring for a client who has a history of sleep apnea. The client is scheduled for a colon resection the following morning and asks if the sleep apnea machine should be brought to the hospital. What is the nurse's best response? 1. Yes, bring the sleep apnea machine. 2. No, do not bring the sleep apnea machine. 3. It is your choice. 4. Call your primary healthcare provider.
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1. Correct: Yes, especially now that the client will be having narcotics for pain and decreased activity level.
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An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? 1. Intake and output every shift 2. Lung assessments every 2-4 hours 3. Vital signs every shift 4. IV site assessment every 2-4 hours
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2. Correct: The older adult is at risk for circulatory overload and should be closely monitored with rapid infusion rates.
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The nurse is caring for a burn client in the emergent phase. The client becomes extremely restless while on a ventilator. What is the priority nursing assessment? 1. Assess patency of endotracheal tube. 2. Auscultate lungs for adventitious breath sounds. 3. Check for fluid in the ventilator tubing. 4. Determine if ventilator settings are correct as prescribed.
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1. Correct: With restlessness, think hypoxia. Start assessment with ABCs. Check for patency of the ET tube. That is the airway.
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Which action by an unlicensed nursing assistant would require the nurse to intervene? 1. Collecting I & O totals for unit clients at the end of shift. 2. Elevating the head of the bed 30°- 40° for the client immediately post thoracotomy 3. Ambulating a client who is 2 days post vaginal hysterectomy 4. Turning off continuous tube feeding to reposition a client, then turning the feeding back on
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4. Correct: The unlicensed nursing assistant should not turn tube feedings off or on. The nurse should do this when repositioning is needed. Prior to turning feeding back on, tube placement needs to be verified.
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A client is admitted to the hospital with acute exacerbation of COPD following an upper respiratory infection. His daughter found him at home, confused and in respiratory distress, a day after he developed a cold. He was placed on 4 L/min of oxygen via nasal cannula, but oxygen saturation remains at 89%. Based on this assessment, the nurse suspects that the client has developed which acid base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
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1. Correct: Respiratory failure, COPD, muscular weakness can lead to respiratory acidosis. Signs and symptoms: hypoventilation, sensorium changes, somnolence, semicomatose to comatose state. pH 45, HCO3 normal.
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A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? 1. PT of 16 2. PTT of 22 3. INR of 2.5 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)
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2. Correct: The test that monitors the efficacy of heparin is the PTT. The normal range for a PTT is 30-40 seconds, but desired outcome of heparin therapy is PTT of 1.5-2.5 times the control without signs of hemorrhage.
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The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? 1. What type of heat do you use in the home? Select all that apply: 2. Does anyone in the home have hobbies that involve sanding of wood or use of chemicals? 3. Is there anyone in the home who smokes? 4. Do you routinely use aerosol sprays for personal care or cleaning? 5. Is your water supply treated by a municipal agency?
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1., 2., 3. & 4. Correct: Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems.
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Which client should the nurse assign to a room closest to the nurse's station? 1. A multigravida admitted with a new diagnosis of gestational diabetes 2. A primigravida admitted with a diagnosis of placenta previa 3. A primigravida admitted with a diagnosis of complete abortion 4. A pregestational diabetic admitted for glycemic control
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2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely.
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The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which complications? Select all that apply: 1. Kidney stones 2. Diarrhea 3. Osteoporosis 4. Tetany 5. Fluid volume deficit
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1. & 3. Correct: Yes, because too much calcium in blood = too much calcium in urine and increased risk of kidney stones. Increased PTH is pulling the calcium from the bones, leaving them weak.
