12345678

Sequence for using crutches?

"1. Place body weight on crutches. 2. Bring the crutches and the affected leg up to the stair. 3. Shift weight from the crutches to the unaffected leg. 4. Advance the unaffected leg onto the stair." *Not correct "1. Place body weight on crutches. 2. Bring the crutches and the affected leg up to the stair. 3. Shift weight from the crutches to the unaffected leg. 4. Advance the unaffected leg onto the stair." *Not correct ?? pg. 230 - doesn't provide step just basic instructions

A charge nurse is providing an educational session about infection control for a group of staff nurses. Which of the following statements by one of the staff nurses indicates an understanding of isolation precautions?

"A client who requires airborne precautions should be placed in a negative-pressure airflow room."

A nurse in a provider's office is assessing an adolescent who has been taking ibuprofen for 6 months to treat juvenile idiopathic arthritis. Which of the following questions should the nurse ask to assess for an adverse effect of this medication?

"Have you had any stomach pain or bloody stools?"

A nurse is providing teaching about advance directives to a middle adult client. Which of the following client responses indicates an understanding of the teaching?

"I can designate my partner as my health care surrogate."

A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism?

"I told my doctor that I would like to start a support group for other women who are sick in my community." -- This statement indicates that the client is using the constructive defense mechanism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept.

A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?

"I will be checking you once with your eyes open and once with them closed."

A nurse is providing discharge instructions about newborn care to a client who is postpartum. Which of the following statements indicates to the nurse that the client understands the teaching?

"I will cover my baby's body when I wash her hair." "I will use the bulb syringe first in her mouth and then in her nose."

A nurse is providing education to the parent of a school-age child who has asthma. Which of the following statements by the parent indicates an understanding of the teaching?

"I will make sure my child receives a yearly influenza immunization." -- Children who have asthma should be immunized and protected from infections.

A nurse is teaching a client who has a new prescription for a total parenteral nutrition through a central line. Which of the following information should the nurse include in the teaching?

"I will need to measure your weight daily." -- The nurse should instruct the client that daily weight measurement is a necessary part of administering nutrition through a central line to avoid fluid overload and monitor for adequate weight gain.

A nurse is providing teaching to the guardians of a newborn about measures to prevent SIDS. Which of the following guardian statements indicates an understanding of the teaching?

"I will not allow anyone to smoke near my baby." -- This statement by the guardian indicates an understanding of the nurse's instructions. Research indicates a strong correlation between exposure to cigarettes smoke and the occurrence of SIDS.

Client who has has esophageal cancer and is to udnergo radiation therapy. Client statement indicating understanding of teaching?

"I will use my hands rather than a washcloth to clean the radiation area. "This will prevent irritation to the area and removal of markings."

A nurse is teaching a client who is at 20 weeks of gestation about common discomforts associated with pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I will wear a supportive bra overnight."

A home health nurse is caring for a group of older adult clients. The nurse should initiate a referral to the Program of All-Inclusive Care for the Elderly (PACE) for which of the following clients?

A client whose caregiver requests adult day care services

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations?

A is correct. Zenker's diverticulum, or pharyngeal pouch, is a herniation of the esophagus occurring through the cricopharyngeal muscle in the midline of the neck. Repair of the diverticulum is accomplished through an open incision in the client's neck.

A nurse working in an emergency department is triaging four clients. Which of the following clients should the nurse recommend for treatment first?

A middle adult client who has unstable vital signs

A charge nurse notices that one of the nurses on the shift frequently violates unit policies by taking an extended amount of time for break. Which of the following statements should the charge nurse make to address this conflict?

"I would like to talk to you about the unit policies regarding break time." -- The charge nurse is dealing with the conflict in a cooperative, positive manner by using this statement to open the conversation in a nonthreatening way. The focus is on the length of the break time and is not a personal affront.

A home health nurse is evaluating a school-age child who has cystic fibrosis. The nurse should initiate a request for a high-frequency chest compression vest in response to which of the following parent statements?

"My child has only a small amount of mucus after percussion therapy."

A nurse is providing discharge teaching for the parents of a preschool-age child who has a new prescription for amoxicillin/clavulanate suspension. Which of the following instructions should the nurse include in the teaching?

"Shake the medication bottle feel before each dose is given." "Store the medication in the refrigerator." "Report diarrhea to the provider immediately."

A nurse is caring for a client who has cancer and is deciding between two treatment plans. The client asks the nurse for assistance in making the decision. Which of the following responses should the nurse make?

"Tell me more about your understanding of the options."

A hospice nurse is consulting with a client and her family about receiving home services. Which of the following statements should the nurse identify as an indication that the family understands home hospice care?

"We can expect the hospice nurse to provide support for us after our mother's death." -- Hospice care includes bereavement services after a family member's death.

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

"You have the right to change your mind about this procedure at any time."

A nurse is assessing a client whose partner recently died. The client states, "I don't know what to do without my partner. Life is just not worth living." Which of the following responses should the nurse make?

"You seem to be having a difficult time right now."

A nurse is providing teaching to a client who is at 24 weeks of gestation and is scheduled for a 3-hr oral glucose tolerance test. Which of the following instructions should the nurse include in the teaching?

"You will need to fast the night before the test."

A nurse is caring for a client who recently signed an informed consent form to donate a kidney to her sibling who has end-stage kidney disease. The donor states to the nurse, "I don't want my brother to die, but what if I need this kidney one day?" Which of the following responses should the nurse make?

"You're afraid that your other kidney will fail at some point after the organ donation."

A nurse is providing client teaching about the basal body temperature method of birth control. Which of the following information should the nurse include in the teaching?

"Your body temperature might decrease slightly just prior to ovulation."

A nurse is conducting a physical examination for an adolescent and is assessing the range of motion of the legs. Which of the following images indicates the adolescent is abducting the hip joint?

(image with patient facing you with her right leg lifted)

A nurse is reviewing the medication history of a client who is to undergo allergy testing. The nurse should instruct the client to discontinue which of the following medications before the testing?

...

Manifestations of ICP in a patient with a closed head injury

1. Sleepiness exhibited by the client. 2. Widening pulse pressure - late finding of Cushings triad w/severe HTN and bradycardia 3. Decereberate posturing - due to deteriorating motor function pg. 81

Neurologic deficits that should be expected in right-hemispheric stroke

1. Visual Spatial Deficits 2. Left Hemianopsia 3. One sided neglect

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.)

1.Follow a smoking cessation program. 2.Maintain an appropriate weight. 3.Eat a low-fat diet. "Atherosclerosis is plaque/fat b/u in the inner walls of the arteries which is caused by not following things mentioned above."

Greatest amount of calcium

12 almonds

A nurse is providing dietary teaching to a client who is post-operative following a thyroidectomy with removal of the parathyroid glands the nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet

12 almonds because they are the best source of calcium to recommend because they contain 36 milligrams of calcium removal of the parathyroid glands which regulate calcium in the body can result in hypocalcemia

A nurse is preparing to administer lactated Ringer's 1,500 mL IV to infuse at 50 mL/hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

12.5 gtt/min

TPN 2,000 kcal per day; 500 kcal/L. How many mL/hr?

167 mL/hr "2,000/24hrs = 83.333 83.333/500= 0.1667*1000=166.666 Round to the nearest whole number =167"

A nurse is caring for a client who has a new prescription for tpn the client is to receive 2,000 kcalories per day the t-pn solution has 500 kcalories per liter the IV pump should be set at how many milliliters per hour

167 milliliters per hour 2000 kcl - 500 kcl = 4L Total infusion time 24h 4000ml / 24hr = 166.67 167ml/hr

A nurse is preparing to administer mannitol 0.2 g/kg IV bolus over 5 min as a test dose to a client who has severe oliguria. The client weighs 198 lbs. What is the amount in grams the nurse should administer?

18 g

Inguinal hernia

A "This hernia occurs from a weak area in the muscle. Protrusion common in the groin area, umbilicus, and a healed incision." pg. 340

A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain.

A nurse is providing teaching a client who has a new diagnosis of type 1 DM and is planning a trip. Which of the following instructions should the nurse include in the teaching? A. "Take additional pairs of shoes." B. "Store prefilled syringes in a plastic bag in the bottom of your luggage." C. "Test your urine for ketones three times daily while on vacation." D. "Increase insulin dosages if weight gain occurs."

A. "Take additional pairs of shoes." The nurse should instruct the client to take additional pairs of shoes and to change shoes several times throughout the day to prevent injury to the feet. The client should purchase shoes that are not open-toed sandals or have straps between the toes as these can result in foot injury. Clients who have diabetes should not wear the same pair of shoes for consecutive days.

A nurse is caring for a client who has type 1 diabetes mellitus and has acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? A. "Take insulin even if you are unable to eat your regular diet." B. "It's okay if your ketone levels are temporarily high." C. "Monitor your blood glucose levels every 12 hours." D. "Call the provider if your glucose levels reach 170 mg/dl"

A. "Take insulin even if you are unable to eat your regular diet." The client should continue her medication regimen when ill to prevent hyperglycemia.

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to assess for this sign? A. Stroke the lateral aspect of the sole of the foot. B. Ask the client to blink his eyes. C. Observe for facial drooping. D. Have the client stand erect with eyes closed.

A. A Babinski sign is elicited by stroking the lateral aspect of the sole of the foot. B. Asking the client to blink his eyes assesses cranial nerve function and is not part of the Romberg test. C. Observing for facial drooping assesses cranial nerve function and is not part of the Romberg test. D. CORRECT: A positive Romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed.

A nurse is providing teaching to a client who has hypertension and a new prescription for Verapamil. Which of the following statements by the client indicates an understanding of the teaching? A. "I will count my heart beats before taking this medication." B. " I should limit my time in the sun while taking this medication." C. "I should avoid drinking orange juice while taking this medication." D. "I should decrease my fiber intake while taking this medication."

A. "I will count my heart beats before taking this medication." The client should monitor his heart rate and blood pressure while taking this medication and inform the provider if his pulse is less than 60/min.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin Alfa. Which of the following client statements indicates an understanding of the teaching? A. "I will monitor my blood pressure while taking this medication." B. "I should take a vitamin D supplement to increase the effectiveness of the medication" C. "An increase in my appetite indicates that the medication has reached a toxic level" D. "I will decrease the amount of protein in my diet while taking this medication."

A. "I will monitor my blood pressure while taking this medication." The client should monitor his blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse report? A. "It's like a curtain closed over my eye." B. "This sharp pain in my eyes started 2 hours ago." C. I've been having more and more difficulty seeing over the last few weeks." D. "I seem to have more problems seeing different colors."

A. "It's like a curtain closed over my eye." A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

Teaching about client rights. Instructions the nurse should include.

A client should sign an informed consent before receiving a placebo during a research trial. "The client should be informed although it is a placebo because they are being part of a clinical trial in which those who may not receive the placebo may experience side effects. Patients are not told they have the placebo for the trial to work so everyone is given the same info."

A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism?

A client who channels their energy into a new hobby following the loss of their job -- The nurse should identify that this client is using the defense mechanism of sublimation by channeling negative feelings over the loss of their job into a new hobby.

Which patient should the nurse assess first?

A client who had a MI 4 days ago and is asking for a PRN sublingual nitro tablet. "The nurse should treat this patient first because they can become unstable, at risk for another MI. Very painful. Seeing them first will be considered prophylactic treatment of chronic stable angina or variant angina." *Pt with pneumonia is presenting with expected symptoms, still needs to be monitored though.

A nurse on a medical-surgical unit is receiving change of shift report on four clients which of the following clients should the nurse identify as having the greatest risk for developing an infection

A client who has COPD and is receiving steroid therapy because of decreased oxygenation and increased mucus production additionally taking a steroid medication increases the client's risk for infection by suppressing the immune system and masking the presence of an infection

A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?

A client who has cellulitis and is receiving oral antibiotics every 8 hr

A nurse is assessing a client who has experienced a left‑hemispheric stroke. Which of the following is an expected finding? A. Impulse control difficulty B. Poor judgment C. Inability to recognize familiar objects D. Loss of depth perception

A client who has experienced a right‑hemispheric stroke will experience difficulty with impulse control. B. A client who has experienced a right‑hemispheric stroke will experience poor judgment. C. CORRECT: A client who experienced a left‑hemispheric stroke will demonstrate the inability to recognize familiar objects, known as agnosia. D. A client who experienced a right‑hemispheric stroke will experience a loss of depth perception.

Client at risk for experiencing a role change.

A client who has multiple sclerosis and is experiencing progressive difficulty ambulating. "This patient may have to depend on other for help causing them to not be as independent as they are used too."

An antepartum nurse is caring for four clients. For which of the following clients should the nurse initiate seizure precautions?

A client who is at 33 weeks of gestation and has severe gestational hypertension -- The nurse should initiate seizure precautions for a client who has severe gestational hypertension because an extremely elevated blood pressure in an antepartum client can trigger seizure activity. The nurse should provide the client with a quiet, darkened environment, place suction equipment and oxygen at the bedside, and position the call light within the client's reach.

A nurse has just received change-of-shift report on four clients. Which of the following clients should the nurse assess first?

A client who is postoperative with abdominal distention and no bowel sounds.

A nurse has received change-of-shift report on four assigned clients. For which of the following clients should the nurse intervene to prevent a potential food and medication interaction?

A client who is receiving an MAOI and is requesting a cheeseburger for dinner.

A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A client who was abused as a child describes the abuse as if it happened to someone else.

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? A. "This medication can decrease my immune response." B. "I take this medication to prevent asthma attacks." C. "I need to take this medication with food." D. "This medication has a slow onset to treat my symptoms."

A. A bronchodilator does not decrease the body's immune response. However, an anti‑inflammatory medication can cause this effect. B. CORRECT: A bronchodilator can prevent asthma attacks from occurring. C. An oral bronchodilator does not need to be taken with food. However, an anti‑inflammatory medication can cause gastrointestinal distress and needs to be to be given with food. D. A bronchodilator has a fast onset to relieve asthma attack symptoms

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? A. Antibiotic B. Beta‑blocker C. Antiviral D. Beta2 agonist

A. An antibiotic typically is given for a bacterial infection. B. A beta‑blocker typically is given for dysrhythmias, heart disease, or hypertension. C. An antiviral typically is given for a virus. D. CORRECT: The nurse should administer a beta2 agonist, which causes dilation of the bronchioles to relieve symptoms.

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply.) A. Administer antibiotics. B. Provide supplemental oxygen. C. Administer antiviral medications. D. Administer of bronchodilators. E. Maintain ventilatory support.

A. Antibiotics are given to treat bacterial infections. This would not be indicated for SARS. B. CORRECT: Providing supplemental oxygen should be included in the plan of care for SARS. Oxygen is administered given to treat severe hypoxemia. C. SARS is caused by the coronavirus. There are no effective antiviral medications to treat this virus. D. CORRECT: Administration of bronchodilators should be included in the plan of care for SARS. Bronchodilators are used to vasodilate the client's airway. E. CORRECT: Maintaining ventilatory support should be included in the plan of care for SARS. Intubation can be required to maintain a patent airway.

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has acute respiratory distress syndrome (ARDS). Which of the following statements by the newly licensed nurse indicates understanding of the teaching? A. "This medication is given to treat infection." B. "This medication is given to facilitate ventilation." C. "This medication is given to decrease inflammation." D. "This medication is given to reduce anxiety.

A. Antibiotics are given to treat infection. B. CORRECT: Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption. C. Corticosteroids are given to treat inflammation. D. Benzodiazepines are given to treat anxiety.

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication can increase my blood sugar levels." B. "This medication can decrease my immune response." C. "I can have an increase in my heart rate while taking this medication." D. "I can have mouth sores while taking this medication."

A. Anti‑inflammatory agents, such as corticosteroids, can cause hyperglycemia. B. Anti‑inflammatory agents can decrease the immune response. C. CORRECT: Bronchodilators, such as albuterol, can cause tachycardia. D. Anti‑inflammatory agents can cause mouth sores.

A nurse is assessing a client who is reporting pain despite analgesia. Which of the following actions should the nurse take to assess the intensity of the client's pain? A. Ask the client what precipitates his pain. B. Question the client about the location of his pain. C. Offer the client a pain scale to measure his pain. D. Use open‑ended questions to identify the sensation of his pain.

A. Assessment of pain triggers will provide valuable information to help select pain‑control interventions, but it does not provide information about the intensity of pain. B. Identification of the location of the client's pain provides valuable information to help select pain‑control interventions, but it does not provide information about the intensity of pain. C. CORRECT: The nurse should use a pain scale to help the client measure the amount of pain he has and its intensity. D. Asking open‑ended questions is important in pain assessment, but it does not provide for quantification of pain intensity.

A nurse is planning care for a client who is receiving mechanical ventilation. Which of the following modes of ventilation that increases the effort of the client's respiratory muscles should the nurse include in the plan of care? (Select all that apply.) A. Assist‑control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

A. Assist‑control mode takes over the work of breathing. B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths. D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths. E. Independent lung ventilation mode is used for unilateral lung disease to ventilate the lung individually.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) A. A client who experienced a near‑drowning incident B. A client following coronary artery bypass graft surgery C. A client who has a hemoglobin of 15.1 mg/dL D. A client who has dysphagia E. A client who experienced a drug overdose

A. CORRECT: A client who experienced a near‑drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. B. CORRECT: A client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. C. Hemoglobin of 15.1 mg/dL is within the expected reference range. A client who has a low hemoglobin is at risk for developing ARDS. D. CORRECT: A client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. E. CORRECT: A client who experienced a drug overdose is at risk for developing ARDS due to damage to the central nervous system.

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? A. "I should restrict rapid movements and avoid bending from the waist for several weeks." B. "I should wait until the day after surgery to wash my hair." C. "I will remove the dressing behind my ear in 7 days." D. "My hearing should be back to normal right after my surgery."

A. CORRECT: Rapid movements and bending from the waist should be avoided for 3 weeks following ear surgery. B. The client should avoid showering and washing hair for at least several days up to 1 week following ear surgery. The ear must remain dry during this time. C. Middle ear surgery is performed through the tympanic membrane, and the client will have a dry dressing within the ear canal. There is no external excision. D. Decreased hearing is expected following middle ear surgery due to presence of a dressing within the ear canal and possible drainage

A nurse at a provider's office is reviewing the laboratory test results for a group of clients. The nurse should identify that which of the following results indicates the client is at risk for heart disease? (Select all that apply.) A. Cholesterol (total) 245 mg/dL B. HDL 90 mg/dL C. LDL 140 mg/dL D. Triglycerides 125 mg/dL E. Troponin I 0.02 ng/mL

A. CORRECT: A client who has a total cholesterol level greater than 200 mg/dL is at increased risk for heart disease. B. An HDL level greater than 55 mg/dL for a female client or greater than 45 mg/dL for a male client decreases the client's risk for heart disease. C. CORRECT: A client who has an LDL level greater than 130 mg/dL is at increased risk for heart disease. D. A triglyceride level between 35 and 135 mg/dL for a female client or 40 and 160 mg/dL for a male client is within the expected reference range and does not indicate an increased risk for heart disease. E. Troponin I level is monitored to detect cardiac injury due to an MI rather than to identify a client's risk for heart disease. A Troponin I level less than 0.03 ng/mL is within the expected reference range.

A nurse on a cardiac unit is caring for a group of clients. The nurse should recognize which of the following clients as being at risk for the development of a dysrhythmia? (Select all that apply.) A. A client who has metabolic alkalosis B. A client who has a serum potassium level of 4.3 mEq/L C. A client who has an SaO2 of 96% D. A client who has COPD E. A client who underwent stent placement in a coronary artery

A. CORRECT: A client who has an acid‑base imbalance such as metabolic alkalosis is at risk for a dysrhythmia. B. A serum potassium of 4.3 mEq/L is within the expected reference range and does not increase the risk of a dysrhythmia. C. SaO2 of 96% is within the expected reference range and does not increase the risk of a dysrhythmia. D. CORRECT: A client who has lung disease, such as COPD, is at risk for a dysrhythmia. E. CORRECT: A client who has cardiac disease and underwent a stent placement is at risk for a dysrhythmia.

A nurse is caring for a client who has experienced a right‑hemispheric stroke. Which of the following are expected findings? (Select all that apply.) A. Impulse control difficulty B. Left hemiplegia C. Loss of depth perception D. Aphasia E. Lack of situational awareness

A. CORRECT: A client who has experienced a right‑hemispheric stroke will exhibit impulse control difficulty, such as the urgency to use the restroom. B. CORRECT: A client who has experienced a right‑hemispheric stroke will exhibit left‑sided hemiplegia. C. CORRECT: A client who has experienced a right‑hemispheric stroke will experience a loss in depth perception. D. A client who has experienced a left‑hemispheric stroke will experience aphasia E. CORRECT: A client who has experienced a right‑hemispheric stroke will demonstrate a lack of awareness of surroundings.

A nurse is caring for a client who is having surgery for the removal of an encapsulated acoustic tumor. Which of the following potential complications should the nurse monitor for postoperatively? (Select all that apply.) A. Increased intracranial pressure B. Hemorrhagic shock C. Hydrocephalus D. Hypoglycemia E. Seizures

A. CORRECT: A client who has had a craniotomy should be monitored postoperatively for increased ICP. B. Although hypovolemic shock can occur secondary to SIADH, hemorrhagic shock is not a concern. C. CORRECT: Following a craniotomy, the client should be monitored for the development of hydrocephalus. D. An alteration in glucose metabolism is not usually a postoperative concern after this surgery. E. CORRECT: Seizures is a postoperative complication that should be monitored following a craniotomy.

A nurse is beginning a physical assessment of a client who has a new diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (Select all that apply.) A. Areas of paresthesia B. Involuntary eye movements C. Alopecia D. Increased salivation E. Ataxia

A. CORRECT: Areas of loss of skin sensation are a finding in a client who has MS. B. CORRECT: Nystagmus is a finding in a client who has MS. C. Hair loss is not a finding in a client who has MS. D. Dysphagia, swallowing difficulty, is a finding in a client who has MS. E. CORRECT: Ataxia occurs in the client who has MS as muscle weakness develops and there is loss of coordination.

