2019 med surg A

a nurse is caring for a client who has a new prescription for TPN. the client is to recieve 2000 kcal per day. the TPN solutionhas 500 kcal/l. the IV pump should be set at how many ml/hr.

167

a nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which finding? Dysphagia Aphasia Ataxia Hemianopsia

Dysphagia

what do the eyeballs look like of a patient with exophthalmos?

The nurse should identify an outward protrusion of the eyes as 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 home health nurse is assigned to a to a client who was recently discharged from a rehabilitation center after experiencing a right hemispheric stroke. which neurologic deficits should the nurse expect to find when assessing the patient. Expressive aphasia Visual spatial deficits Left hemianopsia Right hemiplegia One-sided neglect

**Visual spatial deficits is correct. **Left hemianopsia is correct. **One-sided neglect is correct.

a nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. to help reduce the risk for migraine headaches, which of the following foods should the nurse recommend the client to avoid? Shellfish Aged cheese Peppermint candy Enriched pasta

aged cheese

a nurse is performing a cardiac assessment for a client who had an MI 2 days ago. which of the following actions should the nurse take after hearing this sound? Obtain a 12-lead ECG for the client. Request to obtain the client's cardiac enzymes. Check the client's blood pressure manually. Listen with the client on their left side.

listen to the client on their left side.

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

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 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 wash the ink markings off the radiation area after each treatment." "I will use my hands rather than a washcloth to clean the radiation area." "I will be able to be out in the sun 1 month after my radiation treatments are over." "I will use a heating pad on my neck if it becomes sore during the radiation therapy."

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

a nurse is caring for a client with type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following should the nurse include when instructing the client. "Take insulin even if you are unable to eat your regular diet." "It's okay if your ketone levels are temporarily high." "Monitor your blood glucose levels every 12 hours." "Call the provider if your glucose levels reach 170 milligrams per deciliter."

"Take insulin even if you are unable to eat your regular diet"

A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which manifestations should the nurse expect?(SATA) Fever Nonpitting edema Hypertension Tachycardia Hypoglycemia

**Fever is correct. Nonpitting edema is incorrect. **Hypertension is correct. **Tachycardia is correct. Hypoglycemia is incorrect.

a nurse is providint dietary teaching to a client who is postoperatie 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 One small banana 1 tbsp peanut butter 1/2 cup tomato juice

12 almonds

a nurse is caring for a client with DKA. Which of the following laboratory findings should the nurse expect?

BUN 32

know where to palpate for an inguinal hernia

C. top of pelvic area.

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 indicated n understanding of the teaching? "I should take calcium supplements so the medication will work better in my system." "I am taking this medication to increase my energy level." "This medication can cause my blood pressure to drop." "I will not need to restrict protein in my diet while taking this medication."

I am taking this medication to increase my energy level it increases the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

A nurse is providing instruction to a patient with type 2 DM and a new prescription for metformin. which statement by the client indicates an understanding of the teaching. "I will monitor my blood sugar carefully because the medication increases the secretion of insulin." "I should take this medication with a meal." "I can expect to gain weight while taking this medication." "While taking this medication, I will experience flushing of my skin."

I should take this with food.

a nurse is providing teaching to a client who is recieving chemotherapy and has a new prescription for epoetin alfa. which of the following client statements indicates understanding of the teaching? "I will monitor my blood pressure while taking this medication." "I should take a vitamin D supplement to increase the effectiveness of the medication." "I should inform the provider if I experience an increased appetite while taking this medication." "I will decrease the amount of protein in my diet while taking this medication."

I will monitor