A nurse is completing an assessment of a client who has increased intracranial pressure (ICP). Which of the following are expected findings? (Select all that apply.) A. Disoriented to time and place B. Restlessness and irritability C. Unequal pupils D. ICP 15 mm Hg E. Headache

A. CORRECT: Changes in level of consciousness are an early indicator of increased ICP. B. CORRECT: Increased ICP can cause behavior changes, such as restlessness and irritability. C. CORRECT: Unequal pupils indicates pressure on the oculomotor nerve secondary to increased ICP. D. An ICP of 15 mm Hg is within the expected reference range. E. CORRECT: A headache is a manifestation of increased ICP.

A nurse is caring for a client who has global aphasia (both receptive and expressive). Which of the following should the nurse include in the client's plan of care? (Select all that apply.) A. Speak to the client at a slower rate. B. Assist the client to use flash cards with pictures. C. Speak to the client in a loud voice. D. Complete sentences that the client cannot finish. E. Give instructions one step at a time.

A. CORRECT: Clients who have global aphasia have difficulty with speaking and understanding speech. One strategy that can enhance client understanding is speaking to the client at a slower rate. B. CORRECT: One strategy that can enhance understanding is the use of alternative forms of communication, such as flash cards with pictures or a computer. C. For the client who has aphasia, speaking in a loud voice is unnecessary and can be interpreted as patronizing. D. The nurse should allow the client adequate time to finish sentences and not complete the sentences for him. E. CORRECT: One strategy that can enhance understanding is giving instructions one step at a time.

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? (Select all that apply.) A. "It is given to reduce swelling of the brain." B. "You will need to monitor for low blood sugar." C. "You may notice weight gain." D. "Tumor growth will be delayed." E. "It can cause you to retain fluids."

A. CORRECT: Dexamethasone is a common steroid prescribed to reduce cerebral edema. B. The client can experience hyperglycemia as an adverse effect of dexamethasone. C. CORRECT: Weight gain is an adverse effect of dexamethasone. D. Dexamethasone does not affect tumor growth. It is given to prevent cerebral edema. E. CORRECT: Fluid retention is an adverse effect of dexamethasone.

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply.) A. Dyspnea B. Localized bloody drainage on the dressing C. Fever D. Hypotension E. Report of pain at the puncture site

A. CORRECT: Dyspnea can indicate a pneumothorax or a reaccumulation of fluid. The nurse should notify the provider immediately. B. Localized bloody drainage contained on a dressing is an expected finding following a thoracentesis. C. CORRECT: Fever can indicate an infection. The nurse should notify the provider immediately. D. CORRECT: Hypotension can indicate intrathoracic bleeding. The nurse should notify the provider immediately. E. The client's report of pain at the puncture site is an expected finding following a thoracentesis.

A nurse is reviewing the health record of a client who has severe otitis media. Which of the following are expected findings? (Select all that apply.) A. Enlarged adenoids B. Report of recent colds C. Client prescription for daily furosemide D. Light reflex visible on otoscopic exam in the affected ear E. Ear pain relieved by meclizine

A. CORRECT: Enlarged tonsils and adenoids are a finding associated with a middle ear infection. B. CORRECT: Frequent colds are findings associated with a middle ear infection. C. Furosemide is an ototoxic medication and can cause sensorineural hearing loss, but taking furosemide does not cause a middle ear disorder. D. Light reflexes are absent or in altered positions in a client who has a middle ear disorder. E. CORRECT: Meclizine is prescribed to relieve vertigo for inner ear disorders, but does not relieve the pain of a middle ear infection.

A nurse is caring for a client who has Alzheimer's disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurse's response? (Select all that apply.) A. Exposure to metal waste products B. Long-term estrogen therapy C. Sustained use of vitamin E D. Previous head injury E. History of herpes infection

A. CORRECT: Exposure to metal and toxic waste is a risk factor for Alzheimer's disease. B. Long-term estrogen therapy can prevent Alzheimer's disease. C. Long-term use of vitamin E is not a risk factor for Alzheimer's disease. D. CORRECT: A previous head injury is a risk factor for Alzheimer's disease. E. CORRECT: A history of herpes infection is a risk factor for Alzheimer's disease.

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply.) A. Fentanyl B. Furosemide C. Midazolam D. Famotidine E. Dexamethasone

A. CORRECT: Fentanyl is a pain medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. B. Furosemide is a diuretic used to release fluid from the body. C. CORRECT: Midazolam is a sedative medication used to treat clients who have ARDS when a neuromuscular blocking agent such as vecuronium is administered. D. Famotidine is an H2 receptor antagonist given to treat upset stomach and heartburn. E. Dexamethasone is a corticosteroid used to treat inflammation such as arthritis or an immune disorder.

A nurse in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.) A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension

A. CORRECT: Headache is a finding associated with increased ICP. B. CORRECT: Dilated pupils is a finding associated with increased ICP. C. Bradycardia, not tachycardia, is a finding associated with increased ICP. D. CORRECT: Decorticate or decerebrate posturing is a finding associated with increased ICP. E. Hypertension, not hypotension, is a finding associated with increased ICP.

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.40, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid‑base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. CORRECT: Nail polish can affect the accuracy of pulse oximetry and result in an incorrect pulse oximetry level . B. CORRECT: Inadequate peripheral circulation can result in a low reading while obtaining a pulse oximetry level. C. Hypothermia can result in a low reading while obtaining a pulse oximetry level. D. A decreased Hgb level can result in a low reading while obtaining a pulse oximetry level. E. CORRECT: Edema can result in a low reading while obtaining a pulse oximetry level.

A nurse is assessing the pain level of a client who came to the emergency department reporting severe abdominal pain. The nurse asks the client whether he has nausea and has been vomiting. The nurse is assessing which of the following components of a pain assessment? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. CORRECT: Nausea and vomiting are common manifestations clients have when they are in pain. B. The location of the pain is where the client feels the pain. C. Pain quality is what the pain feels like, such as throbbing and dull. D. Aggravating and relieving factors are what might make the pain better or worse.

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescription for bromocriptine. Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing. B. Expect urine to become dark‑colored. C. Avoid foods containing tyramine. D. Report any skin discoloration.

A. CORRECT: Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness. B. The client should expect urine to turn dark when taking entacapone, a COMT inhibitor. Dark urine is not an expected finding when taking bromocriptine. C. The client should avoid tyramine in the diet when taking selegiline, a monoamine type B inhibitor. However, bromocriptine does not interact with foods that contain tyramine. D. Skin discoloration is an adverse effect of amantadine, an anti‑viral medication. However it is not an adverse effect of bromocriptine.

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the client's room? (Select all that apply.) A. Oxygen equipment B. Incentive spirometer C. Pulse oximeter D. Sterile dressing E. Suture removal kit

A. CORRECT: Oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. B. An incentive spirometer is indicated for a client following thoracic surgery to promote improved oxygenation and pulmonary function. C. CORRECT: Pulse oximetry is necessary to monitor oxygen saturation level during the procedure. D. CORRECT: A sterile dressing is necessary to apply to the puncture site following the procedure. E. A suture removal kit is needed to remove sutures following surgery.

A nurse is preparing to care for a client following chest tube placement. Which of the following items should be available in the client's room? (Select all that apply.) A. Oxygen B. Sterile water C. Enclosed hemostat clamps D. Indwelling urinary catheter E. Occlusive dressing

A. CORRECT: Oxygen should be readily available in case the client develops respiratory distress following chest tube placement. The nurse should monitor respiration, oxygen saturation, and lung sounds. B. CORRECT: If the chest tubing becomes disconnected, the end of the tubing should be placed in sterile water to restore the water seal. C. CORRECT: Hemostat clamps should be available for the nurse to use to check for air leaks. D. An indwelling urinary catheter is not indicated for a client who has a chest tube. E. CORRECT: If the chest tubing becomes disconnected, the nurse should immediately place a gauze dressing over the site. An occlusive dressing can also be necessary to prevent the redevelopment of a pneumothorax.

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? A. Position the client in an upright position, leaning over the bedside table. B. Explain the procedure. C. Obtain ABGs. D. Administer benzocaine spray.

A. CORRECT: Positioning the client in an upright position and bent over the bedside table widens the intercostal space for the provider to access the pleural fluid. B. It is the responsibility of the provider, not the nurse, to explain the procedure to the client. C. It is not indicated that the client needs ABGs drawn. D. Benzocaine spray is administered for a bronchoscopy, not a thoracentesis.

A nurse is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the nurse include in the plan of care? (Select all that apply.) A. Have suction equipment available for use. B. Feed the client thickened liquids. C. Place food on the unaffected side of the client's mouth. D. Assign an assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed.

A. CORRECT: Suction equipment should be available in case of choking and aspiration. B. CORRECT: The client should be given liquids that are thicker than water to prevent aspiration. C. CORRECT: Placing food on the unaffected side of the client's mouth will allow her to have better control of the food and reduce the risk of aspiration. D. Due to the risk of aspiration, assistive personnel should not be assigned to feed the client because the client's swallowing ability should be assessed, and suctioning can be needed if choking occurs. E. CORRECT: The client should be taught to flex her neck, tucking the chin down and under to close the epiglottis during swallowing.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. Condom catheter B. Intermittent urinary catheterization C. Credé's method D. Indwelling urinary catheter

A. CORRECT: The nurse should implement the noninvasive use of a condom catheter, because the bladder will emptyon its own due to the client having an upper motor neuron injury, which is manifested by a spastic bladder. B. The nurse should implement intermittent urinary catheterization method for a client who has a flaccid bladder. C. The nurse should implement the Credé's method for a client who has a flaccid bladder. D. An indwelling urinary catheter is an invasive procedure. The nurse should not implement this bladder management method for the client

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

A. CORRECT: The nurse should include in the teaching that a persistent cough is a manifestation of tuberculosis. B. The nurse should include in the teaching that weight loss is a manifestation of tuberculosis. C. CORRECT: The nurse should include in the teaching that fatigue is a manifestation of tuberculosis. D. CORRECT: The nurse should include in the teaching that night sweats is a manifestation of tuberculosis. E. CORRECT: The nurse should include in the teaching that purulent sputum is a manifestation of tuberculosis.

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse? A. "There are portable oxygen delivery systems that you can take with you." B. "When you go out, you can remove the oxygen and then reapply it when you get home." C. "You probably will not be able to go out as much as you used to." D. "Home health services will come to you so you will not need to get out."

A. CORRECT: The nurse should inform the client that there are portable oxygen systems that he can use to leave the house. This should alleviate the client's anxiety. B. The nurse should tell the client use oxygen at all times to prevent becoming hypoxic. C. The nurse should encourage the client to return to his daily routine, but include periods of rest. D. The nurse should encourage the client to return to his daily routine. Home health services promote a client's independence.

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (Select all that apply.) A. Avoid overwhelming fatigue. B. Remove caffeinated products from the diet. C. Limit looking at flashing lights. D. Perform aerobic exercise. E. Limit episodes of hypoventilation. F. Use of aerosol hairspray is recommended.

A. CORRECT: The nurse should instruct the client to avoid overwhelming fatigue, which can trigger a seizure by stimulating abnormal electrical neuron activity. B. CORRECT: The nurse should instruct the client to remove caffeinated products from the diet, which can trigger a seizure by stimulating abnormal electrical neuron activity. C. CORRECT: The nurse should instruct the client to refrain from looking at flashing lights, which can trigger a seizure by stimulating abnormal electrical neuron activity. D. The nurse should instruct the client to avoid vigorous physical activity, which can help to avoid triggering a seizure. E. The nurse should instruct the client to limit excess hyperventilation, which can trigger a seizure by stimulating abnormal electrical neuron activity. F. The nurse should instruct the client to avoid using aerosol hairspray, which can trigger a seizure by stimulating abnormal electrical neuron activity.

A nurse is planning care for a client following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply.) A. Encourage the client to cough every 2 hr. B. Check for continuous bubbling in the suction chamber. C. Strip the drainage tubing every 4 hr. D. Clamp the tube once a day. E. Obtain a chest x‑ray.

A. CORRECT: The nurse should instruct the client to cough every 2 hr. This promotes oxygenation and lung reexpansion. B. CORRECT: The nurse should check for continuous bubbling in the suction chamber to verify that suction is being maintained at an appropriate level. C. The nurse should not milk or strip the drainage tubing to check for kinks. This action is only to be done when prescribed. Stripping creates negative high pressure and can damage lung tissue. D. The nurse should not clamp the tubing unless indicated by the provider. This is done to verify for the presence of an air leak or if the tubing accidentally has been disconnected. Clamping can cause a tension pneumothorax. E. CORRECT: A chest x‑ray is obtained following the procedure to verify chest tube placement.

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? A. Increase intake of deep yellow and orange vegetables. B. Administer eye drops twice daily. C. Avoid bending at the waist. D. Wear an eye patch at night.

A. CORRECT: The nurse should instruct the client to increase dietary intake of carotenoids and antioxidants to slow the progression of the macular degeneration. B. A client who has primary open‑angle glaucoma should administer eye drops twice daily. C. A client who is at risk for increased intraocular pressure, such as following cataract surgery, should avoid bending at the waist. D. A client who has had eye surgery, such as cataract surgery, should wear an eye patch at night to protect the eye from injury.

A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply.) A. Hypokalemia B. Tachycardia C. Fluid retention D. Nausea E. Black, tarry stools

A. CORRECT: The nurse should observe for hypokalemia. This is an adverse effect of prednisone. B. Tachycardia is an adverse effect of a bronchodilator. C. CORRECT: The nurse should observe for fluid retention. This is an adverse effect of prednisone. D. Nausea is an adverse effect of a bronchodilator. E. CORRECT: The nurse should monitor for black, tarry stools. This is an adverse effect of prednisone.

A nurse in the emergency department is assessing a client who is unresponsive. The client's partner states, "He was pulling weeds in the yard and slumped to the ground." Which of the following techniques should the nurse use to open the client's airway? A. Head‑tilt, chin‑lift B. Modified jaw thrust C. Hyperextension of the head D. Flexion of the head

A. CORRECT: The nurse should open the client's airway by the head‑tilt, chin‑lift because the client is unresponsive without suspicion of trauma. B. The nurse should not open the client's airway with the modified jaw thrust because this method is used for a client who is unresponsive with suspected traumatic neck injury. C. The nurse should not open the client's airway with hyperextension of the head because hyperextension of the head can close off the airway and cause injury. D. The nurse should not open the client's airway with flexion of the head because flexion of the head does not open the airway.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position. B. Flex client's hip and knee. C. Place hands behind the client's neck. D. Bend client's head toward chest. E. Straighten the client's flexed leg at the knee.

A. CORRECT: The nurse should place the client in supine position when assessing for Brudzinski's sign. B. The nurse should flex the client's hip and knee when assessing for Kernig's sign. C. CORRECT: The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck. D. CORRECT: The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign. E. The nurse should straighten the client's flexed leg at the knee when assessing for Kernig's sign

A nurse is developing a plan of care for a client who is scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (Select all that apply.) A. "I think I might be pregnant." B. "I take warfarin." C. "I take antihypertensive medication." D. "I am allergic to shrimp." E. "I ate a light breakfast this morning."

A. CORRECT: The nurse should report the client's statement of possible pregnancy to the provider because the contrast dye can place the fetus at risk. B. CORRECT: The nurse should report that the client is taking warfarin to the provider due to the potential for bleeding following angiography. C. There is no contraindication related to contrast dye for a client who is taking antihypertensive medication. D. CORRECT: The nurse should report a client's report of allergy to shrimp, which is a shellfish, to the provider due to a potential allergic reaction to the contrast dye. E. CORRECT: The nurse should report a client's intake of food to the provider since the client should remain NPO for 4 to 6 hr prior to the procedure.

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

A. Gender is not a risk factor associated with glaucoma. B. CORRECT: Genetic predisposition is a risk factor associated with glaucoma. C. CORRECT: Hypertension is a risk factor associated with glaucoma. D. CORRECT: Age is a risk factor associated with glaucoma. E. CORRECT: Diabetes mellitus is a risk factor associated with glaucoma

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. Hand hygiene decreases the risk of the client spreading influenza viruses. B. CORRECT: Fluid intake should be increased if findings develop to maintain hydration and effectiveness of expectoration of mucous. C. Influenza vaccines are administered yearly. The client should receive a vaccination yearly. D. Cough etiquette includes the client to sneeze into the shoulder or elbow rather than the hands.

A nurse is caring for a client who has increased ICP and a new prescription for mannitol. For which of the following adverse effects should the nurse monitor? A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria

A. Hyperglycemia is not an adverse effect of mannitol. B. CORRECT: Mannitol is a powerful osmotic diuretic. Adverse effects include electrolyte imbalances, such as hyponatremia. C. Hypovolemia is an adverse effect of mannitol and should be monitored. D. Polyuria is an adverse of mannitol and should be monitored.

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessing stools. Which of the following findings is an A/E of this medication? A. Hypokalemia B. Hypercalcemia C. Gastrointestinal bleeding D. Confusion

A. Hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.

A nurse is caring for a client who is experiencing an acute MI. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? A. Hypotension B. Bradypnea C. Warm, dry skin D. Increased urinary output

A. Hypotension Cardiogenic shock occurs when a large portion of the left ventricle has died following a myocardial infarction. The decrease in cardiac output results in decreased blood pressure.

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? A. Increase fluid intake B. Take on over-the-counter antidiarrheal medication C. Expect black, tarry stools D. Follow a low-fiber diet

A. Increase fluid intake The nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should indicate in the plan of care? A. Keep a lead-lined container in the client's room B. Limit each visitor to 1 hr per day C. Place a dosimeter badge on the client D. Remove soiled linens from the client's room each day

A. Keep a lead-lined container in the client's room. The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client. B. Place the client in a room close to the nurses' station. C. Encourage the client to ask for assistance. D. Remind the client to walk with someone for support.

A. Keeping the call light within the client's reach is an appropriate action, but not the first action because the client might not remember to use it. B. CORRECT: Using the safety and risk reduction priority-setting framework, placing the client in close proximity to the nurses' station for close observation is the first action the nurse should take. C. Encouraging the client to ask for assistance is an appropriate action, but not the first action because the client might not remember to ask for assistance. D. Reminding the client to walk with someone is an appropriate action, but not the first action because the client might not remember to call for assistance.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings the nurse expect? A. Low urine specific gravity B. Hypertension C. Bounding peripheral pulses D. Hyperglycemia

A. Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas

A. Lung percussion is not an appropriate technique to identify manifestations of sinusitis; it is appropriate for a client who has pneumonia. B. Auscultation of the trachea is not an appropriate technique to identify manifestations of sinusitis; it is appropriate for a client who has bronchitis. C. Inspection of the conjunctiva is not an appropriate technique to identify manifestations of sinusitis; it is appropriate for a client who has anemia D. CORRECT: Palpation of the orbital, frontal, and facial areas will elicit a report of tenderness, which is a manifestation in a client who has sinusitis.

A nurse in the emergency department is caring for a client who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply.) A. SaO2 95% B. Wheezing C. Retraction of sternal muscles D. Pink mucous membranes E. Premature ventricular complexes (PVCs)

A. Oxygen saturation 95% is an expected finding within the respiratory system and exhibits no signs of distress. B. CORRECT: Wheezing is a manifestation indicating the client's respiratory status is declining. C. CORRECT: Retraction of sternal muscles is a manifestation that the client's respiratory status is declining. D. Pink mucous membranes is an expected finding within the respiratory system and exhibits no signs of distress. E. CORRECT: PVCs are a manifestation that the client's respiratory status is declining

A nurse is orienting a newly licensed nurse who is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the newly licensed nurse indicates an understanding of PSV? A. "It keeps the alveoli open and prevents atelectasis." B. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

A. PEEP maintains pressure in the lungs to keep alveoli open or prevent atelectasis. B. CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing. C. PSV does not guarantee minimal minute ventilation because no ventilator breaths are delivered. D. Assist‑control (AC) mode delivers a preset ventilatory rate and tidal volume to the client.

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply.) A. Reduce exposure to bright lighting. B. Move head slowly when changing positions. C. Do not eat fruit high in potassium. D. Plan evenly spaced daily fluid intake. E. Avoid fluids containing caffeine.

A. CORRECT: Remaining in a darkened, quiet environment can reduce vertigo, particularly when it is severe. B. CORRECT: Moving slowly when standing or changing positions can reduce vertigo. C. The client who has vertigo should be instructed to avoid foods containing high levels of sodium to reduce fluid retention, which can cause vertigo. D. CORRECT: Fluid intake should be planned so that it is evenly spaced throughout the day to prevent excess fluid accumulation in the semicircular canals. E. CORRECT: The client should avoid fluids containing caffeine or alcohol to minimize vertigo.

A nurse is making a home visit to a client who has AD. The client's partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? (Select all that apply.) A. Remove floor rugs. B. Have door locks that can be easily opened. C. Provide increased lighting in stairwells. D. Install handrails in the bathroom. E. Place the mattress on the floor.

A. CORRECT: Removing floor rugs can decrease the risk of falling. B. Easy-to-open door locks increase the risk for a client who wanders to get out of his home and get lost. C. CORRECT: Good lighting can decrease the risk for falling in dark areas, such as stairways. D. CORRECT: Installing handrails in the bathroom can be useful for the client to hold on to when his gait is unsteady. E. CORRECT: By placing the client's mattress on the floor, the risk of falling or tripping is decreased.

A nurse is assessing a client who is undergoing hemodynamic monitoring. The client has a CVP of 7 mm Hg and a PAWP of 17 mm Hg. Which of the following findings should the nurse expect? (Select all that apply.) A. Poor skin turgor B. Bilateral crackles in the lungs C. Jugular vein distension D. Dry mucous membranes E. Hepatomegaly

A. The client's CVP and PAWP are above the expected reference range. The nurse should expect the client to have poor skin turgor for a decreased CVP and PAWP. B. CORRECT: The nurse should expect the client to have bilateral crackles in the lungs for an increased CVP and PAWP. C. CORRECT: The nurse should expect the client to have jugular vein distension for an increased CVP and PAWP. D. The nurse should expect the client to have dry mucous membranes for a decreased CVP and PAWP. E. CORRECT: The nurse should expect the client to have hepatomegaly for an increased CVP and PAWP.

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? A. "This medication will help you with your tremors." B. "This medication will help you with your bladder function." C. "This medication may cause your skin to bruise easily." D. "This medication may cause your skin to appear yellow in color."

A. Primidone and clonazepam are beta blockers given to clients who have MS to treat tremors. B. Propantheline is an anticholinergic medication that is given to clients who have MS to treat bladder dysfunction. C. Prednisone is a corticosteroid medication that is given to clients who have MS to treat inflammation. An adverse effect of this medication is bruising of the skin. D. CORRECT: Dantrolene and tizanidine are antispasmodic medications that are given to clients who have MS to treat muscle spasms. An adverse effect of this medication is a yellow appearance of the skin, also known as jaundice. The nurse should instruct the client to monitor for this finding, as this can be an indication of impaired liver function.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

A. Remain with the client for the first 15 min of the infusion. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse in a provider's office is assessing a client who has hypertension and takes Propanolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? A. Report of a night cough B. Report of tinnitus C. Report of excessive tearing D. Report of increase salivation

A. Report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify which of the following findings requires further screening? A. Shellfish allergy B. Appendectomy 1 year ago C. Penicillin allergy D. Total knee arthroplasty 6 months ago

A. Shellfish allergy A shellfish allergy indicates that the client is allergic to iodine, which is used as a contrast agent. Therefore, this finding calls for further investigation by the nurse. Other conditions that can result in a reaction to contrast media include asthma and allergies to foods, such as eggs, milk, and chocolate.

A nurse is assessing a client who had extracorporeal shock wave (ESWL) 6 hr ago. Which of the following should the nurse expect? A. Stone fragments in the urine B. Fever C. Decreased urine output D. Bruising on the lower abdomen

A. Stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

A nursing is caring for a client who has a closed‑head injury with ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? (Select all that apply.) A. Suction the endotracheal tube frequently. B. Decrease the noise level in the client's room C. Elevate the client's head on two pillows. D. Administer a stool softener. E. Keep the client well hydrated.

A. Suctioning increases ICP and should be performed only when indicated. B. CORRECT: Decreasing the noise level and restricting the number of people in the client's room can help prevent increases in ICP. C. Hyperflexion of the client's neck with pillows carries the risk of increasing ICP and should be avoided. The head of the bed should be raised to at least 30°, but the head should be maintained in an upright, neutral position. D. CORRECT: Administration of a stool softener will decrease the need to bear down (Valsalva maneuver) during bowel movements, which can increase ICP. E. Overhydration carries the risk of increasing ICP and should be avoided. The nurse should monitor fluid and electrolyte levels closely for the client who has increased ICP.

A nurse is assessing a client following IV urography. Which of the following findings is the priority? A. Swollen lips B. Pain at the IV catheter insertion site C. Decreased urine output D. Pink-tinged urine

A. Swollen lips Swollen lips indicate that this client is having an anaphylactic reaction to the contrast media which is the greatest risk to the client. Therefore, this finding is the priority.

A nurse is caring for a client who has just been admitted following surgical evacuation of a subdural hematoma. Which of the following is the priority assessment? A. Glasgow Coma Scale B. Cranial nerve function C. Oxygen saturation D. Pupillary response

A. The Glasgow Coma Scale is important. However, another assessment is the priority. B. Assessment of cranial nerve function is important. However, another assessment is the priority. C. CORRECT: Using the airway, breathing, and circulation (ABC) priority‑setting framework, assessment of oxygen saturation is the priority action. Brain tissue can only survive for 3 min before permanent damage occurs. D. Assessment of pupillary response is important. However, another assessment is the priority.

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply.) A. Use the Glasgow Coma Scale when assessing the client. B. Assist the client to a supine position. C. Administer an opioid medication. D. Encourage the client to increase fluid intake. E. Instruct the client to perform deep breathing and coughing exercises.

A. The Glasgow Coma Scale is used to assess a client's level of consciousness and is not necessary following a lumbar puncture. B. CORRECT: The nurse should assist the client to a supine position, which can relieve a headache following a lumbar puncture. C. CORRECT: The nurse should administer an opioid medication for a client's report of headache pain. D. CORRECT: The nurse should encourage an increased fluid intake to maintain a positive fluid balance, which can relieve a headache following a lumbar puncture. E. Coughing can increase ICP, which can result in an increase in the client's headache.

A nurse is planning to instruct a client on how to perform pursed‑lip breathing. Which of the following should the nurse include in the plan of care? A. Take quick breaths upon inhalation. B. Place your hand over your stomach. C. Take a deep breath in through your nose. D. Puff your checks upon exhalation.

A. The client should take a slow deep breath upon inhalation. This improves breathing and allows oxygen into lungs. B. The client should place her hand on her stomach while performing diaphragmatic or abdominal breathing. This allows resistance to be met and serves as a guide that the client is inhaling and exhaling correctly. C. CORRECT: The client should take a deep breath in through her nose while performing pursed‑lip breathing. This controls the client's breathing. D. The client should not puff her cheeks upon exhalation. This does not allow the client to optimally exhale the carbon dioxide from her lungs.

A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse? A. Teach the client to walk more quickly when ambulating. B. Complete passive range‑of‑motion exercises daily. C. Place the client on a low‑protein, low‑calorie diet. D. Give the client extra time to perform activities.

A. The client who has PD develops a propulsive gait and tends to walk increasingly rapidly. The client should be reminded to stop occasionally when walking to prevent a propulsive gait and decrease the risk for falls. B. The nurse should encourage active, not passive, range‑of‑motion exercises to promote mobility in the client who has PD and is displaying bradykinesia. C. The client who has PD often requires high‑calorie, high‑protein supplements between meals in order to maintain adequate weight. D. CORRECT: Bradykinesia is abnormally slowed movement and is seen in clients who have PD. The client should be given extra time to perform activities and should be encouraged to remain active.

A nurse in a health care clinic is evaluating the level of wellness for clients using the illness‑wellness continuum tool. The nurse should identify which of the following clients as being at the center of the continuum? A. A college student who has influenza B. An older adult who has a new diagnosis of type 2 diabetes mellitus C. A new mother who has a urinary tract infection D. A young male client who has a long history of well‑controlled rheumatoid arthritis

A. The client who has influenza is measured on the continuum by the level of health to illness in comparison to the norm for the client. B. The client who is newly diagnosed with type 2 diabetes mellitus is measured by the level of health to illness in comparison to the norm for the client. C. The client who has a urinary tract infection is measured on the continuum by the level of health to illness in comparison to the norm for the client. D. CORRECT: The client who has well‑controlled rheumatoid arthritis is measured at the center of the continuum, which is the client's normal state of health.

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include in the teaching? A. "You will need to continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."

A. The client who has tuberculosis needs to continue taking the multimedication regimen for 6 to 12 months. B. CORRECT: The client who has tuberculosis needs to provide sputum samples every 2 to 4 weeks to monitor the effectiveness of the medication. C. The client who has tuberculosis is often treated in the home setting. D. The client who has tuberculosis needs to wear a mask when in public areas.

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."

A. The client who is receiving rifampin should expect to see his urine turn a dark orange. B. The client who is taking ethambutol does not have an adverse effect resulting in changes to the sclera of the eyes. C. CORRECT: The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication. D. The client who is taking isoniazid should take vitamin B6 daily and observe for signs of hepatotoxicity.

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cyanosis C. Hypotension D. Dyspnea E. Paradoxic chest movement

A. The client will have tachycardia as a manifestation indicative of flail chest due to inadequate oxygenation. B. CORRECT: The client can have cyanosis as a manifestation indicative of flail chest due to inadequate oxygenation. C. CORRECT: The client can have hypotension as a manifestation indicative of flail chest. D. CORRECT: The client can have dyspnea as a manifestation indicative of flail chest. This is due to injury and the client's inability to effectively inhale and exhale. E. CORRECT: The client can have paradoxic chest movement as a manifestation indicative of flail chest. This is due to injury to the chest and the inability to inhale and exhale.

A nurse is caring for a client who is receiving TPN and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? A. Check the client's blood glucose according to facility mealtimes B. Contact the primary care provider to clarify the prescription C. Request for meals to be provided for the client D. Hold the prescription until the client is no longer NPO

B. Contact the primary care provider to clarify the prescription. Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.

A nurse is caring for a client who was just told she has breast cancer. The nurse evaluates the client's response. Which of the following statements by the client reflects a lack of understanding of an illness perspective? A. "I have no family history of breast cancer." B. "I need a second opinion. There is no lump." C. "I am glad we live in the city near several large hospitals." D. "I will schedule surgery next week, over the holidays."

A. The client's lack of a family history of cancer can influence the client's response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective. B. CORRECT: The client's statement of denial reflects a lack of understanding of the illness perspective and can influence the client's acceptance of the diagnosis. C. Access to health care resources can influence the client's response to the new diagnosis, but it does not reflect a lack of understanding of an illness perspective. D. Time constraints can influence a client's response to the diagnosis, but it does not reflect a lack of understanding of an illness perspective.

A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group. B. Integrate a daily exercise routine. C. Provide a walker for ambulation. D. Perform ADLs for the client.

A. The client/family should be involved in a community support group at the onset of the disease process to enhance coping mechanisms. B. The client should perform daily exercises with the onset of the disease process to promote mobility and independence for as long as possible. C. CORRECT: The client should use a walker for ambulation in stage III of Parkinson's disease because movement slows down significantly and gait disturbances occur. D. The client loses ability to perform ADLs during stage V of Parkinson's disease and is dependent on others for care at that time. During earlier stages, the client should be encouraged to remain as independent as possible.

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics. B. Implement droplet precautions. C. Initiate IV access. D. Decrease bright lights.

A. The nurse should administer antibiotics to stop the micro‑organisms from multiplying, but this is not the priority action. B. CORRECT: When using the urgent vs. nonurgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others. C. The nurse should initiate IV access to allow IV medication and fluid administration, but this is not the priority action. D. The nurse should decrease bright lights because of the client's sensitivity to light, but this is not the priority action.

A nurse is caring for a client who experienced a cervical spine injury 24 hr ago. Which of the following types of prescribed medications should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

A. The nurse should administer glucocorticoids to decrease edema of the spinal cord. B. The nurse should administer plasma expanders to treat hypotension caused by the SCI. C. The nurse should administer H2 antagonists to decrease the complication of developing a gastric ulcer from stress. D. CORRECT: The nurse should clarify with the provider the need for the client to receive muscle relaxants. The client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.

A nurse is orienting a newly licensed nurse on performing routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching? A. Apply a vest restraint if self‑extubation is attempted. B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 1 to 2 hr

A. The nurse should apply soft wrist restraints to prevent self‑extubation or according to facility policy. B. The nurse should monitor ventilator settings hourly. C. The nurse should document tube placement in centimeters at the client's teeth or lips. D. CORRECT: The nurse should assess the breath sounds of a client on mechanical ventilation every 1 to 2 hr.

A nurse is caring for a client who has increased ICP and is receiving mannitol via continuous IV infusion. Which of the following is an A/E of this medication? A. Rhinitis B. Crackles heard on auscultation C. Increased urinary output D. Decreased deep tendon reflexes

B. Crackles heard on auscultation Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

A nurse is developing a teaching plan for a client who has gout. Which of the following recommendations should the nurse include? A. Take a daily aspirin B. Decrease intake of purine meats C. Avoid milk products D. Take allopurinol for an acute attack

B. Decrease intake of purine meats A client who has gout should follow a low-purine diet and avoid foods, such as organ meats and shellfish, to prevent precipitating an attack that causes pain and inflammation in the joints.

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? A. Warm, moist skin B. Distended neck veins C. Presence of tenting D. Orthostatic hypotension

B. Distended neck veins The nurse should identify distended neck and hand veins as an indicator of fluid volume overload.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? A. Decreased prothrombin time B. Elevated bilirubin level C. Decreased ammonia level D. Elevated albumin level

B. Elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

A nurse is caring for a client who has a peripherally inserted catheter (PICC). Which of the following actions should the nurse take to manage the PICC? A. Use a noncoring needle for medication administration B. Flush the PICC line with 10 mL NS before and after medication administration. C. Remove the old dressing by pulling away from the insertion site D. Slowly infuse continuous heparinized saline if no blood return is present

B. Flush the PICC line with 10 mL NS before and after medication administration. The nurse should flush the PICC line with 5 to 10 mL of 0.9% sodium chloride before and after medication administration to prevent a medication interaction from occurring and to ensure the client receives the full dose of medication.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? A. INR 1 B. INR 2.5 C. aPTT 45 seconds D. aPTT 90 seconds

B. INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock? A. Decreased diastolic blood pressure B. Increased heart rate C. Respiratory rate 14/min D. Hyperactive bowel sounds

B. Increased heart rate Compensatory shock, the first stage of shock, is associated with an increase in heart rate as the body attempts to compensate by increasing blood flow to the tissues.

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first? A. Assess the client's pain. B. Obtain a large‑bore IV needle for decompression. C. Administer lorazepam. D. Prepare for chest tube insertion.

A. The nurse should assess the client's pain and administer pain medication. However, another action is the priority. B. CORRECT: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to establish and maintain the client's respiratory function. Obtaining a large‑bore IV needle for decompression is the priority action by the nurse. C. The nurse can administer benzodiazepine to treat anxiety. However, another action is the priority. D. The nurse should gather supplies to prepare for chest tube insertion. However, another action is the priority.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? A. Temperature 38.4 C B. Increased respiratory secretions C. Fluid intake of 200 ml in the prior 8 hr D. Limited range of motion

B. Increased respiratory secretions Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions because these secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia.

A nurse is assessing a client who is postoperative following a TURP and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? A. Remove the client's indwelling urinary catheter B. Irrigate the indwelling urinary catheter C. Clamp the indwelling urinary catheter D. Apply traction to the indwelling urinary catheter

B. Irrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse? A. "I am allergic to morphine." B. "I take antacids several times a day." C. "I had a blood clot in my leg several years ago." D. "It hurts to take a deep breath."

A. The nurse should document the client's allergy to morphine to manage the client's discomfort due to a blood clot. However, another action is the priority. B. CORRECT: The greatest risk to the client is the possibility of bleeding from a peptic ulcer. The priority intervention is to notify the provider of the finding. C. The nurse should know the client's history of a blood clot to provide preventative measures. However, another action is the priority. D. The nurse should expect the client to report pain with breathing. However, another action is the priority.

A client who has a diagnosis of C-diff is placed on contact precautions. Which of the following actions should the nurse take? A. Remove protective gloves after leaving the client's room B. Leave a stethoscope in the room for blood pressure monitoring C. Wear a mask when working within 3 feet of the client D. Keep the door to the client's room closed at all times

B. Leave a stethoscope in the room for blood pressure monitoring. C. difficile can be transmitted to others via inanimate objects. Therefore, the nurse should leave a dedicated stethoscope in the room for blood pressure monitoring to avoid the spread of infectious organisms to other clients.

A nurse is assessing a client who has a pulmonary embolism. Which of the following manifestations should the nurse expect to find? (Select all that apply.) A. Bradypnea B. Pleural friction rub C. Hypertension D. Petechiae E. Tachycardia

A. The nurse should expect the client to have tachypnea, which is a manifestation associated with a pulmonary embolism. B. CORRECT: The nurse should expect the client to have a pleural friction rub, which is a manifestation associated with a pulmonary embolism. C. The nurse should expect the client to have hypotension, which is a manifestation associated with a pulmonary embolism. D. CORRECT: The nurse should expect the client to have petechiae, which is a manifestation associated with a pulmonary embolism. E. CORRECT: The nurse should expect the client to have tachycardia, which is a manifestation associated with a pulmonary embolism.

A nurse is completing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? A. "It is safe to use microwaves that are 1,200 watts or less." . B. "You should avoid the use of CT scans with contrast.". C. "You should place a magnet over the implantable device when you feel an aura occurring." D. "It is recommended that you use ultrasound diathermy for pain management."

A. The nurse should instruct the client to avoid using a microwave, regardless of wattage, which can affect the function of the stimulator. B. The nurse should instruct the client to avoid MRIs, which can affect the function of the stimulator. C. CORRECT: The nurse should instruct the client to hold a magnet over the implantable device when an aura occurs so as to decrease seizure activity. D. The nurse should instruct the client to avoid the use of ultrasound diathermy for pain management because of its effect on the function of the stimulator.

A nurse is monitoring a client who is receiving opioid analgesia. Which of the following findings should the nurse identify as adverse effects of opioid analgesics? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea PRACTICE

A. Urinary retention, not urinary incontinence, is a common adverse effect of opioid analgesia. B. Constipation, not diarrhea, is a common adverse effect of opioid analgesia. C. CORRECT: Respiratory depression, which causes respiratory rates to drop to dangerously low levels, is a common adverse effect of opioid analgesia. D. CORRECT: Dizziness or lightheadedness when changing positions is a common adverse effect of opioid analgesia. E. CORRECT: Nausea and vomiting are common adverse effects of opioid analgesia.

A nurse is caring for a client who has ingested a toxic agent. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Induce vomiting. B. Instill activated charcoal. C. Perform a gastric lavage with aspiration. D. Administer syrup of ipecac. E. Infuse IV fluids.

A. Vomiting places the client at risk for aspiration. B. CORRECT: This is an appropriate action by the nurse because activated charcoal adsorbs toxic substances, and the charcoal does not pass into the bloodstream. C. CORRECT: This is an appropriate action by the nurse because gastric lavage with aspiration removes the toxic substance when the instilled fluid is suctioned from the gastrointestinal tract. D. Administering syrup of ipecac is not recommended because it induces vomiting, which increases the client's risk for aspiration. E. CORRECT: This is an appropriate action by the nurse because intravenous fluids help dilute the toxic substances in the bloodstream and promote elimination from the body through the kidneys.

A nurse is preparing to administer a new prescription for isoniazid (INH) to a client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints." C. "You might notice tingling of your hands." D. "You might experience a loss of appetite."

A. Y ellowing of the skin is an adverse effect of rifampin or pyrazinamide. B. Experiencing pain in the joints is an adverse effect of rifampin. C. CORRECT: Tingling of the hands is an adverse effect of isoniazid. D. Loss of appetite is an adverse effect of rifampin.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? A. Administer antihistamine B. Slow the infusion rate C. Give the client a corticosteroid D. Elevate the client's lower extremities

B. Slow the infusion rate. Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. A diuretic might be prescribed to alleviate the fluid overload.

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription?

BUN

Expected lab findings for a patient with DKA?

BUN 32 mg/dL "In dka the c02 may be high and the bicarb and ph will be low due to fluid loss. You pee/vomit out all the base leaving you acidic. Fluid loss also causes the BUN to be elevated. (10-20)"

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

BUN 34 mg/dL

Assessment finding the nurse should report to the provider for a patient with a new diagnosis of hyperthyroidism?

Blood pressure 170/80 mm Hg "BP of 160/80 or higher needs to be reported, can indicate hypertensive crisis."

A nurse is caring for a client who has a new diagnosis of hyperthyroidism which of the following is the priority assessment finding that the nurse should report to the provider

Blood pressure of 170 over 80 because using the Urgent vs. Non-urgent approach to client care the nurse determines that the priority funding is a systolic blood pressure of 170 which indicates that the client is at risk for thyroid storm

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? A. "This medication will relieve my symptoms by causing my blood vessels to dilate." B. "I should take this medication daily to prevent the headache from occurring." C. "I should expect facial flushing when I take this medication." D. "This medication will lower my sensitivity to food triggers."

A. Z olmitriptan causes cranial arteries, the basilar arteries, and blood vessels in the dura mater to constrict. B. Z olmitriptan is used for abortive therapy in treating migraine headaches. It is not used for headache prevention. C. CORRECT: Zolmitriptan can cause facial flushing, tingling, and warmth. D. Z olmitriptan is used as a component of abortive therapy for treatment of migraine headaches and does not affect a client's sensitivity to food triggers.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take.

Administer oxygen via a nonrebreather mask Initiate IV therapy with a large bore catheter Insert NG tube Administer Ranitidine

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take.

Administer oxygen via a nonrebreather mask Initiate IV therapy with large bore catheter Insert a NG tube Administer ranitidine Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer ranitidine when the client is no longer bleeding.

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Administer the medication at the same time each day. The nurse administer the medication to the client at the same time each day to maintain consistent serum levels

A nurse manager is preparing an educational session about advocacy to a group of nurses. The nurse manager should include which of the following information in the teaching?

Advocacy is a leadership role that helps others to self-actualize

A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse identify as an adverse effect of the medication?

Blurred vision -- The nurse should identify blurred vision as an adverse effect of amitriptyline and notify the provider. Other adverse effects include constipation, urinary retention, and dry mouth.

A nurse in a mental health clinic is assessing a client who has a history of seeking counseling for relationship problems. The client shows the nurse multiple superficial self-inflicted lacerations on their forearm The nurse should identify these behaviors as characteristics of which of the following personality disorders?

Borderline

What food from the list should the client avoid to reduce the risk of migraine headaches?

Aged Cheese "Tyramine products can increase r/4 headaches."

A rural community health nurse is developing a plan to improve health care delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?

Agency for Healthcare Research and Quality

A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity?

Bradycardia

**** A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia R: A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

Components of cushings triad?

Bradycardia "Other components inculde hypertension and irregular/dec. respirations. AKA intrcranial HTN."

A nurse is caring for an older adult client who is experiencing chronic anorexia and is receiving enteral tube feedings. Which of the following laboratory values indicates that the client needs additional nutrients added to the feeding?

Albumin 2.8 g/dL

A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?

Allow for frequent rest periods throughout the day -- The nurse should encourage clients who have rheumatoid arthritis to balance rest with exercise to maintain muscle strength, joint function, and range of motion.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints

A nurse is caring for a client who is in the fourth stage of labor and is receiving oxytocin via continuous IV infusion. Which of the following assessments is the nurse's priority?

Amount of vaginal bleeding

A nurse is caring for a group of clients. Which of the following clients should the nurse attend to first?

An older adult client who is anxious and attempting to pull out an IV line

A nurse is providing dietary teaching to a client who has a new prescription for phenelzine. Which of the following food recommendations should the nurse make? (Select all that apply.)

Broccoli, Yogurt, Cream Cheese

A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect?

Bruit heard over the middle upper abdomen

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

Bubbling in the water seal chamber has ceased. "??" pg. 669

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

Bubbling in the water-seal chamber has ceased.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

Apply firm pressure to the insertion site

Nurse notes the formation of a hematoma at the insertion site and a dec. pulse rate in the affected extremity 1hr after a cardiac Cath. Nursing priority?

Apply firm pressure to the insertion site. "Hold pressure at the site to control bleeding as assessed by the pt having a hematoma and dec. pulse rate at the extremity." pg. 174

A nurse is caring for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Arrange the lunch tray for a client who has a hip fracture.

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Ask another nurse to witness the disposal of the new patch

A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifestations of HD?

C

A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?

Ask the partner to list specific concerns.

A nurse is assessing for correct placement of a client's NG feeding tube prior to administering a bolus feeding. Which of the following actions should the nurse take?

Aspirate contents from the tube and verify the pH level

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? A. "Ginkgo biloba relieves nausea for people who have vertigo." B. "Taking ginkgo biloba will help relieve your joint pain." C. "Ginkgo biloba can cause an increased risk for bleeding." D. "Taking ginkgo biloba decreases the risk of migraine headache."

C. "Ginkgo biloba can cause an increased risk for bleeding." Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. "I will need to take antibiotics for 1 year." B. "My partner will need to take an antiviral medication." C. "My joints ache because I have Lyme disease." D. "I bruise easily because I have Lyme disease."

C. "My joints ache because I have Lyme disease." Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

A nurse is reviewing that lab results of a client who has AIDS and is taking Amphotericin B for a fungal infection. The nurse should identify that which of the following values as an indicator of an A/E of the medication? A. Potassium 4.8 meq/L B. Magnesium 1.7 meq/L C. BUN 34 mg/dL D. Hematocrit 45%

C. BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN and/or an elevated creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings shows re-expansion? A. The chest tube is draining serosanguineous fluid at 65 ml/hr B. The client tolerates gently milking of the tubing C. Bubbling in the water seal chamber has ceased. D. There is tidaling in the water seal chamber

C. Bubbling in the water seal chamber has ceased. Bubbling in the water seal chamber ceases when the lung re-expands.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client the following supplements can interfere with the effectiveness of the medication? A. Gingko biloba B. Glucosamine C. Calcium D. Vitamin C

C. Calcium Calcium limits the development of osteoporosis in women who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A home health nurse is providing teaching to a client who has a stage 1 pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? A. Clean the wound daily with an antiseptic B. Use a donut-shaped pillow when sitting in a chair C. Change position every hour D. Massage the area two times daily

C. Change position every hour. Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.

A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism? A. Dyspnea B. Fever C. Petechiae on the chest D. Fat globules in the urine

C. Consume at least 30 g of fiber daily. Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain, bloating, and either constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Exhibit button) - Disease process - Lab findings - Current medications - Family history

C. Current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? A. Temperature 38.8 C B. SBP 70 mmhg C. Heart rate 52/min D. Respiratory rate 8/min

C. Heart rate 52/min A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? A. Kidney donation must come from a living donor B. Immunosuppressive therapy is necessary until the donated kidney begins producing urine C. Hemodialysis is sometimes needed following surgery D. Diabetes mellitus is the major cause of death following a kidney transplant

C. Hemodialysis is sometimes needed following surgery. When a kidney comes from a deceased donor, it might not function immediately, requiring the recipient to continue hemodialysis postoperatively.

A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? A. Obtain ABGs B. Administer propofol to the client C. Instruct the client to allow the machine to breathe for him D. Disconnect the machine and manually ventilate the client

C. Instruct the client to allow the machine to breathe for him. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. A. Murmur B. S4 C. Pericardial friction rub D. Ventricular gallop

C. Pericardial friction rub The nurse is hearing a pericardial friction rub, which is a scratchy, high-pitched sound associated with infection, inflammation, or infiltration and can be a manifestation of pericarditis. A pericardial friction rub is best heard with the diaphragm of the stethoscope.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following should the nurse monitor? A. Hyperreflexia B. Increased blood pressure C. Respiratory paralysis D. Tachycardia

C. Respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include? A. Swallow the tablets whole B. Expect pain relief to begin 10 min after administration C. Store the medication in its original container D. Take the medication on an empty stomach

C. Store the medication in its original container. Nitroglycerin is inactivated by heat, light, and moisture. The nurse should instruct the client to keep the medication in its original dark glass container with the lid tightly closed.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? A. "This measures how much blood my heart is pumping." B. "This identifies if I have a defective heart valve." C. "This identifies if the pacemaker cells of my heart are working properly." D. This measures the blood circulating to my heart muscle."

C. This identifies if the pacemaker cells of my heart are working properly. Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

Pernicious anemia

C. This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an A/E? A. Frequent coughing B. Increased bowel sounds C. Urinary retention D. Pupillary dilation

C. Urinary retention Because morphine causes urinary retention, the nurse should frequently monitor the client's urinary output and check for bladder distention.

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing? A. WBC 6,000/mm3 B. BMI 24 C. Urine output 25 mL/hr D. Albumin 4 g/dl

C. Urine output 25 mL/hr Urinary output is a reflection of fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take? A. Apply a wet-to-dry gauze dressing B. Irrigate with hydrogen peroxide solution C. Use a 30 mL syringe D. Attach a 24-gauge angiocatheter to the syringe

C. Use a 30 mL syringe. The nurse should use a 30 mL to 60 mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication?

Calcium R: Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A client who has hypothyroidism and is receiving levothyroxine. What supplement can intefere with effectiveness of medication?

Calcium "Fiber, calcium, iron, and antacid supplements can interfere with absorption. FICA" pg. 532

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer?

Calcium carbonate

A patient undergoing hemodialysis for ESKD needs what med if they report muscle cramps and a tingling sensation in their hands.

Calcium carbonate "Hypocalcemia causes paresthesia.

A nurse is providing teaching to a client who has hypothyroidism and is receiving Levothyroxine the nurse should instruct the client that which of the following could interfere with the absorption of the medication

Calcium supplements

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? Select all that apply.

Calf pain, numbness in the arms and intense headache. Calf pain is an indication of DVT and the client should report this finding to the provider immediately. Numbness in the arms can indicate cerebrovascular accident which is an adverse effect of hormone replacement therapy and an intense headache can indicate a cerebrovascular accident.

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy when removing the dressing with the nurse notes that a large part of the bowel is protruding through the abdomen which of the following actions should the nurse take first

Call for help because evidence based practice indicates that the nurse should first stay with the client and call for assistance the client will require emergency surgery and is at risk for shock therefore the nurse should attain immediate assistance

First action for the nurse to take after noting a large part of the bowel protuding through the abdomen?

Call for help. "Call for help because this is a surgical emergency." pg. 343

A nurse is caring for a client following a vacuum-assisted birth. The nurse should monitor the client for which of the following complications related to vacuum-assisted birth?

Cervical laceration

A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour

A nurse is caring for a client who has a clogged percutaneous gastrostomy feeding tube. Which of the following actions should the nurse take first?

Change the position of the client.

A nurse is caring for a client who is receiving plasmapheresis through a venous access site. Which of the following actions should the nurse take?

Check electrolyte levels before and after therapy. R: Plasmapheresis can cause citrate induced hypocalcemia. Therefore the nurse should monitor the clients electrolyte levels before and after therapy.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer. "The nurse should ensure they have the correct blood before doing anything else to ensure the patient will have safe administration." pg. 260

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer. According to evidence based practice the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the clients medication administration record.

Nursing actions for a client with a plaster cast applied to the leg 2hrs ago?

Check that one finger fits between the cast and the leg. "This ensures that the cast isn't too tight. Document any drainage or sudden increase in drainage; report to provider. Inspect cast q 8-12hrs"

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall during the assessment the client states last week I crashed my car because my vision suddenly became blurry which of the following actions is the nurses priority

Check the clients neurologic status because the first action you should take is to assess the client

A nurse is providing teaching to a female client who has a history of urinary tract infections which of the following information should the nurse include in the teaching

Clean the perineum from front to back after voiding or defecating to avoid introducing bacteria to the urethra

The nurse should plan to make a referral to physical therapy for which type of client?

Client receiving prep teaching for a r-knee arthroplasty "Client will need to be taught how to ambulate safely"

A nurse is planning care for a client who is post-operative following a laparotomy and has a closed suction drain which of the following actions should the nurse take to manage the drain

Compress the drain Reservoir after emptying because it creates a vacuum that draws fluid out of the room through the drain and into the reservoir

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation "Other signs of hypothyroidism includes bradycardia, Cold intolerance, weight gain, dry skin, and fatigue."

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect

Constipation. A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism resulting and slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid and take to reduce the risk of constipation

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching?

Consume at least 30 g of fiber daily

A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse. Which of the following actions should the nurse take?

Contact CPS

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the primary care provider to clarify the prescription.

A nurse is teaching about adverse effects with a client who is starting to take captopril. Which of the following findings should the nurse identify as an adverse effect of the medication to report to the provider?

Cough -- The client can develop a cough due to a buildup of bradykinin in the lungs.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider?

Crackles heard on auscultation

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Create complete outfits and allow the client to select one each day. "They may not remember how to put outfits together but still needs to be allowed to make choices."

A nurse is caring for a client who has active pulmonary tuberculosis. Which of the following actions should the nurse take?

Assign the client to a private room with negative air pressure

A nurse is caring for a client who had abdominal surgery 24 hr ago. Which of the following actions is the nurse's priority?

Assist with deep breathing and coughing -- The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Auscultate the apical pulse at least 1 minute.

A nurse manager is reviewing clients' rights with the nurses on the unit. The nurse manager should tell the nurses that informed consent promotes which of the following ethical principles?

Autonomy

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

Avocados "An allergy to banana or kiwi (fruit) can indicate allergy to latex." *shellfish allergy contraindicated in iodine. *eggs or soybean contraindicated in propofol or anesthesia. pg.

A nurse is planning care for a client who is receiving chemotherapy and has neutropenia. Which of the following interventions should the nurse include in the plan?

Avoid including raw fruits in the client's diet.

Precautions for a patient who is immunocompromised to prevent a pseudomonas aeruginosa infection.

Avoid placing plants or flowers in the client's room. "These items can have harmful bacteria on them that can increase the r/4 infection."

A nurse is in a provider's office is providing teaching to a client who has a urinary tract infection and a new prescription for ciprofloxacin. Which of the following instructions should the nurse include

Avoid taking magnesium containing antacids with this medication. The nurse should instruct the client to take Ciprofloxacin either two hours before or 6 hours after taking an antacid but not to take Ciprofloxacin with an antacid because magnesium containing antacids decrease the absorption of Ciprofloxacin

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. "I will wash the ink markings off the radiation area after each treatment." B. "I will use my hands rather than a washcloth to clean the radiation area." C. "I will be able to be out in the sun 1 month after my radiation treatments are over." D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy."

B. "I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with her hands using warm water and mild soap to protect the skin from further irritation.

A nurse is teaching a group of newly licensed nurses about pain management for older adults clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "Older adult clients may require up to 6 grams of acetaminophen over 24 hours for effective pain control" B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients." C. "Meperidine is the medication of choice for older adult clients experiencing severe pain." D. "Older adult clients taking oxycodone are at risk for diarrhea."

B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients." A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first? A. Obtain a blood sample for cardiac enzymes and biomarkers B. Administer morphine C. Transfer the client to ICU D. Prepare the client for a cardiac catheterization

B. Administer morphine. The greatest risk to the client is injury from myocardial ischemia. Therefore, the first action the nurse should take is to administer morphine to increase the client's oxygen supply and decrease the oxygen demand of the heart.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain? A. Increased intake of foods containing calcium B. Alternate application of heat and cold to the affected joints C. Keep the affected extremities elevated D. Limit movement of the affected joints

B. Alternate application of heat and cold to the affected joints. The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions in the nurse's priority? A. Initiate oxygen at 2 L/min via nasal cannula B. Apply firm pressure to the insertion site C. Take the client's vital signs D. Obtain a stat order for an aPTT

B. Apply firm pressure to the insertion site. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.

A nurse is caring for a client who has a diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? A. Negative urine ketones B. BUN 32 mg/dL C. pH 7.43 D. HCO 23 meq/L

B. BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? A. Take a calcium antacid before meals and at bedtime B. Consume at least 30 g of fiber daily. C. Take a stimulant laxative daily D. Consume no more than 1,000 ml of water per day

B. Consume at least 30 g of fiber daily. Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain, bloating, and either constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia?

The client has to turn her head to see the entire visual field.

A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

pH 7.31

Priority finding for a client who has been suspected of having a stroke?

Dysphagia "This puts the client at a high risk of aspirating." *Ataxia - lack of coordination in muscle movements, body does what it wants.

A nurse is assessing a client who has had a suspected cerebrovascular accident the nurse should place the priority on which of the following findings

Dysphasia because it indicates that the client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity

A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?

Dyspnea

A nurse is assessing a client for compartment syndrome. Which of the following findings should the nurse expect?

Edema

A nurse at an urgent care clinic is assessing a client who reports impaired vision in one eye. Which of the following reports by the client should indicate to the nurse that the client has a detached retina?

Floating dark spots

A nurse is teaching an older adult client about osteoporosis prevention the nurse should instruct the client that which of the following medications can increase her risk for developing osteoporosis

Fludrocortisone due to an increase in bone resorption by osteoclasts it can also reduce intestinal absorption of calcium

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC?

Flush the PICC line with 10 mL NS before and after medication administration.

A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction?

Flushing

A nurse is assessing a client following IV urography. Which of the following findings is the priority?

swollen lips

A nurse is preparing to present a program about atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? Select all that apply.

Follow a smoking cessation program maintain an appropriate weight eat a low-fat diet Smoking cessation is an important lifestyle modification to prevent Arthur sclerosis and preventing obesity through diet and exercise can help prevent atherosclerosis. Eating a low fat diet decreases LDL cholesterol and can prevent atherosclerosis. Eat more fruits and veggies and whole grains. Decrease intake of sugary foods and sweetened foods. Complex carbs like fiber can reduce heart disease.

A nurse manager in a long-term care facility is having difficulty with staffing for weekend shifts and is planning to implement some changes to the scheduling procedure. Which of the following actions should the nurse manager take first?

Form a committee of staff members to investigate current staffing issues.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

Ginkgo biloba can cause an increased risk for bleeding

A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color

Glossitis

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL "Glucose above 300 in ATI indicates dka, lower than that condition is improving."

A nurse is caring for a client who has dka which of the following findings should indicate to the nurse at the client's condition is improving

Glucose of 272 because a glucose reading less than 300 indicates Improvement in the client's status

A nurse is teaching to a client who has hypertension and a new prescription for Verapamil. Which of the following juices should the nurse instruct the client to avoid

Grapefruit because it inhibits the hepatic metabolism of the medication and then place the current client at risk for toxicity

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching?

Grilled chicken breast

Nursing findings to indicate fluid volume deficit

Heart rate 110/min *In hypovolemia the HR will elevate and the BP will lower." *The higher (> 1.030) the urine specific gravity the more dehydrated the patient.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. Heart rate 110/minB. Blood pressure 138/90 mm HgC. Urine specific gravity 1.020D. BUN 15 mg/dL

Heart rate 110/min R: A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

Heart rate 52/min

1 week follow up for heart failure, report which finding?

Heart rate 55/min "HR is below the normal"

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit

Heart rate of 110 per minute Fluid volume devicit increases heart rate. Other options are within range

A nurse is caring for a client who presents to a clinic for a one-week follow-up visit after hospitalization for heart failure based on the information in the clients chart which of the following findings should the nurse report to the provider

Heart rate of 55 per minute is a significant drop from the clients Baseline of 74 permanent and it can indicate the development of digoxin toxicity

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?

Hemodialysis is sometimes needed after surgery.

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide?

Hemodialysis is sometimes required following surgery. "The new kidney may not work immediately and the patient may need assistance."

Postop following a total hip arthroplasty. Which lab value needs to be reported?

Hgb 8 g/dL "Normal 12-17; may indicate excess blood loss during surgery."

Finding requiring further assessement for a patient who is about to undergo a CT scan with an IV contrast agent.

History of asthma "?"

A nurse is preparing to administer insulin to a client via a pen device. Which of the following actions should the nurse take?

Hold the insulin pen device perpendicular to the client's skin to inject the medication.

A nurse is providing teaching to a client who has asthma about the use of a metered dose inhaler the nurse should identify that which of the following client actions indicates an understanding of the teaching

Holding breath for 10 seconds after inhaling so that the medication can move deep into the Airways

Manifestation of chronic glomerulonephritis?

Hyperkalemia

A nurse is caring for a client who has chronic glomerulonephritis with oliguria which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis

Hyperkalemia as a result of kidney failure because kidney failure results in decreased excretion of potassium

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds

Potassium level of 3 mEq/L. Expected nursing assessment?

Hypoactive bowel sounds. "Hypokalemia slows things down in the body. can cause n/v, abd distention." pg. 286

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia

*****A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication?

Hypokalemia R: Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration.

Lactulose adverse effect? Used to treat hepatic encephalopathy. (The liver is severly damaged causing a decline in the brain, and a b/u of toxins in the bloodstream.)

Hypokalemia "Lactulose is used to treat constipation; in return it can cause diarrhea and fluid/electrolyte loss leading to hypokalemia and hypernatremia. (Rxlist)"

A nurse is caring for a client who is in the resuscitation phase of burn injury. Which of the following findings should the nurse expect?

Hyponatremia

A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock?

Hypotension

BMI of 32 in a older adult female who has stress incontinence. Statement by client understanding teaching?

I am dieting to lose weight. "A normal bmi is 18 to 25; being overweight can cause excess pressure on the pelvic area leading to incontinence."

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching question mark

I am dieting to lose weight. Excess weight cut creates increased abdominal pressure that can result in stress incontinence.

Client teaching for patient with chronic kidney disease with a new prescription for erythropoietin. Client statement that indicates understanding of the teaching.

I am taking this medication to increase my energy level. "Chronic kidney disease can cause anemia due to low productions of rbcs. Patients may also loose blood through hemodialysis. Low rbc levels can cause fatigue."

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

I am taking this medication to increase my energy level. The goal of erythropoietin therapy is to increase the level of hematocrit and clients who have anemia. When the medication is effective the client should have a decreasing fatigue and an improvement and activity tolerance.

A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make?

I can speak to the provider about incorporating acupuncture into your treatment plan. "This statement acknowledges the patients thoughts and promotes them having options."

A nurse is providing instructions to a client who has Type 2 diabetes mellitus and a new prescription for metformin which of the following statements by the client indicates an understanding of the teaching

I should take this medication with a meal to improve absorption and to minimize gastrointestinal distress

Understanding of the teaching for metformin?

I should take this medication with a meal. "This medication can cause n/v and gi issues; ex. upset stomach."

Successfully coping with change in a client who has a new diagnosis of type 1 diabetes.

I used to never worry about my feet. Now, I inspect my feet everyday with a mirror.

A nurse is providing discharge instructions to a client who has laryngeal cancer and received is receiving radiation treatment which of the following statements by the client indicates an understanding of the teaching

I will avoid direct exposure to the Sun because the client should avoid exposure of irradiated skin areas to the Sun for at least one year after completing radiation therapy skin in the radiation path is especially sensitive to sun damage

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching?

I will count my heart beats before taking this medication.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

I will eat more high-fiber foods. The client should eat high-fiber foods to help prevent constipation which is a common adverse effect of oral iron supplements.

A charge nurse is instructing a newly licensed nurse about caring for a client who has MRSA which of the following statements by the newly licensed nurse indicates an understanding of the teaching

I will leave assessment equipment in the room to use on this client the nurse should follow contact precautions and use dedicated equipment when assessing the client to prevent cross-contamination with other clients

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

I will monitor my blood pressure while taking this medication.

Statement that indicates understanding in a patient with a new prescription for epoetin alfa.

I will monitor my blood pressure while taking this medication. "This medication can cause HTN due to the fast increase in rbc production; especially in those with kidney disease."

A nurse is providing teaching to a client who has Type 1 diabetes mellitus and a new prescription for insulin lispro which of the following statements by the client indicates an understanding of the teaching

I will need to take this bro in addition to my other prescribed insulin because it is a rapid-acting insulin that the client can use in conjunction with an intermediate or long-acting insulin

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

I will refer you to community resources that can provide support. "Client may have struggles with adjusting to the new body image. The support groups can provide a safe space to talk to other people in similar situations."

A nurse is providing teaching to a client who has AIDS which of the following statements by the client indicates an understanding of the teaching

I will take my temperature once a day a client who has AIDS is immunocompromised and is at risk for infection the client should take his temperature daily to identify a temperature greater than 100 degrees which is an early manifestation of an infection

A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching?

I will use an electric razor to shave. "This will reduce the risk of bleeding when shaving."

A nurse is providing discharge teaching to a client who is to self administer heparin subcutaneously. Which of the following responses by the client indicates an understanding of the teaching

I will use an electric razor to shave. Heparin is an anticoagulant that places the client at risk for bleeding therefore the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

I will use my hands rather than a washcloth to clean the radiation area

Teaching a client with venous insufficiency about self care. Statement indicating understanding of teaching?

I will wear clean graduated compression stockings every day. "This will help to promote venous return, increasing blood flow."

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands teaching?

I will wear clean graduated compression stockings everyday. The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy?

INR 2.5

A nurse in an emergency department is caring for a client who has full thickness Burns over 20% of his total body surface area after ensuring a patent Airway and administering oxygen which of the following items should the nurse prepared to administer first

IV fluids to provide circulatory support

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

Ibuprofen can cause gastrointestinal bleeding in older adult clients.

A nurse on a mental health unit is conducting a mental status examination (MSE) on a new admitted client. Which of the following components of the MSE is the priority for the nurse to assess?

Ideas of self-harm.

A nurse is caring for a client who has a positive culture for Clostridium difficile which of the following actions should the nurse take

Implement contact precautions for the client because direct contact is the mode of transmission

A nurse on an inpatient unit is caring for a client who has schizophrenia and recently started taking risperidone. Which of the following actions should the nurse take?

Implement fall precautions for the client.

Nursing teaching for a client with IBS.

Increase fiber intake to at least 30 g per day. pg. 340 "Soluble fiber will help promote good bowel function by slowing things down to help with diarrhea the ibs patient may have, they should avoid insoluble fiber because it can increase diarrhea."

A nurse is providing teaching to a client who has irritable bowel syndrome which of the following instructions should the nurse include in teaching

Increase fiber intake to at least 30 grams per day to produce bulky soft stools and establish regular bowel patterns

Information to provide to a patient following an upper GI series with barium contrast.

Increase fluid intake.

A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Increase the client's dietary iron intake

A nurse is caring for a client who has a magnesium level of 2.7 mEq/L. Which of the following interventions should the nurse plan to take?

Initiate continuous cardiac monitoring -- The nurse should initiate continuous cardiac monitoring because a client who has hypermagnesemia is at risk for cardiac dysrhythmias and cardiac arrest.

A nurse in an emergency department is caring for a child who has a fever and fluid-filled vesicles on the trunk and extremities. Which of the following interventions should the nurse identify as the priority?

Initiate transmission-based precautions

A nurse is caring for a client who has a fecal impaction. Which of the following actions should the nurse take when digitally evacuating the stool?

Insert a lubricated gloved finger and advance along the rectal wall

A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.

Inspection, Auscultation, Percussion, Palpation

Patient on a vent appears anxious and restless; high pressure alarm is sounding. What is the nurses first action?

Instruct patient to allow the machine to breathe for them "Least invasive to most invasive"

Pain management for a patient needing a dressing change. Patient is worried about getting addicted to morphine. What should the nurse say?

Instruct the client on alternative therapies for pain reduction. "This statement acknowledges the patient's concern and provides therapeutic options."

A nurse is planning care for a client who was having a modified radical mastectomy of the right breast which of the following interventions should the nurse include in the plan of care

Instruct the client that the drain is removed when there is 25 milliliters of output or less over a 24-hour period the drain will remain in place for one to three weeks after surgery and we've removed when there is 25 milliliters of output or less in a 24-hour period

A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for him.

***A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for him. R: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse is caring for a client who is receiving continuous bladder irrigation following transurethral resection of the prostate. The client reports bladder spasms, and the nurse observes a decreased urinary output. Which of the following actions should the nurse take?

Irrigate the catheter with 0.9% sodium chloride irrigation.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

Irrigate the indwelling urinary catheter

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypolglycemia?

Irritability

A nurse is assessing an infant who has hydrocephalus and is 6 hr postoperative following placenta of a VP shunt. Which of the following findings should the nurse report to the provider?

Irritability when being held.

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

It's like a curtain closed over my eye.

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

It's like a curtain closed over my eye. R: A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

A client in the ER has a detached retina. What should the nurse expect the client to report?

It's like a curtain closed over my eye. "Retina has detached from the blood vessels that give it O2 and nutrients; medical emergency."

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client's room

a nurse is caring for a client who had an open thoracotomy with chest tube insertion which of the following actions should the nurse take

Keep the chest tube collection chamber below the level of the lungs

A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take?

Leave a stethoscope in the room for blood pressure monitoring.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound?

Listen with the client on his left side. When providing nursing care the nurse should first use the least invasive intervention. Therefore after auscultating a murmur the first action the nurse should take is to place the client on his left side and listen to his heart again.

What action should the nurse take first after hearing the following sound? Client had a MI 2 days ago.

Listen with the client on their left side. "?"

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen restrictive clothing

A client is experiencing a tonic-clonic seizure. Nursing action?

Loosen restrictive clothing. "Prevent any obstructions to the airway."

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? *DI causes the The kidneys to make too much urine at the solutes become diluted.

Low urine specific gravity

A nurse is preparing a sterile field to perform a sterile dressing change. Which of the following interventions should the nurse use to maintain surgical ascetic technique?

Maintain sterile objects within the line of vision.

A nurse on a medical-surgical unit is caring for a client who has a new diagnosis of terminal cancer. The client tells the nurse that they would like to go home to be with family and loved ones. Which of the following actions should the nurse take?

Make a referral for social services

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

Making a list of activities to complete.

A nurse is caring for a client who has fluid volume overload. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Measure the client's daily weight.

Feverfew is a plant used to treat migraines. Which medication will interact with feverfew?

Naproxen "Patients taking garlic, feverfew, and ginger may experience gi bleeding while also taking NSAIDS. Ginkgo biloba is also contraindicated due to the suppression of coagulation." pg. 284

A nurse in a provider's office is assessing a client who has migraine headaches and is taking Feverfew to prevent her headaches the nurse should identify that which of the following client medications interact with Feverfew

Naproxen because they both impaired platelet aggregation and place the client at risk for bleeding

A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?

Nasal flaring

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Non-rebreather mask

Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Nonrebreather mask

A nurse is assigning task roles for a group of clients in a community mental health clinic. Which of the following tasks should the nurse assign to the member of the group functioning as the orienteer?

Noting the progress of the group toward assigned goals.

A nurse is assessing a school-age child who has bacterial meningitis. Which of the following findings should the nurse expect?

Nuchal rigidity

A nurse is caring for a client who has an arteriovenous fistula for dialysis which of the following requires intervention by the nurse

Numb fingers distal to the fistula it indicates impaired circulation and requires intervention

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? Radical = removal of breast, some chest muscle and lymph nodes.

Numbness can occur along the inside of the affected arm. "The patient needs to report numbness, heavy feeling, pain, and impaired motor function to the dr." pg. 636

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs R: The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

Client has portal hypertension. Vomiting blood mixed with food after a meal. 1st nursing action?

Obtain vital signs. "Assess first"

A nurse is assessing a client who has a chest tube. Which of the following findings should the nurse expect?

Occlusive dressing on the insertion site

Adverse effect of enlapril

Orthostatic hypotension "Calcium channel blocker"

A nurse is caring for a client who has a prescription for Enalapril the nurse should identify which of the following findings as an adverse effect of the medication

Orthostatic hypotension because dilation of arteries and veins causes orthostatic hypotension which is an adverse effect of Enalapril

A nurse is assessing a client following a vaginal delivery and notes heavy loch and a boggy fundus. Which of the following medications should the nurse expect to administer?

Oxytocin

A nurse is planning to delegate client care tasks to an assistive personnel. Which of the following tasks should the nurse plan to delegate to the AP?

Perform gastrostomy feedings through a client's established gastrostomy tube

a nurse is caring for a client who is experiencing supraventricular tachycardia upon assessing the client the nurse observes the following findings heart rate 200 per minute blood pressure 78 over 40 and respiratory rate 30 per minute which of the following actions should the nurse take

Perform synchronized cardioversion

A nurse is providing medication teaching to a group of clients who have seizure disorders which of the following information should the nurse include about phenytoin

Phenytoin decreases the effectiveness of oral contraceptives because it stimulates the synthesis of hepatic enzymes which can decrease the activity of other medications including oral contraceptives

Nursing actions for a patient 12 hr postoperative following a total hip arthroplasty?

Place a pillow between the client's legs "This action will allow the patient to avoid dislocation" pg. 437

A nurse is caring for a client who is 12 hours post-operative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the clients legs. The nurse should place a pillow between the clients legs to prevent hip dislocation.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution. "This is a hemodynamics system that monitors the patients hemodynamics status by using a pressure transducer, pressure tubing, monitor, and a pressure bag with a flush device."

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution because the pressure from an artery is greater than that of the line

A nurse is planning care for a client who is postoperative following a parathyroidectomy (Removal of one or more parathyroid glands). Which of the following actions should the nurse identify as the priority?

Place a tracheostomy tray at the bedside. "Client is at risk for respiratory distress due to edema. Keep supplies at the bedside. The nurse should also help patient to turn cough and deep breath; suction if needed; provide humidified air." Pg. 528

A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use.

Place body weight on the crutches Advance the unaffected leg onto the stair shift weight from the crutches to the unaffected leg and then bring the crutches and the affected leg up to the stair

A nurse is caring for a client who has bilateral pneumonia and an spo2 of 85% the client is dyspneic and productive cough and is using accessory muscles to breathe which of the following actions should the nurse take first

Place the client in a high Fowler's position

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure?

Place the client in a quiet environment

A client has bilateral pneumonia and an SaO2 of 85% with dyspnea, productive cough and is using accessory muscles to breathe. Which action should the nurse take first?

Place the client in high-Fowler's position. "This will help the client breathe better until further interventions are put into place."

A client is admitted to the ER with anxiety loss of muscle coordination and skin is hot and dry the client had been working on the yard prior to coming to the hospital which of the following actions should the nurse anticipate taking first

Place the client on a cooling blanket because these findings indicate the client is at greatest risk for hyperthermia

A nurse is planning care for a client who is post-operative following a parathyroidectomy which of the following actions should the nurse identify as the priority

Placed a tracheostomy tray at the bedside in case of Airway obstruction

A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes?

Polyuria Polydipsia Neuropathy

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

The client is pacing around the chair in which their partner is sitting -- Hyperactivity and pacing indicates that this client is at risk for violent behavior. The nurse should assess the situation further and attempt to de-escalate the situation by speaking to the client in a low, calm voice using short sentences.

A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective?

The client reports a decrease in episodes of nausea.

a nurse is caring for a client who had a nephrostomy tube inserted 12 hours ago. Which of the following findings should the nurse report to the provider

The client reports back pain the nurse should notify the provider if the client reports back pain which can indicate that the nephrostomy tube is dislodged or clogged

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?

The client reports back pain. "This can indicate their is a infection higher up in the urinary tract."

A nurse is teaching a client who has end-stage kidney disease about organ donation which of the following information should the nurse include in the teaching

The client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased

A nurse is assessing a client while suctioning the clients tracheostomy tube which of the following findings should indicate to the nurse that the client is experiencing hypoxia

The clients heart rate increases because hypoxia related to suctioning can cause the clients heart rate to increase if this occurs the nurse should discontinue the sectioning and immediately oxygenate the client with 100% oxygen the nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia

A nurse is teaching a client who has atrial fibrillation about the purpose of wearing a Holter monitor. Which of the following information should the nurse include in the teaching

This device can detect when you have an irregular heart rate because it reports and transmits electrical impulses of the heart and alerts the nurse to dysrhythmias myocardial injury or conduction defects a Holter monitor allows the client freedom of movement while cardiac activity is recorded

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

This identifies if the pacemaker cells of my heart are working properly.

A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations?

Throat

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?

Time the medication was given

A nurse is caring for a client who has hyperthyroidism. Which of the following findings should the nurse expect?

Tremors -- Tremors are a manifestation of hyperthyroidism, along with tachycardia, diaphoresis, weight loss, insomnia, and exophthalmia.

A nurse is preparing to assist with the insertion of a non tunneled percutaneous central venous catheter into a client's subclavian vein the nurse should plan to place the client in which of the following positions

Trendelenburg disposition facilitates the insertion of the catheter by dilating the blood vessels of the clients neck and

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)?

Troponin 8 ng/mL

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?

Troponin I 8 ng/mL "This lab is the most common MI lab ran, the normal value is 0-0.4. The higher the number indicates Some form of heart abnormality or injury. "

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for potassium sparing diuretic which of the following information should the nurse include in the teaching

Try to walk at least 3 times per week for exercise because the development of a regular exercise routine can improve outcomes in clients who have heart failure

A client with HF a new prescription for a potassium-sparing diuretic. Nursing teaching?

Try to walk at least three time per week for exercise.

A nurse is caring for a client who has a prescription for a continuous passive motion machine following a total knee arthroplasty. Which of the following actions should the nurse take?

Turn off the CPM machine during mealtime -- The nurse should turn off the CPM machine during meals to promote client comfort and dietary intake.

A nurse is caring for a client who is having a seizure which of the following interventions is the nurses priority

Turn the client to the side because the greatest risk to this client is hypoxia from an impaired Airway

What is the nurses priority for a patient having a seizure?

Turn the client to the side. "The patient should be side-lying to prevent them from aspirating. This also allows oral secretions to come out that may obstruct the airway." *Other actions - loosen clothing around neck, check pupils, and move furniture away from pt. *Look for safety risks first. Follow ABC! Assess which risk is greater before acting.

A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication?

Urinary retention

A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr

*****A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr R: Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

Findings contributing to delayed wound healing?

Urine output 25 mL/hr *Encourage patient to intake 2-3l of fluid if there aren't any present contraindications." pg. 341 Normal albumin - 3.4 to 5.4 Normal WBC - 4,000 to 11,000 BMI should be between 18 and 25

Assessment for a patient suspected of hypertonic dehydration

Urine specific gravity 1.045 *Patients may also have Na level > 145, and blood osmolality > 295. pg. 278

A nurse in an emergency department is caring for a client who is at 9 weeks of gestation and reports nausea and vomiting for the past 2 days. Which of the following findings should the nurse expect?

Urine specific gravity 1.052 -- The nurse should recognize this urine specific gravity is significantly elevated above the expected reference range of 1.005 to 1.030. An increased urine specific gravity indicates dehydration from vomiting.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity is 1.045

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use a 30 mL syringe

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use a 30 mL syringe R: The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

Nursing actions to take when planning to irrigate and dress a clean, a granulating wound for a client who has a pressure injury.

Use a 30-mL syringe. "Do not apply a wet to dry gauze because it will take off the good skin when dry, use a 30ml syringe to irrigate because it holds enough fluid to be able to irrigate."

A nurse is caring for a newborn immediately after delivery. Which of the following interventions should the nurse implement to prevent heat loss by conduction?

Use a protective cover on the scale when weighing the infant.

A nurse is providing teaching about home care to the parents of a child who has autism spectrum disorder. Which of the following instructions should the nurse include?

Use a reward system to modify the child's behavior.

A nurse is providing teaching for a client who has a fracture of the right fibula with a short leg cast in place and a new prescription for crutches. The client is non-weight-bearing for 6 weeks. Which of the following instructions should the nurse include in the teaching?

Use a three-point gait.

A nurse is preparing to administer an IM injection to a client who is obese. Which of the following actions should the nurse plan to take?

Use the ventrogluteal site.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity which of the following instructions should the nurse include in the plan of care

Used crutches with rubber tips to prevent the client from slipping and decrease the risk of Falls

A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

Verify the client and blood product information with another licensed nurse.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client?

Visual spatial deficits Left hemianopsia One-sided neglect

A home health nurse is assigned to a client who has recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident (CVA). Which of the following neurologic deficits should the nurse expects to find when assessing the client? (Select all that apply) - Expressive aphasia - Visual spatial deficits - Left hemianopsia - Right hemianopsia - One-sided neglect

Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric CVA. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric CVA. One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric CVA.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

Void before and after intercourse R: The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.

Nursing teaching for a female client who has recurrent urinary tract infections.

Void before and after intercourse. "This will allow her to void bacteria that may contribute to her UTIs. Wear cotton underwear to absorb the moisture, take showers, and drink 2-3L of fluid."

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

WBC count 2,000/mm3 "Aplastic anemia occurs when the body doesn't produce enough rbcs puttting the client at risk for increased fatigue and infection."

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery the nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider

Warfarin because it is an anticoagulant which increases the client's risk for bleeding and is contraindicated for a client scheduled for I or Central Nervous System since surgery

Nursing actions to include in the clients plan of care for a patient receiving brachytherapy. (Internal radiation placed in a closed area of the body to target cancerous tissue)

Wear a lead apron while providing care to the client. "Protects the nurse from the radiation, must wear a dosimeter to measure exposure." D/C Teaching "The clients urine and feces can contain radioactive substances which can be harmful to other if disposed of improperly, will need to place urine and feces in a bio bag." pg. 606

A nurse is providing discharge teaching to a client who is to receive home oxygen therapy. Which of the following instructions should the nurse include in the teaching?

Wear clothing made with cotton fabrics while oxygen is in use

A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider?

Weight gain

A nurse is assessing a client who is taking propranolol. Which of the following findings should indicate to the nurse that this client is experiencing an adverse reaction to propranolol?

Wheezing

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication?

White blood cell count of 2000. This white blood cell count is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is caring for a client who has a pulmonary embolism. The client is receiving heparin via continuous IV infusion at 1,200 units/hr and warfarin 5 mg PO daily. The morning laboratory values for the client are aPTT 98 seconds and INR 1.8. Which of the following actions should the nurse take?

Withhold the heparin infusion

A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes? (Select all that apply) - Polyuria - Dysphagia - Polydipsia - Photophobia - Neuropathy

Polyuria is correct. Excessive urination is a common manifestation of type 1 diabetes mellitus and is caused by increased glucose levels in the blood and urine having an osmotic effect and pulling more water into the system. Polydipsia is correct. Thirst is a common manifestation of type 1 diabetes mellitus because the increased glucose levels create intracellular dehydration as water is osmotically pulled into circulation. This cellular action stimulates the hypothalamus, creating the sensation of thirst. Neuropathy is correct. Elevated glucose levels associated with type 1 diabetes mellitus cause changes to the microvasculature. The subsequent damage to the neurons and neuronal pathways results in diabetic neuropathy, characterized by burning, tingling, or the absence of feeling.

A nurse is reviewing the medication history of a client who is to undergo allergy testing the nurse should instruct the client to discontinue which of the following medications before testing

Prednisone because it is a glucocorticoid that can cause the client to have false negative test results they should discontinue antihistamine medications several weeks prior to testing

A nurse in an emergency department is planning care for a client who has a flail chest on the right side following a motor vehicle crash which of the following actions should the nurse plan to take

Prepare the client for positive pressure ventilation to promote lung expansion and stabilize the pressure within the client's chest then there should also administer analgesics to alleviate pain while breathing to achieve optimal lung reexpansion

A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?

Proceed with provision of medical care.

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

Radial vein of the inner arm

A nurse is assessing a client following a colonoscopy. Which of the following findings should indicate to the nurse that the client is hemorrhaging?

Rapid decrease in blood pressure

A nurse in a provider's office is caring for an 18-month-old toddler who has a blood lead level of 3 mcg/dL. Which of the following actions should the nurse take?

Recommend rescreening in 1 year.

A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings

Discharge teaching for a client who has a partial thickness burn on the hand?

Wrap fingers with individual dressings. "You want to maintain active and passive ROM" pg. 503

A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management which of the following information should the nurse include in the teaching

You should increase your fiber intake to prevent constipation because opioids slow paracelsus in the gastrointestinal tract which causes constipation

Older client with cancer and a new prescription for an opiod analgesic for pain management. Nursing teaching?

You should void every 4 hours to decrease the risk of urinary retention. "Pain meds can slow the body down."

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include?

You will need to stay still in the bed during each treatment session. "Patient needs to remain in the instructed position to prevent the radiation implant from moving." Pg. 606

Client teaching for a patient receiving sildenafil to treat erectile dysfunction.

You will not be able to use sildenafil if you are taking nitroglycerin. "This combination can cause severe hypotension and/or death."

A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make?

You will not be able to use sildenafil if you are taking nitroglycerin. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension

A nurse is caring for a client who is receiving a continuous heparin infusion. Which of the following lab tests should the nurse review prior to adjusting the client's heparin?

aPTT

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent Airway which of the following interventions is the priority

applying oxygen via face mask because the priority intervention is for the nurse to apply oxygen using a high-flow non-rebreather mask to deliver oxygen at 90 to 100%

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

Regular insulin 20 units IV "Bolus of regular insulin will help to lower severely elevated levels quickly,"

Nursing action for RBC infusion

Remain with the client for the first 15 min of the infusion. "Patient is at highest risk for dev. an allergic reaction."

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 minutes of the infusion.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 minutes of the infusion. R: The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

Older client who has hemianopsia; at risk for falls. Nursing teaching?

Remind client to scan their complete range of vision during ambulation "Hemianopsia cause a patient to experience vertical midline blindness in 1/2 of their visual field, usually caused by a stroke."

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough

A nurse is assessing a client after administering epinephrine for an anaphylactic reaction. Which of the following findings should the nurse identify as an adverse effect of this medication?

Report of chest pain

The nurse should postpone the allergy testing and report to the provider which of the following findings?

Current Medications "Clients should avoid corticosteroids and avoid antihistamines from 48hr to 2 weeks to prep for testing according to how long they last."

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings?

Current medications

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish and ureterostomy. Which of the following statements should the nurse include in the teaching

Cut the opening of The Skin Barrier one eighth of an inch wider than the stoma. The client should cut the opening of The Skin Barrier 1/8 inch wider than the stoma to minimize irritation of the skin from exposure to urine

Nursing teaching for a patient that will undergo a cutaneous diversion procedure to establish a ureterostomy. *Cutaneous diversion - occurs when a patient has bladder cancer. The provider creates a reservoir from a section in the bowel that will allow the urine to flow to another area via the ureters instead of the bladder.

Cut the opening of the skin barrier 1/8 inch wider than the stoma. pg. 241

A pacu nurse is assessing a client who is post-operative following a right nephrectomy the client's initial vital signs for heart rate 80 permanent blood pressure 130 over 70 respiratory rate 16 and temperature 96.8 which of the following Vital sign changes should alert the nurse the client might be hemorrhaging

heart rate of 110 per minute because one of the first signs of hemorrhage is an increase in the heart rate from the clients Baseline which occurs to compensate for blood

a nurse is conducting an admision history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings require further assessment? quizlet

history of asthma R: A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

A client with hypertension and taking propranolol in a provider's office. What indicates the client is experiencing a adverse effect to the medication?

Report of night cough. "This medication can cause hypoglycemia and bronchospasms. Mon. BP and HR." pg. 179

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?

Report of sore throat. "These patients are immunocompromised and at risk for developing an infection that can make them really sick."

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory Paralysis

***A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory Paralysis R: The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mmHg, and HCO3- of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?

Respiratory acidosis

A nurse is assessing a client following the completion of hemodialysis which of the following findings is the nurses priority to report to the provider

Restlessness because using the Urgent vs. Non-virgin approach to client care the nurse to determine that the priority funding to report to the provider is restlessness which can be an indication of the client is experiencing disequilibrium syndrome which is caused by the rapid removal of electrolytes for the clients blood and can lead to dysrhythmias or seizures other manifestations include nausea vomiting fatigue and headache

How to perform testicular self-examination.

Roll each testicle between the thumb and fingers. "Perform after a bath to allow for the testicles to drop, eval each separately."

A nurse is caring for a client who is eight hours post-operative following a total hip arthroplasty the client is unable to void on the bed pan Which of the following actions should the nurse take first

Scan the bladder with a portable ultrasound the first action should be using the nursing process which is assisting the client scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client?

Scan the environment by turning your head from side to side. "The visual loss from the stroke can increase the risk for fall."

A nurse is developing a client education program about osteoporosis for older adult clients. The nurse should indicate which of the following variables as a risk factor for osteoporosis?

Sedentary lifestyle -- The nurse should encourage older adult clients to engage in weight-bearing exercises because they will promote bone health by increasing calcium and phosphorus levels.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate. "This lab value indicates infection development when elevated. Normal 0 to 22 in men and 0 to 29 in women."

A nurse is providing follow-up care for a client who sustained a compound fracture three weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider

Sedimentation rate. And increased sedimentation rate occurs when a client has any type of inflammatory process such as osteomyelitis

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's Triad? A. Hypotension B, Tachypnea C. Nuchal rigidity D. Bradycardia

D. Bradycardia A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for Gentamicin which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider

Serum creatinine because a client who has an elevated serum creatinine level should not receive Gentamicin because the medication is nephrotoxic

A nurse is caring for a school-age child who is taking valproic acid. The nurse should expect the provider to order which of the following diagnostic tests?

Serum liver enzyme levels

A nurse is caring for a client who has hypotonic dehydration and is receiving an oral rehydration solution. Which of the following laboratory results indicates that the treatment regimen is effective?

Serum sodium 136 mEq/L

A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer? A. Epoetin alfa B. Furosemide C. Captopril D. Calcium carbonate

D. Calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan administer a calcium supplement, such as calcium carbonate, as a calcium replacement.

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A. Decreased T cells B. Increased creatinine clearance C. Increased eosinophils D. Decreased viral load

D. Decreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.

A nurse is preparing a cient who has supraventricular tachycardia for elective cardioversion. Which of the following prescriptions should the nurse instruct the client to withhold for 48 hr prior to cardioversion? A. Enoxaparin B. Metformin C. Diazepam D. Digoxin

D. Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates and pulls back blood in the syringe. Which of the following actions should the nurse take? A. Obtain a new needle and continue administering the medication as prescribed B. Withdraw the syringe and reinsert it in a different location C. Continue with the injection site after pulling back on the needle slightly D. Dispose of the medication

D. Dispose of the medication The presence of blood indicates improper needle placement. The medication and needle are now contaminated. The nurse should dispose of the medication according to facility protocol and obtain a new dose of medication, syringe, and needle.

A nurse is reviewing the laboratory results of a client who ad a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies? A. Alanine aminotransferase (ALT) B. Total bilirubin C. Alkaline phosphatase (ALP) D. Enzyme immunoassay (EIA)

D. Enzyme immunoassay (EIA) EIA testing is completed to screen a client who has suspected hepatitis C virus to confirm the diagnosis and identify the hepatitis C antibodies.

A nurse is providing education to a client who has TB and his family. Which of the following information should the nurse include in the teaching? A. After 1 week of medication, TB is no longer communicable B. Dispose of contaminated tissues in a paper bag C. Airborne precautions are necessary in the home D. Family members in the household should undergo TB testing

D. Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse is caring for a client who has a potassium level of 3 meq/L. Which of the following assessment findings should the nurse expect? A. Positive Trousseau's sign B. 4 + deep tendon reflexes C. Deep respiration D. Hypoactive bowel sounds

D. Hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

A nurse admits a client who has anorexia., low grade fever, night sweats and productive cough. Which of the following actions should the nurse take first? A. Obtain a sputum sample B. Administer antipyretics C. Secure venous access D. Initiate airborne precautions

D. Initiate airborne precautions. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? A. Check the laboratory values for recent hemoglobin and hematocrit levels. B. Establish a peripheral IV line for possible transfusion C. Call the laboratory to obtain a stat platelet count D. Obtain vital signs

D. Obtain vital signs The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening?

Shellfish allergy

A nurse is providing teaching to a client who is scheduled for electroconvulsive therapy (ECT). The nurse should inform the client that which of the following findings is an adverse effect of ECT?

Short-term memory loss

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate. "?"

A nurse is reviewing the lab report of a client who has end-stage kidney disease and received hemodialysis 24 hr ago. Which of the following lab values should the nurse report to the provider?

Sodium 148 mEq/L

A nurse is providing discharge instructions to a client who has active tuberculosis which of the following information should the nurse include in the instructions

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures after three negative sputum cultures the client is no longer considered infectious

A nurse preceptor is evaluating the performance of a newly licensed nurse. Which of the following actions by the newly licenses nurse requires intervention by the preceptor?

Starts a task then determines what supplies are needed

A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine R: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

Expected findings 6hrs after etracorporeal shock wave lithotripsy (ESWL)?

Stone fragments in the urine. "The nurse should assess for hematuria and strain the urine after the procedure. Bruising will only be at the site where the waves were applied." pg. 408

A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include?

Store the medication in its original container

A nurse is caring for a client who has cirrhosis of the liver with esophageal varices. Which of the following activities should the nurse instruct the client to avoid?

Straining to have bowel movements

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy to the nurse should recognize that which of the following complications is associated with long-term mechanical ventilation

Stress ulcers because of elevated levels of hydrochloric acid in the stomach

A nurse in an outpatient mental health facility is assessing a child who has autism spectrum disorder. Which of the following manifestations should the nurse expect?

Strict adherence to routines

a nurse is caring for a client following excavation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately

Strider. Using the Urgent vs. Non-urgent approach to client care the nurse should determine that the priority finding a Strider. Strider can indicate and narrowing Airway or possible obstruction caused by edema or laryngeal spasms the nurse should report the finding immediately Implement an intervention

A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately?

Stridor "This finding can indicate that the airway has become compromised."

Caring for a client with dysphagia. (Difficulty swallowing) Bedside item?

Suction machine "This item should be in place to readily suction the patient if the airway starts to become obstructed."

A nurse is creating a plan of care for a client who has left-sided weakness following a stroke. Which of the following interventions should the nurse include in the plan?

Support the client's left arm on a pillow while sitting.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to give? A. 240 ml (8 oz) of orange juice B. 1 ampule of 50% dextrose IV bolus C. NPH insulin 60 units subcutaneous D. Regular insulin 20 units IV bolus

D. Regular insulin 20 units IV bolus DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.

Client has a new prescription for omeprazole for a gastric ulcer. Provides relief by which of the following actions?

Suppressing gastric acid production. "This medication is a proton pump inhibitor."

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for Omeprazole. The nurse should instruct the client that the medication provides Relief by which of the following actions

Suppressing gastric acid production. Omeprazole is a proton pump inhibitor it relieves manifestations of gastric ulcers by suppressing gastric acid production

A school nurse is notified of an emergency in which several children were injured following the collapse of playground equipment. Upon arrival at the playground, which of the following actions should the nurse take first?

Survey the scene for potential hazards to staff and children.

Acute cholecystitis - Inflammation of the gallbladder wall. Priority finding for the nurse?

Tachycardia "Rebound tenderness is also a priority but it can only be assessed by the provider; pain will only be in the r-upper quadrant and radiate to the right shoulder as an expected finding." pg. 355

A nurse is reviewing the lab findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? A. Calcium 9.5 mg/dl B. High-density lipoprotein (HDL) 65 mg/dl C. Alanine aminotransferase (ALT) 28 units/L D. Troponin I 8 ng/mL

D. Troponin I 8 ng/mL Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? A. Serum sodium level is 145 meq/L B. Forearm skin tents when pinched C. Respiratory rate is decreased D. Urine specific gravity is 1.045.

D. Urine specific gravity is 1.045. A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching?

Take additional pairs of shoes

A nurse is providing instruction about traveling for a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip by airplane which of the following should the nurse include in the teaching

Take an additional pair of shoes

Teaching for a female client who has a history of UTIs?

Take daily cranberry supplements. "The compound in the fruit helps to avoid some bacteria from sticking to the mucous membranes in the urinary track to reduce r/4 infection." pg. 401

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

Take insulin even if you are unable to eat your regular diet.

Type 1 diabetic with acute bronchitis for the past 3 days. Nursing instructions?

Take insulin even if you are unable to eat your regular diet. "Being sick can cause your blood glucose levels to rise without the patient being aware, they should check levels more often and call the dr. for bg above 250."

A nurse is assessing a client who is taking Carvedilol for heart failure. Which of the following findings is the priority for the nurse to report to the provider? A. Fatigue B. Diarrhea C. Rhinitis D. Weight gain

D. Weight gain Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is weight gain because it can indicate a worsening of the client's heart failure and requires immediate intervention.

A nurse is providing discharge instructions to a client who has a partial thickness burns of the hand. Which of the following instructions should the nurse include? A. Change the dressing every 72 hr B. Immobilize the hand with a pressure dressing C. Take pain medication 30 min after changing the dressing D. Wrap fingers with individual dressing

D. Wrap fingers with individual dressing The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range of motion exercises to each finger every hour while awake to promote function of the injured hand.

A nurse is caring for a client who has a prescription for chlorpromazine. Which of the following findings should the nurse identify as an indication that the medication is effective?

Decreased hallucinations -- The nurse should recognize that chlorpromazine is an antipsychotic medication administered to decrease hallucinations and other manifestations of schizophrenia.

A nurse is assessing a client who has hypokalemia which of the following manifestations should the nurse expect

Decreased peristalsis due to a decrease in gastrointestinal smooth muscle contraction

A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment?

Decreased sodium

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment?

Decreased viral load

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following method should the nurse include in the teaching?

Delegate non-nursing tasks to ancillary staff.

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Take the medication 15 min before playing sports.

A nurse in an emergency department is admitting a client who reports dyspnea and shortness of breath. Which of the following actions is the priority for the nurse to perform prior to administering oxygen?

Determine if the client has a history of COPD. According to evidence based practice the nurse should first assess if the client has COPD. Administering oxygen can worsen chronic hypercarbia in a client who has COPD

A nurse is updating the plan of care for a client who is 48 hr postoperative following a laryngectomy and is unable to speak. Which of the following actions should the nurse plan to take first?

Determine the client's reading skills -- The first action the nurse should take when using the nursing process is to assess the client. By determining the client's level of reading skills and cognition, the nurse can best provide the client with a variety of customized techniques to practice and use after verbal skills are lost.

A nurse on a medical-surgical unit is assessing a client who has had a stroke. For which of the following findings should the nurse initiate a referral for occupational therapy?

Difficulty performing ADLs -- The nurse should initiate a referral for occupational therapy to teach the client the skills necessary to become independent in performing ADLs such as bathing, dressing, and eating.

A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin

Medication to withhold for 48hr period to a cardio version for a patient with supra ventricular tachycardia ?

Digoxin "This helps bring the heart back to a normal rhythm for the critical first few hours after cardioversion. This will allow the physician to fix the original problem."

A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take?

Dispose of the medication

A nurse is assessing a client's hydration status. Which of the following findings indicate fluid volume overload?

Distended neck veins

A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker the nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take

Document that depolarization has occurred. When a pacing stimulus is delivered to The ventricle a spike appears on the ECG Rhythm strip this bike should be followed by a QRS complex which indicates pacemaker capture or depolarization

A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output?

Dopamine

A nurse is providing teaching to a client who has a new prescription for psyllium which of the following information should the nurse include in the teaching

Drink 240 milliliters of water after Administration

Interventions the nurse should include in the plan of care for a patient starting dialysis treatments for chronic kidney disease.

Tell the client that it is possible to return to similar previous levels of activity. "Other options are not therapeutic or medically correct. This statement can be true if patient has positive outcomes from the treatment which may be causing negative side effects."

A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?

Tension pneumothorax

A nurse is admitting a client who has pneumonia. The nurse should initiate which of the following isolation precautions for the client?

Droplet

A nurse is caring for a client who has a new prescription for clonidine. The nurse should inform the client that which of the following findings is an adverse effect of this medication?

Dry mouth

An RN is observing a licensed practical nurse and an assistive personnel move a client up in bed. For which of the following situations should the nurse intervene?

The LPN and the AP grasp the client under his arms to lift him up in bed

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

The child exhibits discomfort while walking.

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

"How does this make you feel?"

A nurse is providing teaching about lithium to a client who has bipolar disorder. Which of the following statements should the nurse include in the teaching?

"Notify your provider if you experience increased thirst."

Manifestations of a thyroid storm?

1. Fever - report increase of 1 degree or more because this can become a thyroid crisis 2.Hypertension 3.Tachycardia pg. 526

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24

Amikacin

400 ml/hr

A nurse is reviewing the lab results of a toddler who has hemophilia A. Which of the following aPTT values should the nurse expect?

45 seconds

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client? A. "Notify your provider if you experience weakness." B. "You should be able to return to work in 1 week." C. "You need to wear a mask when in crowded areas." D. "Notify your provider if you experience a productive cough."

A. Weakness is an expected finding following recovery from a pneumothorax. B. The client should expect a lengthy recovery following a pneumothorax. C. The client should wear a mask if immunosuppressed. D. CORRECT: The client should notify the provider of a productive or persistent cough. This can indicate that the client might need treatment of a respiratory infection.

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching? A. Chocolate pudding B. Grilled chicken breast C. Macaroni and cheese D. Peanut butter and saltine crackers

B. Grilled chicken breast Clients who have celiac disease should avoid food that contains gluten. In a person who has celiac disease, gluten causes inflammation of the small intestine mucosa and can increase the risk of cancer. A grilled chicken breast does not contain gluten and is, therefore, a good food choice.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

Bradycardia

Expected lab findings for a patient with pancreatitis that will be lower than normal.

Calcium "Calcium and mag may be lower than normal due to fat necrosis (occurs when fatty tissue is damaged). pg. 360

A nurse is caring for a client who is postoperative after receiving moderate (conscious) sedation. The client suddenly becomes restless and reports feeling lightheaded. Which of the following actions should the nurse take?

Check the client's oxygen saturation level -- Restlessness and lightheadedness are indications of hypoxia.

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Administer an antipyretic medication to promote client comfort.

Correct order B. The client's respiratory and heart rates are elevated, and her oxygen saturation is 91% on room air. Using the ABC priority framework, providing oxygen is the first intervention. C. Obtaining a sputum culture is the second nursing intervention. It should be done prior to administering oral medicationsto obtain an appropriate and adequate specimen. A. Administration of antibiotics is the third action the nurse should take. The sputum culture should be obtained prior to antibiotic administration. D. Administering an antipyretic medication is the fourth nursing intervention

A nurse on medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should the indicate to the nurse that the client requires a revision of his IV therapy prescription? (Exhibit button for labs) - Blood pressure - Prescribed medications - Oxygen saturation - BUN

D. BUN The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity? A. Hypertension B. Restlessness C Weight gain D. Bradycardia

D. Bradycardia The nurse should recognize that bradycardia is an early manifestation of digoxin toxicity. Digoxin toxicity is more common in older adult clients due to decreased renal excretion of the medication. Other indications of digoxin toxicity include anorexia, nausea, and visual disturbances. Digoxin toxicity can occur as a result of hypokalemia and is seen when digoxin levels are greater than 0.8 ng/mL.

A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect? A. Difficulty swallowing B. Deviation of the trachea away from midline C. Paradoxical chest wall movement D. Bruit heard over the middle upper abdomen

D. Bruit heard over the middle upper abdomen A client who has an abdominal aortic aneurysm can have a pulsating mass with a bruit heard over the middle upper abdomen, just to the left of the midline. In addition, the nurse should expect the client to report abdominal, flank, or back pain.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following lab results to be below the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium

D. Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is caring for a client who is experiencing a tonic clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade B. Apply oxygen C. Restrain the client D. Loosen restrictive clothing

D. Loosen restrictive clothing. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

A nurse is administering packed RBC's to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? A. Anorexia and jaundice B. Bronchospasm and urticaria C. Hypertension and bounding pulse D. Low back pain and apprehension

D. Low back pain and apprehension Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse is caring for a client who has cirrhosis of the liver with esophageal varices. Which of the following activities should the nurse instruct the client to avoid? A. Airplane travel B. Sleeping supine C. Using lemon juice to season foods D. Straining to have bowel movements

D. Straining to have bowel movements Esophageal varices are fragile and thin-walled veins that bleed easily. The nurse should instruct the client to avoid activities that increase intra-abdominal pressure, such as straining during bowel movements, because straining increases the risk of the varices bleeding.

A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following should the nurse include in the teaching? A. Take tub baths daily B. Drink at least 1 L of fluid daily C. Wear underwear made of nylon D. Void before and after intercourse

D. Void before and after intercourse. The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.

Finding that indicates positive response to the prescibed HIV treatment in a client with HIV?

Decreased viral load

Preop teaching for patient undergoing a open cholecystectomy.

Demonstrate ways to deep breath and cough. "Need to do this to prevent pneumonia and to protect incision from popping open."

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy which of the following actions should the nurse take

Demonstrate ways to deep breathe and cough to prevent respiratory complications

A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism.

Dyspnea

A nurse is caring for a client who has acute blood loss following a trauma. The client refuses a blood transfusion that might potentially save their life. Which of the following actions should the nurse take first?

Explore the client's reasons for refusing the treatment.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider?

Extremity cool upon palpation

A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial butterfly rash. "Most common sign of SLE."

A nurse is caring for a client who is post-operative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

HGB of 8. The nursery report and HGB level of 8 which is below the expected reference range and as an indicator of postoperative hemorrhage or anemia.

A nurse is assessing a client who has peripheral artery disease which of the following findings should the nurse expect

Hair loss on the lower legs the nurse should expect a client who is Peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth

A nurse is caring for a client who has active TB. Which of the following actions should the nurse plan to take to prevent the transmission of the disease?

Have the client wear a surgical mask while being transported outside the room.

A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective?

Hgb 14.9 g/dL

A nurse is caring for a client who recently had a stroke of the right hemisphere which of the following manifestations should the nurse expect

Impulsive behavior

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increased fluid intake

A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock?

Increased heart rate

A nurse is assessing a client who has a decreased visual acuity due to cataracts. The nurse should identify that which of the following physiological changes is the cause for the client's visual loss?

Increased opacity of the lens

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

Increased respiratory secretions

Client with ALS being admitted to hospital with pneumonia. Nursing priority assessment?

Increased respiratory secretions. "Risk for aspiration due to inability to clear airway."

A nurse is reviewing the laboratory results of a client who has a new diagnosis of acute leukemia which of the following findings should the nurse identify as an expected finding

Increased white blood cell count do to overproduction of white blood cells by the bone marrow

A patient has a full-thickness burn over 20% of their total body surface area. After ensuring a patent airway and administering O2 what should the nurse do first?

Iniate IV fluids "Client is at risk for hypovolemic shock due to fluid loss through the purns. Client will need pain management next."

Client has anorexia, low grade fever, night sweats, and a productive cough. Which action should the nurse take first?

Initiate airborne precaution. "These symptoms are those of TB in which the nurse should immediately protect those around the patient until sputum samples come back which is the second action they should take."

A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions

Nursing action for a patient with a new prescription of subQ enoxaparin.

Inject the medication into the anterolateral abdominal wall. "Do not expel the bubble in this type of syrine or massage site.

A nurse is preparing to assist with a thoracentesis for a client who has pleurisy. The nurse should plan to perform which of the following actions?

Instruct the client to avoid coughing during the procedure.

A nurse is caring for a client who has deep-vein thrombosis. Which of the following actions should the nurse take?

Instruct the client to elevate the affected extremity when sitting.

A nurse is preparing a client for a paracentesis. Which of the following actions should the nurse take?

Instruct the client to void.

A nurse is caring for a client who is taking valproic acid for seizure control. For which of the following adverse effects should the nurse monitor and report?

Jaundice

A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect?

Muscle atrophy

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

Paco2 of 56. A client who has COPD retains paco2 due to the weakening and the collapse of the alveolar sacs which decreases the area and lungs for gas exchange and causes the paco2 to increase above the expected reference range.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?

Pain that increases with passive movement "Compartment syndrome causes pain that increases with passive movement and is not relieved with pain management." Pg. 474

A nurse is assessing for compartment syndrome in a client who has a short leg cast which of the following findings should the nurse identify as a manifestation of this condition

Pain that increases with passive movement because compartment syndrome results from a decrease in blood flow in the extremities because of a decrease in the muscle compartment size due to a cast that is too tight

Client has supraventricular tachycardia. HR of 200/min, BP 78/40, and Resp rate of 30/min. Nursing action?

Perform synchronized cardioversion. "You need to get the patients heart rhythm back regular. Cardioversion uses lower jules than defribrillation."

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip.

Pericardial friction rub

A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?

Pink, frothy sputum

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

Regular insulin 20 units IV bolus

Adverse effect of magnesium sulfate.

Respiratory paralysis "Have calcium gluconate on hand as the antidote."

A nurse manager is planning to use a democratic leadership style?

Seeks input from the other nurses

A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect?

Stone fragments in the urine

Where would you palpate to assess for an inguinal hernia

The nurse should palpate at the right groin area because an inguinal hernia forms of the peritoneum which contains part of the intestine and can protrude into the scrotum in males

Instructions for the AP caring for a pt with bacterial meningitis.

Wear a mask. "This type of meningitis can be infectious; can be transferred through droplets, initiate droplet precaution." pg. 32

A nurse is assessing a client who has bipolar disorder. Which of the following alterations in speech is the client using?

Flight of ideas

A nurse working on a cardiac unit is admitting a client who is to undergo a cardioversion and is reviewing the health record. Which of the following data requires that the nurse notify the provider to cancel the procedure? (Review the data below for additional client information.) MAR Ferrous Sulfate 200 mg PO 0800 and 2000 Diazepam 2 mg PO 0800 and 2000 Isosorbide 2.5 mg PO 4 times a day AC and HS VITAL SIGNS 0800 T 99° F (37.2° C) Blood pressure 142/86 mm Hg Heart rate 88/min and irregular Respirations 20/min HISTORY AND PHYSICAL Bariatric surgery 10 years ago Dyspnea with exertion for 3 years Atrial fibrillation began 3 years ago Client reports taking the following medications for the past 6 weeks: iron supplement, multivitamin, antilipemic, and nitroglycerin A. Respiratory history B. Vital signs C. Medication history D. Medications to be administered

A. A client who has a dysrhythmia often has a history of lung disease, which can make him a candidate for cardioversion. B. A client who has a dysrhythmia might have an irregular pulse, which can make him a candidate for cardioversion. C. CORRECT: A client who is to undergo cardioversion needs to be on anticoagulant therapy for 4 to 6 weeks prior to the procedure. D. A client who has a dysrhythmia often has a history of cardiac disease and angina, which can make him a candidate for cardioversion.

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open‑angle glaucoma C. Macular degeneration D. Angle‑closure glaucoma

A. A client who has cataracts experiences a decrease in peripheral and central vision due to opacity of the lens. B. CORRECT: This is a manifestation of open‑angle glaucoma. A gradual loss of peripheral vision is a manifestation associated with this diagnosis. C. A client who has macular degeneration experiences a loss of central vision. D. A client who has angle‑closure glaucoma experiences sudden nausea and severe pain and halos around lights.

A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? A. Teach the client to scan to the right to see objects on the right side of her body. B. Place the bedside table on the right side of the bed. C. Orient the client to the food on her plate using the clock method. D. Place the wheelchair on the client's left side.

A. A client who has left homonymous hemianopsia has lost the left visual field of both eyes. The client should be taught to turn his head to the left to visualize the entire field of vision. B. CORRECT: The client is unable to visualize to the left midline of her body. Placing the bedside table on the right side of the client's bed will permit visualization of items on the table. C. Using the clock method of food placement will be ineffective because only half of the plate can be seen. D. The wheelchair should be placed to the client's right or unaffected side.

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? A. Blood‑tinged sputum B. Dry, nonproductive cough C. Sore throat D. Bronchospasms

A. A client who is experiencing respiratory acidosis will have a decreased pH and an increased PaCO2. B. CORRECT: A client who is experiencing respiratory alkalosis will have an increased pH and a decreased PaCO2. Possible causes of respiratory alkalosis include hyperventilation, fever, and respiratory infections. C. A client who is experiencing metabolic acidosis will have a decreased pH and a decreased HCO3. D. A client who is experiencing metabolic alkalosis will have an increased pH and an increased HCO3.

A nurse is discussing pain assessment with a newly licensed nurse. Which of the following information should the nurse include? A. Most clients exaggerate their level of pain. B. Pain must have an identifiable source to justify the use of opioids. C. Objective data are essential in assessing pain. D. Pain is whatever the client says it is.

A. A misconception about pain is that clients exaggerate their pain level. B. Clients can have pain without being able to identify the source. C. Objective data are not always present when clients have pain. D. CORRECT: The nurse should identify that pain is a subjective experience, and the client is the best source of information about it.

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

A. A nonrebreather mask delivers an approximated amount of oxygen. B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered. C. A nasal cannula delivers an approximated amount of oxygen. D. A simple face mask delivers an approximated amount of oxygen.

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? A. Pearly, gray tympanic membrane (TM) B. Malleus visible behind the TM C. Presence of soft cerumen in the external canal D. Fluid bubble seen behind the TM

A. A pearly, gray TM is an expected finding during an otoscopic examination. B. Visualization of the malleus behind the TM is an expected finding during an otoscopic examination. C. Cerumen of various colors, depending on the client's skin color or ethnic background, is an expected finding in the external ear canal. D. CORRECT: Fluid behind the TM indicates the possibility of otitis media and is not an expected finding.

A nurse is providing discharge instructions to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? A. Use music therapy for relaxation with the onset of the headache. B. Increase physical activity when a headache is present. C. Drink beverages that contain artificial sweeteners to prevent headaches. D. Apply a cool cloth to the face during a headache.

A. A quiet, dark environment can provide comfort during a migraine headache. B. Increasing physical activity during a migraine headache can worsen the pain. C. Artificial sweeteners contain tyramine, which can trigger a migraine headache. D. CORRECT: A cool cloth placed over the client's eyes provides comfort and can relieve pain.

A nurse working in a long-term care facility is planning care for a client in stage V of Alzheimer's disease. Which of the following interventions should be included in the plan of care? A. Use a gait belt for ambulation. B. Thicken all liquids. C. Provide protective undergarments. D. Assist with ADLs.

A. Ambulation is affected as the client advances into stage VII of Alzheimer's disease. B. Impaired swallowing is a finding as the client advances into stage VII of Alzheimer's disease. C. The client in stages VI and VII of Alzheimer's disease experiences episodes of urinary and fecal incontinence. D. CORRECT: A client in Alzheimer's disease stage V requires assistance with ADLs as increasing cognitive deficits emerge.

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.) A. Implement seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently.

A. CORRECT: The client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizure precautions to reduce the client's risk for injury. B. The nurse should perform neurological checks at least every 2 hr for a client who is at risk for increased ICP. C. The nurse should avoid administering opioids to a client who is at risk for increased ICP. Opioids can mask changes in the client's level of consciousness. D. CORRECT: The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. E. CORRECT: The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP. F. The nurse should instruct the client to avoid coughing because this action can cause increased ICP

A nurse is caring for a group of clients. Which of the following clients are at risk for a pulmonary embolism? (Select all that apply.) A. A client who has a BMI of 30 B. A female client who is postmenopausal C. A client who has a fractured femur D. A client who is a marathon runner E. A client who has chronic atrial fibrillation

A. CORRECT: The client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. B. A woman who is postmenopausal has decreased estrogen levels and is not at risk for developing a pulmonary embolism. C. CORRECT: The client who has a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. D. The client who is a marathon runner has increased blood flow and circulation of his body, which decreases the risk for developing a pulmonary embolism. E. CORRECT: The client who has turbulent blood flow in the heart, such as with atrial defibrillation, is also at increased risk of a blood clot.

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply.) A. Tachypnea B. Deviation of the trachea C. Bradycardia D. Decreased use of accessory muscles E. Pleuritic pain

A. CORRECT: The client who has a pneumothorax can experience tachypnea related to respiratory distress caused by the injury. B. CORRECT: The client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. C. The client who has a pneumothorax can experience tachycardia related to respiratory distress and pain. D. The client who has a pneumothorax can experience an increase in the use of accessory muscles as respiratory distress occurs. E. CORRECT: The client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

A nurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving ventilation F. Client who has myasthenia gravis

A. CORRECT: The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration. B. CORRECT: The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. C. The client who has recently been vaccinated in the past few months has a decreased risk to acquire pneumonia. D. A client who is postoperative and has received local anesthesia has a decreased risk to acquire pneumonia. E. CORRECT: Mechanical ventilation is invasive and increases the risk of pneumonia. F. CORRECT: A client who has myasthenia gravis has generalized weakness and can have difficulty clearing airway secretions, which increases the risk of pneumonia.

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy? A. Hip arthroplasty 2 weeks ago B. Elevated sedimentation rate C. Incident of exercise‑induced asthma 1 week ago D. Elevated platelet count

A. CORRECT: The client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site. B. An elevated sedimentation rate does not place the client at risk for hemorrhage. C. An incident of exercise‑induced asthma does not place the client at risk for hemorrhage, nor is it contraindicated with this type of medication. D. An elevated platelet count does not place the client at risk for hemorrhage when receiving this medication.

A nurse is caring for a client who experienced defibrillation. Which of the following should be included in the documentation of this procedure? (Select all that apply.) A. Follow‑up ECG B. Energy settings used C. IV fluid intake D. Urinary output E. Skin condition under electrodes

A. CORRECT: The client's ECG rhythm is documented following the procedure. B. CORRECT: Energy settings used during the procedure are documented. C. IV fluid intake is not documented during defibrillation. D. Urinary output is not documented during defibrillation . E. CORRECT: The condition of the client's skin where electrodes were placed is documented.

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine.

A. CORRECT: The first action the nurse should take using the nursing process is to assess the client, which is essential in planning client‑centered care. B. The nurse should obtain a sputum culture to determine sensitivity for antibiotic therapy. However, there is another action the nurse should take first. C. The nurse should obtain a complete history from the client to determine the plan of care. However, there is another action the nurse should take first. D. The nurse should provide for a pneumococcal vaccination to decrease the risk of pneumonia in the future. However, there is another action the nurse should take first.

A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first?

Administer morphine

A nurse is planning care for a client who has a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? A. Prevention of further damage to the spinal cord B. Prevention of contractures of the lower extremities C. Prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. CORRECT: The greatest risk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord. B. The nurse should implement ROM exercise to prevent contractures. However, another action is the priority. C. The nurse should implement a turning schedule to prevent skin breakdown. However, another action is the priority. D. The nurse should slowly move the client to an upright position to prevent postural hypotension. However, another action is the priority.

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? A. Keep the client in a side‑lying position. B. Document the duration of the seizure. C. Reorient the client to the environment. D. Provide client hygiene.

A. CORRECT: The greatest risk to the client is aspiration during the postictal phase. Therefore, the priority intervention is to keep the client in a side‑lying position so secretions can drain from the mouth keeping the airway patent. B. The nurse should document the duration of the seizure in the client's medical record, but there is another action that the nurse should take first. C. The nurse should reorient the client to the environment because the client can feel confused, but there is another action that the nurse should take first. D. The nurse should provide client hygiene if the client experienced incontinence during the seizure, but there is another action that the nurse should take first.

A nurse is caring for a client who was recently admitted to the emergency department following a head‑on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on his forehead that is bleeding. Which of the following is the priority nursing action at this time? A. Keep neck stabilized. B. Insert nasogastric tube. C. Monitor pulse and blood pressure frequently. D. Establish IV access and start fluid replacement.

A. CORRECT: The greatest risk to the client is permanent damage to the spinal cord if a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be ruled out. B. Insertion of a nasogastric tube is not the priority nursing action at this time. C. Frequent monitoring of pulse and blood pressure is important but not the priority nursing action at this time. D. Establishing IV access for fluid replacement is important but not the priority nursing action at this time.

A nurse is evaluating clients at a health fair for modifiable variables affecting health and wellness. The nurse should identify which of the following variables as modifiable? (Select all that apply.) A. Smoking on social occasions B. BMI of 28 C. Alopecia D. Trisomy 21 E. History of reflux

A. CORRECT: The nurse identifies smoking as a modifiable variable that a client can change. The nurse should provide the client with educational materials and information on smoking cessation. B. CORRECT: The nurse identifies a BMI of 28 as a modifiable variable that a client can change. The nurse should provide the client with educational materials and information on weight reduction and exercising. C. The nurse identifies alopecia as a nonmodifiable variable because alopecia is a genetic disorder. D. The nurse identifies Trisomy 21 as a nonmodifiable variable because Trisomy 21 is genetic in origin. E. CORRECT: The nurse identifies reflux as a modifiable variable that a client can change. The nurse should provide the client with step‑by‑step educational information about treatment.

A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication. Which of the following actions should the nurse take to promote client compliance? (Select all that apply.) A. Ask the dietitian to assist with meal planning. B. Contact the client's support system. C. Assess for age‑related cognitive awareness. D. Encourage the use of a daily medication dispenser. E. Provide educational materials for home use.

A. CORRECT: The nurse provides resources to strengthen coping abilities by asking the dietitian to assist the client with meal planning. This will improve client compliance. B. CORRECT: With the client's consent, the nurse can contact members of the client's support system and encourage the client to use this support during times of illness and stress to improve compliance. C. Assessing the client for age‑related cognitive awareness is important but it is not an appropriate intervention that enhances the client's compliance. D. CORRECT: The nurse encourages the use of a daily medication dispenser to reduce health risks and improve medication compliance by the client. E. CORRECT: The nurse provides educational materials to the client to improve health awareness and reduce health risks after discharge.

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? (Select all that apply.) A. Provide privacy. B. Ease the client to the floor if standing. C. Move furniture away from the client. D. Loosen the client's clothing. E. Protect the client's head with padding. F. Restrain the client.

A. CORRECT: The nurse should implement privacy to minimize the client's embarrassment. B. CORRECT: The nurse should ease the client to the floor to prevent falling and injury. C. CORRECT: The nurse should move the furniture away from the client to prevent injury. D. CORRECT: The nurse should loosen the client's clothing to minimize restriction of movement. E. CORRECT: The nurse should protect the client's head from injury by placing the client's head in her lap or using a pillow or blanket under the head during a seizure. F. The nurse should not restrain the client. Restraint can increase the client's risk for injury or more seizure activity.

A nurse is assessing a client who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma? A. Gender B. Environmental allergies C. Alcohol use D. Race

A. Gender is not a risk factor associated with asthma. B. CORRECT: Environmental allergies are a risk factor associated with asthma. A client who has environmental allergies typically has other allergic problems, such as rhinitis or a skin rash. C. Alcohol use is not a risk factor associated with asthma. D. Race is not a risk factor associate with asthma.

A nurse planning care for a client who has a PICC line in the right arm. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Use a 10 mL syringe to flush the PICC line. B. Apply gentle force if resistance is met during injection. C. Cleanse ports with alcohol for 15 seconds prior to use. D. Maintain a transparent dressing over the insertion site. E. Flush with 10 mL heparin before and after medication administration.

A. CORRECT: The nurse should use a 10 mL syringe to flush the PICC line to avoid excess pressure that could cause catheter fracture/rupture. B. The nurse should avoid the application of force if resistance is met during injection. C. CORRECT: The nurse should cleanse insertion ports with alcohol for 15 seconds and allow it to air dry prior to use. This action decreases the risk for bacterial contamination. D. CORRECT: The nurse should maintain a transparent dressing over the insertion site to decrease the risk for infection and allow for visualization. The nurse should plan to change the dressing at least every 7 days and when wet, loose, or soiled. E. The nurse should flush the PICC line with 10 mL 0.9% sodium chloride before, between, and after medications. A flush of 5 mL heparin (10 units/mL) is recommended when the PICC is not actively in use.

A nurse in the emergency department is caring for a client who fell through the ice on a pond and is unresponsive and breathing slowly. Which of the following actions should the nurse take? (Select all that apply.) A. Remove wet clothing. B. Maintain normal room temperature. C. Apply warm blankets. D. Apply a heat lamp. E. Infuse warmed IV fluids.

A. CORRECT: This is an appropriate action by the nurse because the body temperature can rise more quickly when heat is applied to dry skin. B. The nurse should increase the temperature of the room to help return the client to a normal body temperature. C. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warm blankets are applied. D. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when a heat lamp is safely applied. E. CORRECT: This is an appropriate action by the nurse because the client's body temperature can rise more quickly when warmed IV fluids are infused.

A nurse in a provider's office is obtaining a health history from a client who has cluster headaches. Which of the following are expected findings? (Select all that apply.) A. Pain is bilateral across the posterior occipital area. B. Client experiences altered sleep‑wake cycle. C. Headache occurs at approximately the same time of the day. D. Client describes headache pain as dull and throbbing. E. Nasal congestion and drainage occur.

A. Cluster headaches typically cause pain on one side of the head and radiate to the forehead, temple, or cheek. B. CORRECT: Cluster headaches can be due to a lack of continuity in the sleep‑wake cycle. C. CORRECT: Cluster headaches occur at about the same time of day for 4 to 12 weeks. D. Cluster headaches are described as unilateral, intense, and non-throbbing. E. CORRECT: A client can have a runny nose and nasal congestion with a cluster headache.

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches? A. "Do the headaches occur at the same time each day?" B. "Is your headache accompanied by profuse facial sweating?" C. "Does your headache occur on one side of your head?" D. "Is there a pattern of headaches among family members?"

A. Cluster headaches typically occur at the same time each day. B. Profuse facial sweating is typical in the presence of cluster headaches. C. Unilateral headaches are associated with cluster headaches. D. CORRECT: A familial pattern of headaches is a common finding with migraines.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion B. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

A. Confusion is a late manifestation of hypoxemia. B. CORRECT: Pale skin is an early manifestation of hypoxemia. C. Bradycardia is a late manifestation of hypoxemia. D. Hypotension is a late manifestation of hypoxemia. E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply.) A. Continuous bubbling in the water seal chamber B. Gentle constant bubbling in the suction control chamber C. Rise and fall in the level of water in the water seal chamber with inspiration and expiration D. Exposed sutures without dressing E. Drainage system upright at chest level

A. Continuous bubbling in the water seal chamber indicates an air leak. B. CORRECT: Gentle bubbling in the suction control chamber is an expected finding as air is being removed. C. CORRECT: A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly. D. The nurse should cover the sutures at the insertion site with an airtight dressing. E. The drainage system should be maintained in an upright position below the level of the client's chest.

A nurse is reviewing the lab report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following lab findings should the nurse identify as a positive outcome of the treatment? A. Decreased sodium B. Increased urine cortisol C. Decreased calcium D. Increased blood glucose

A. Decreased sodium A client who has Cushing's disease and is responding positively to surgical or nonsurgical treatment will have a decrease in sodium levels.

A client sustained a rattlesnake bite to the lower leg. What prescription should the nurse expect?

Administer an opiod analgesic to the client. "The bite will cause pain and it should be managed as a priority;keep leg at the heart level to dec. circulation of the venom."

A nurse is assessing a client for manifestations of Parkinson's disease. Which of the following are expected findings? (Select all that apply.) A. Decreased vision B. Pill‑rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression

A. Decreased vision is not an expected finding in a client who has PD. B. CORRECT: The client who has PD can manifest pill‑rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. C. CORRECT: The client who has PD can manifest shuffling gait because of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. D. CORRECT: The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine, making the controlled movement of swallowing secretions difficult. E. Bilateral ankle edema is not an expected finding in a client who has PD, but can be an adverse effect of certain medications used for treatment. F. CORRECT: The client who has PD can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.

A nurse is reviewing the common emergency management protocol for clients who have asystole. Which of the following actions should the nurse plan to take during this cardiac emergency? A. Perform defibrillation. B. Prepare for transcutaneous pacing. C. Administer IV epinephrine. D. Elevate the client's lower extremities.

A. Defibrillation is not indicated for asystole, because this is not considered a shockable cardiac rhythm. B. Transcutaneous pacing is not indicated for the treatment of asystole. C. CORRECT: Administering epinephrine during asystole is an appropriate action by the nurse because it increases heart rate, improves cardiac output, and promotes bronchodilation. D. Elevating the client's lower extremities is indicated for the treatment of a client who is in shock, rather than asystole.

A nurse on a cardiac unit is caring for a client who is on telemetry. The nurse recognizes the client's heart rate is 46/min and notifies the provider. The nurse should anticipate that which of the following management strategies will be used for this client? A. Defibrillation B. Pacemaker insertion C. Synchronized cardioversion D. Administration of IV lidocaine

A. Defibrillation is used when a client has ventricular fibrillation or pulseless ventricular tachycardia. B. CORRECT: A client who has bradycardia is a candidate for a pacemaker to increase his heart rate. C. Synchronized cardioversion is used when a client has a dysrhythmia such as atrial fibrillation, supraventricular tachycardia (SVT), or ventricular tachycardia with pulse. D. The administration of IV lidocaine is used in clients who have a pulseless ventricular dysrhythmia to stimulate cardiac electrical function.

A nurse is caring for a client who has just undergone a craniotomy for a supratentorial tumor. Which of the following postoperative prescriptions should the nurse clarify with the provider? A. Dexamethasone 30 mg IV bolus BID B. Morphine sulfate 2 mg IV bolus PRN every 2 hr for pain C. Ondansetron 4 mg IV bolus PRN every 4 to 6 hr for nausea D. Phenytoin 100 mg IV bolus TID

A. Dexamethasone is given to prevent cerebral edema and has no CNS depressant effects. B. CORRECT: Narcotic analgesics should be avoided postoperatively due to their CNS depressant effects. C. Ondansetron is prescribed to manage nausea and has no CNS depressant effects. D. Phenytoin is prescribed to prevent seizures and has no CNS depressant effects.

A nurse is providing teaching to the partner of an older adult client who has Alzheimer's disease and has a new prescription for donepezil. Which of the following statements by the partner indicates the teaching is effective? A. "This medication should increase my husband's appetite." B. "This medication should help my husband sleep better." C. "This medication should help my husband's daily function." D. "This medication should increase my husband's energy level."

A. Donepezil does not affect appetite. B. Donepezil does not affect sleep or sleep patterns. C. CORRECT: Donepezil helps slow the progression of AD and can help improve behavior and daily functions. D. Donepezil does not affect energy levels.

A nurse in the ICU is planning care for a client who is in cardiogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? A. Dopamine B. Nitroglycerine C. Nitroprusside D. Morphine

A. Dopamine The nurse should prepare to administer dopamine to a client who is in cardiogenic shock because dopamine produces inotropic effects and improves cardiac output by strengthening the force of contractions. Dopamine also raises blood pressure by causing vasoconstriction of the blood vessels.

A nurse is caring for a client who is 4hr postoperative following an ORIF of the right ankle. Which of the following assessment findings should the nurse report to the provider? A. Extremity cool upon palpation B. Serosanguineous drainage on the dressing C. Capillary refill of 2 seconds D. Client report of discomfort when moving toes

A. Extremity cool upon palpation The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

A. Eye pain is manifestation associated with primary angle‑closure glaucoma. B. Floating spots are a manifestation associated with retinal detachment. C. CORRECT: Blurred vision is a manifestation associated with cataracts. D. CORRECT: White pupils are a manifestation associated with cataracts. E. Bilateral red reflexes are absent in a client who has cataracts.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Fluctuations in blood pressure B. Loss of cognitive function C. Ineffective cough D. Drooping eye lids

A. Fluctuations in blood pressure is a manifestation associated with amyotrophic lateral sclerosis. B. CORRECT: Loss of cognitive function is a manifestation associated with MS. C. Ineffective cough is a manifestation associated with amyotrophic lateral sclerosis. D. Drooping eyelids is a manifestation associated with myasthenia gravis.

A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicates to the nurse that the client is experiencing an anaphylactic reaction? A. Flushing B. Hypertension C. Hallucinations D. Urinary retention

A. Flushing The nurse should identify facial flushing as a manifestation of an anaphylactic reaction to penicillin G. The nurse should monitor the client's airway and prepare to administer oxygen and epinephrine.

A home health nurse is teaching a client who has active tuberculosis. The provider has prescribed the following medication regimen: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following client statements indicate the client understands the teaching? (Select all that apply.) A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."

A. Medications should not be replaced for one another. It is important that the client adhere to the multi medication regimen prescribed to treat tuberculosis. B. CORRECT: The client should wash her hands each time she coughs to prevent spreading the infection. C. CORRECT: The client should wear a mask while in public areas to prevent spreading the infection. The client has active TB, which is transmitted through the airborne route. D. The client will need to collect sputum cultures every 2 to 4 weeks until three consecutive sputum cultures have come back negative. E. The client should continue to avoid crowded areas if possible and take preventative measures, such as wearing a mask when going out.

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect this same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? A. "It can spread to breasts and kidneys." B. "It can develop in your gastrointestinal tract." C. "It is limited to brain tissue." D. "It probably started in another area of your body and spread to your brain."

A. Metastases of a benign brain tumor do not occur. B. Metastases of a benign brain tumor do not occur. C. CORRECT: Benign brain tumors develop from the meninges or cranial nerves and do not metastasize. D. Benign brain tumors develop from the meninges or cranialnerves and are not secondary to other types of tumors

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care? A. Monitor the client for confusion. B. Encourage the client to use an incentive spirometer every 8hr C. Instruct the client to drink 1 L of fluids daily D. Titrate the oxygen to maintain the SaO2 level at 92%

A. Monitor the client for confusion Pneumonia is an inflammatory process resulting in increased exudate and a thickening and narrowing of the airways, which causes hypoxia. The reduced oxygen level places the client at risk for confusion.

A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect? A. Muscle atrophy B. Ataxia C. Weight loss D. Hypotension

A. Muscle atrophy A client who has Cushing's disease has an oversecretion of glucocorticoids from the adrenal cortex. Excess glucocorticoids in the body results in changes to all body systems. These changes include muscle atrophy, especially in the extremities, from decreased nitrogen and mineral loss; thin skin; bruising and striae from fragile blood vessels; and electrolyte imbalances.

A nurse is caring for a client who has suspected Ménière's disease. Which of the following is an expected finding? A. Presence of a purulent lesion in the external ear canal B. Feeling of pressure in the ear C. Bulging, red bilateral tympanic membranes D. Unilateral hearing loss

A. Ménière's disease is an inner ear disorder. A purulent lesion in the external ear canal is not an expected finding. B. A feeling of pressure in the ear can occur with otitis media, but is not an expected finding in Ménière's C. Ménière's disease is an inner ear disorder. Bulging, red bilateraltympanic membranes is a finding associated with a middle ear infection. D. CORRECT: Unilateral sensorineural hearing loss is an expected finding in Ménière's disease.

A nurse is caring for a client who has a viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for a minute. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? A. Nonrebreather mask B. Venturi mask C. Simple face mask D. Partial rebreather mask

A. Nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

A nurse is caring for a client who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first? A. Obtain a chest x‑ray. B. Apply sterile gauze to the insertion site. C. Place tape around the insertion site. D. Assess respiratory status.

A. Obtaining a chest x‑ray determines if the lung is inflated or if the client has a pneumothorax after the chest tube was accidentally pulled out is an appropriate action, but it is not the first action the nurse should take. B. CORRECT: Using the airway, breathing, and circulation (ABC) priority‑setting framework, application of a sterile gauze to the site should be the first action for the nurse to take. This allows air to escape and reduces the risk for development of a tension pneumothorax. C. Placing tape around the insertion site ensures that the sterile gauze remains intact and is an appropriate action, but it is not the first action. D. Assessing respiratory status is an appropriate action, but it is not the first action.

A nurse in the emergency department is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 38.6° C (101.4° F), and SaO2 92% on room air. Which of the following actions should the nurse take first? A. Obtain a chest x‑ray. B. Prepare for chest tube insertion. C. Administer oxygen via a high‑flow mask. D. Initiate IV access.

A. Obtaining a chest x‑ray to determine the level of injury to the lungs is important, but is not the priority action at this time. B. Preparing the client for chest tube insertion is important to facilitate lung expansion and restore normal intrapleural pressure, but is not the priority action at this time. C. CORRECT: According to the airway, breathing, and circulation to client care, the nurse should place the priority on administering oxygen via high‑flow mask to provide the client oxygen to restore optimal breathing. D. Initiating IV access to administer medications is important, but is not the priority action at this time.

A client is receiving TPN and a new bag is not available and the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives. "The nurse should keep a bag of this solution near the bedside to prevent the risk for hypoglycemia due to abrupt changes in dextrose concentrations if the tpn runs out and nothing is being infused."

A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? A. E2 + V3 + M5 = 10 B. E3 + V4 + M4 = 11 C. E4 + V5 + M6 = 15 D. E2 + V2 + M4 = 8

A. The calculation is incorrect. E2 represents eyes opening secondary to pain, V3 represents verbal response with words spoken inappropriately, and M5 represents motor response to pain with a local reaction. B. CORRECT: The client's score is calculated correctly, indicating moderate head injury. E3 represents opening eyes secondary to voice stimulation, V4 represents verbal conversation that is incoherent and disoriented, and M4 represents motor response as a general withdrawal to pain. C. The client's score is calculated incorrectly. E4 represents eyes opening spontaneously, V5 represents verbal conversation as coherent and oriented, and M6 indicates a client is able to follow commands. D. The client's score is calculated incorrectly. E2 represents eyes opening secondary to pain, V2 represents verbal response by the client making sounds but speaking no words, and M4 is a motor response with a general withdrawal to pain.

A student nurse is observing a cardioversion procedure and hears the team leader call out, "Stand clear." The student should recognize the purpose of this action is to alert personnel that A. the cardioverter is being charged to the appropriate setting. B. they should initiate CPR due to pulseless electrical activity. C. they cannot be in contact with equipment connected to the client. D. a time‑out is being called to verify correct protocols.

A. The cardioverter is charged prior to the delivery of the shock during cardioversion. B. The team leader calls out "Initiate CPR" when members of the team are to begin CPR. C. CORRECT: A safety concern for personnel performing cardioversion is to "stand clear" of the client and equipment connected to the client when a shock is delivered to prevent them from also receiving a shock. D. A "time‑out" is called by personnel during a procedure to verify that proper protocols are being followed.

A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia? A. The client has to turn her head to see the entire visual field B. The client has drooping of the affected eyelid C. The client experiences transient blindness in one eye D. The client has blurred vision in the center of her visual field

A. The client has to turn her head to see the entire visual field. A client experiencing homonymous hemianopsia, which is blindness in the same visual field of both eyes caused by damage to the optic tract or occipital lobe, will find it necessary to turn her head to see her entire visual field.

A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following client statements indicates that the client understands how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop after I use this device." D. "I will ask my son to push the dose button when I am sleeping."

A. The client may use the device when he begins to feel pain. It will help prevent unnecessary worsening of the pain and more doses of analgesia to provide relief. B. A feature of PCA devices is the timing control or lockout mechanism, which enforces a preset minimum interval between medication doses. This safety feature is one means of preventing an overdose because the client cannot self‑administer another dose of medication until that time interval has passed. C. CORRECT: The nurse should identify that PCA is a method of delivering pain medication through an electronic infusion device that allows the client to self‑administer pain medication on an as‑needed basis. If the client is not achieving adequate pain control, he should let the nurse know so that she can initiate a reevaluation of the client's pain management plan. D. The client is the only one who should operate the PCA pump. In situations where the client is not able to do so, the provider may authorize a nurse or a family member to operate the pump.

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? A. Baked salmon B. Salted cashews C. Frozen strawberries D. Fresh asparagus

A. The client should avoid fish that is smoked because it contains tyramine. Baked salmon does not contain tyramine and is not a trigger for migraine headaches. B. CORRECT: Nuts contain tyramine, which can trigger migraine headaches. C. Fruits are not a source of tyramine. D. Vegetables are not a source of tyramine.

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? A. "I will decrease my fluid intake while taking this medication." B. "I will expect to have black, tarry stools." C. "I will take my medication with meals." D. "I will monitor for weight loss while on this medication."

A. The client should drink plenty of fluids while taking this prednisone. This medication can cause the client to have a dry mouth or to become thirsty. B. The client should inform the provider of any black, tarry stools. This medication can increase bleeding tendency. Black stools can be an indication of blood in the stool. C. CORRECT: The client should take this medication with food. Taking prednisone on an empty stomach can cause gastrointestinal distress. D. The client should monitor the mouth for canker sores. This medication can cause bleeding of the gums and soreness in the mouth. It also decreases immune function.

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will place the adapter on my finger to read my blood oxygen saturation level." B. "I will lie on my back with my knees bent." C. "I will rest my hand over my abdomen to create resistance." D. "I will take in a deep breath and hold it before exhaling."

A. The client should place an adapter on her finger to read the blood oxygen saturation level while performing a pulse oximetry reading. B. The client who practices diaphragmatic or abdominal breathing should lie on her back with knees bent. C. The client who practices diaphragmatic or abdominal breathing should rest her hand over her abdomen to determine if the breathing is done correctly. D. CORRECT: The client who is using the spirometer should take in a deep breath and hold it for 3 to 5 seconds before exhaling. As the client exhales, the needle of the spirometer rises. This promotes lung expansion.

A nurse is teaching a client who is scheduled for an angiography. Which of the following statements should the nurse include in the teaching? A. "You should have nothing to eat or drink for 4 hours prior to the procedure." B. "You will be given general anesthesia during the procedure." C. "You should not have this procedure done if you are allergic to eggs." D. "You will need to keep your affected leg straight following the procedure."

A. The nurse should instruct the client to remain NPO for at least 8 hr prior to the procedure to decrease the risk for aspiration while lying flat during the angiography. B. The nurse should instruct the client that he is awake and sedated during the procedure and that a local anesthetic is used at the catheter insertion site. C. The nurse should assess the client for an allergy to iodine/shellfish due to the use of contrast dye. An allergy to eggs is not a contraindication to angiography. D. CORRECT: The nurse should instruct the client of the need to remain on bed rest in the supine position with the affected leg straight for a prescribed amount of time. This positioning decreases the client's risk for bleeding and hematoma formation at the catheter insertion site.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? A. Headache B. Infection C. Aphasia D. Hypertension

A. The nurse should monitor a client who has increased ICP for a headache, but a headache does not indicate a complication directly related to the ventriculostomy. B. CORRECT: The nurse should monitor a client who has a ventriculostomy for infection, which is a complication. The nurse should use strict asepsis to avoid this life‑threatening condition, which can result in meningitis. C. The nurse should monitor a client who has increased ICP for aphasia related to the head injury, but this not a complication directly related to the ventriculostomy. D. The nurse should monitor a client who has increased ICP for hypertension, but this is not a complication directly related to the ventriculostomy.

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications? A. Neurogenic shock B. Paralytic ileus C. Stress ulcer D. Respiratory compromise

A. The nurse should monitor for neurogenic shock, which is a response of the sympathetic nervous system of a client who has a SCI. However, another complication is the priority. B. The nurse should monitor for a paralytic ileus, which is a complication immediately following a SCI. However, another complication is the priority. C. The nurse should monitor for a stress ulcer, which is a response to changes caused from the SCI. However, another complication is the priority. D. CORRECT: When using the airway, breathing, and circulation (ABC) approach to client care, the priority complication is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention.

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? A. "You can resume playing golf in 2 days." B. "You need to tilt your head back when washing your hair." C. "You can get water in your eyes in 1 day." D. "You need to limit your housekeeping activities."

A. The nurse should not instruct the client to resume playing golf for several weeks. This could cause a rise in intraocular pressure (IOP) or possible injury to the eye. B. The nurse should not instruct the client to tilt his head back when washing his hair. This could cause a rise in IOP or possible injury to the eye. C. The client should not get water in his eyes for 3 to 7 days following cataract surgery to reduce the risk for infection and promote healing. D. CORRECT: The nurse should instruct the client to limit housekeeping activities following cataract surgery. This activity could cause a rise in IOP or injury to the eye.

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? A. Consider taking oral contraceptives when on this medication. B. Watch for receding gums when taking the medication. C. Take the medication at the same time every day. D. Provide a urine sample to determine therapeutic levels of the medication.

A. The nurse should not instruct the client to take oral contraceptives, because contraceptive effectiveness is decreased when taking phenytoin. B. The nurse should instruct the client that phenytoin causes overgrowth of the gums. C. CORRECT: The nurse should instruct the client to take phenytoin at the same time every day to enhance effectiveness. D. The nurse should instruct the client to have periodic blood tests to determine the therapeutic level of phenytoin.

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 38.4° C (101.2° F), and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority? A. Notify the provider. B. Administer heparin via IV infusion. C. Administer oxygen therapy. D. Obtain a spiral CT scan.

A. The nurse should notify the provider about the condition. However, another action is the priority. B. The nurse should administer IV heparin as a treatment to prevent growth of the existing clot and to prevent additional clots from forming. However, another action is the priority. C. CORRECT: When using the airway, breathing, circulation (ABC) priority approach to care, the nurse determines that the priority finding is related to the respiratory status. Meeting oxygenation needs by administering oxygen therapy is the priority action. D. The nurse should obtain a spiral CT scan to detect the presence and location of the blood clot. However, another action is the priority

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include blood pressure 220/110 mm Hg and apical heart rate 54/min. Which of the following actions should the nurse take first? A. Notify the provider. B. Sit the client upright in bed. C. Check the urinary catheter for blockage. D. Administer antihypertensive medication.

A. The nurse should notify the provider. However, another action is the priority. B. CORRECT: The greatest risk to the client is experiencing a cerebrovascular accident (stroke) secondary to elevated blood pressure caused by autonomic dysreflexia. The first action the nurse should take is to elevate the head of the bed until the client is in an upright position, which should lower the blood pressure secondary to postural hypotension. C. The nurse should check the client's catheter for blockage. However, another action is the priority. D. The nurse should administer an antihypertensive medication if indicated. However, another action is the priority.

A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should notify the rapid response team for which of the following clients? A. Client who has an ulceration of the right heel whose blood glucose is 300 mg/dL B. Client who reports right calf pain and shortness of breath C. Client who has blood on a pressure dressing in the femoral area following a cardiac catheterization D. Client who has dark red coloration of left toes and absent pedal pulse

A. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition. B. CORRECT: The nurse should identify that the client is at risk for respiratory arrest due to a possible embolism. The nurse should call the rapid response team because the manifestations can indicate the beginning of a rapid decline in the client's condition. C. This assessment does not indicate the beginning of a rapid decline in the client's condition at this time. The nurse should reassess the client and notify the provider if the bleeding increases. D. The nurse should notify the provider. The situation does not indicate the beginning of a rapid decline in the client's condition.

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for bradycardia. B. Provide an emesis basin at the bedside. C. Administer antipyretic medication. D. Perform a skin assessment. E. Keep the head of the bed flat.

A. The nurse should plan to monitor for tachycardia when a client has meningitis. B. CORRECT: The nurse should provide an emesis basin at the bedside because the client who has meningitis can have nausea and vomiting. C. CORRECT: The nurse should plan to administer antipyretic medication for fever to a client who has meningitis. D. CORRECT: The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis. E. The nurse should elevate the head of the client's bed 30° to promote venous drainage from the head and prevent increased ICP.

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which actions should the nurse include in the plan of care? (Select all that apply.) A. Provide three large balanced meals daily. B. Record diet and fluid intake daily. C. Document weight every other week. D. Place the client in Fowler's position to eat. E. Offer nutritional supple

A. The nurse should plan to provide small frequent meals during the day to maintain adequate nutrition. B. CORRECT: The nurse should record the client's diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration. C. The nurse should document the client's weight weekly to identify weight loss and intervene to maintain the client's weight. D. The nurse should ensure that the client is sitting upright for meals rather than in a supported Fowler's position, where the client's head is elevated to 45 to 60°. E. CORRECT: The nurse should offer nutritional supplements between meals to maintain the client's weight

A nurse is orienting a newly licensed nurse on the care of a client who is to have a line placed for hemodynamic monitoring. Which of the following statements by the newly licensed nurse indicates effectiveness of the teaching? A. "Air should be instilled into the monitoring system prior to the procedure." B. "The client should be positioned on the left side during the procedure." C. "The transducer should be level with the second intercostal space after the line is placed." D. "A chest x‑ray is needed to verify placement after the procedure."

A. The nurse should purge air from, rather than instill air into, the monitoring system. B. The nurse should place the client in the supine or Trendelenburg position. C. For hemodynamic monitoring, the nurse should place the transducer level with the 4th intercostal space, which is at the base of the right atrium. D. CORRECT: The nurse should ensure that a chest x‑ray is obtained to confirm proper placement of the lines following placement.

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? A. "Do not wash your hair the morning of the procedure." B. "Try to stay awake most of the night prior to the procedure." C. "The procedure will take approximately 15 minutes." D. "You will need to lie flat for 4 hours after the procedure."

A. The nurse should teach the client to wash her hair on the morning of the procedure to remove oils, gels, and sprays, which can affect the EEG readings. B. CORRECT: The nurse should teach the client to remain awake most of the night to provide cranial stress and increase the possibility of abnormal electrical activity. C. The nurse should teach the client that the procedure will take approximately 1 hr. D. The nurse should teach the client that normal activity can resume immediately following the procedure. NCLEX® Connection: Reduction of Risk Potential

A nurse is reviewing the use of the meningococcal vaccine (MCV4) for the prevention of meningitis with a newly licensed nurse. Which of the following information should the nurse include? A. The vaccine is indicated to reduce the risk of respiratory infection. B. The vaccine is administered in a series of four doses. C. The vaccine is recommended for adolescents before starting college. D. The vaccine is initially given at 2 months of age.

A. The pneumococcal vaccine is primarily indicated to reduce the risk of respiratory infection. However, it also reduces the risk of CNS infection. B. The HIB vaccine is administered to infants in a series of four doses. C. CORRECT: The nurse should identify that the meningococcal vaccine is recommended for adolescents prior to starting college due to the increased risk for infection in communal living facilities. D. The initial dose of the HIB vaccine is recommended for infants at 2 months of age.

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the client to do? A. Lie on his left side. B. Use the incentive spirometer. C. Cough at regular intervals. D. Perform the Valsalva maneuver.

A. The position the client should assume during removal of a chest tube depends upon the location of the insertion site. B. Use of an incentive spirometer is not indicated during chest tube removal. C. The client is instructed to breathe normally and remain calm during the procedure. D. CORRECT: The client should be instructed to take a deep breath, exhale, and bear down (Valsalva maneuver) as the chest tube is being removed. This increases intrathoracic pressure and reduces the risk of an air embolism

A nurse is caring for a client who is receiving tpn a new bag is not available when the current infusion is nearly completed which of the following actions should the nurse take

Administer dextrose 10% in water until the new bag arrives. Tpn Solutions have a high concentration of dextrose therefore if a t-pn solution is temporarily unavailable the nurse administer dextrose 10% or 20% and water to avoid a precipitous drop in the client's blood glucose level

A nurse in a community center is providing an educational session to a group of clients about ovarian cancer. Which of the following manifestations of ovarian cancer should the nurse include in the teaching?

Abdominal bloating

A nurse is caring for a client who is exhibiting manifestations of a febrile reaction while receiving a blood transfusion which of the following medications should the nurse administer

Acetaminophen to reduce fever and decreased the manifestation of the febrile reaction manifestations of a febrile reaction include tachycardia fever hypotension and chills the nurse should discontinue the transfusion and return the blood bag and tubing to the blood bank

A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include the plan?

Administer high-dose antibiotic therapy

A nurse is assessing an older adult client who has pneumonia. Which of the following findings should the nurse expect?

Acute confusion

Diet alterations the nurse should recommend for colorectal cancer?

Add cabbage to the diet? "Patients need low fat, simple carbs, and high fiber. DASH Diet" pg. 623

A nurse is caring for a client who has type 1 diabetes mellitus and reports severe ankle pain after falling off a stepstool at home. Which of the following prescriptions should the nurse clarify with the provider?

Apply a cold pack to the client's ankle for 30 min every hour.

A nurse is preparing to teach about dietary management to a client who has Crohn's disease and an enteroenteric fistula. Which of the following nutrients should the nurse instruct the client to decrease in their diet?

Fiber -- The nurse should instruct the client who has Crohn's disease and an enteroenteric fistula to consume a low-fiber diet to reduce diarrhea and inflammation.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect?

Elevated bilirubin level

Lab values for a client who has cirrhosis?

Elevated bilirubin level "Bilirubin increases because the liver cannot metabolize it properly to maintain blood levels. Can cause jaundice."

A home health care nurse is developing a teaching plan for a client who has a new ileostomy. Which of the following instructions should the nurse include?

Empty the appliance when it is one-third to one-half full.

A nurse is planning care for a client who is scheduled for a thoracentesis which of the following interventions should the nurse include in the plan

Encourage the client to take deep breaths after the procedure to read expand the lung

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan?

Encourage the client to take deep breaths after the procedure. "This action promotes lung expansion."

A nurses in an acute care facility is caring for a client who is at risk for seizures which of the following precautions should the nurse implement

Ensure that the client has a patent IV in the event that the client requires medication to stop seizure activity

Precautions the nurse should implement for a client at risk for seizures.

Ensure that the client has a patent IV. "If the patient starts to have a seizure they will need iv meds immediately."

A nurse is providing discharge teaching about disease management for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following activities is the nurse's priority?

Ensure that the client understands the medication regimen

A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies?

Enzyme immunoassay (EIA)

A nurse is reviewing the medical record of a client who has systemic lupus erythematosus. Which of the following findings should the nurse expect?

Facial butterfly rash. R: A butterfly rash is a manifestation of SLE. It appears as a dry red rash on the clients cheeks and nose and can disappear during times of remission.

A nurse is preparing to transfer a client who has had a stroke to a rehab facility. The client's family tells the nurse they are concerned about the level of care the client will receive. Which of the following actions should the nurse take?

Facilitate an interdisciplinary conference at the new facility for the family.

A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing

A nurse is performing an admission assessment on a client who had a recent positive pregnancy test. The first day of her last menstrual period was May 8. According to Nagele's rule, which of the following dates should the nurse document as the client's estimated date of birth?

Feb 15

A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care?

Monitor the client for confusion

A nurse is caring for a client who has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Monitor the client's mouth every 8 hr.

Nursing intervention for a patient who has neutropenia as a result of chemotherapy.

Monitor the client's temperature every 4hr. "They are at a high risk for infection. A rise in temp can indicate an infection brewing."

During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?

Move the client to a room near the nurses' station.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

My joints ache because I have Lyme Disease

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

My joints ache because I have Lyme disease.

A nurse is assessing a client who has Graves disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

The nurse should identify an outward protrusion of the eyes is exophthalmos a common finding of graves disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision including focusing on objects as well as pressure on the optic nerve.

A nurse is preparing to transfer a client from the ICU to the medical floor. The client was recently weaned from mechanical ventilation following a pneumonectomy. Which of the following information should the nurse include in the change-of-shift report?

The time of the client's last dose of pain medication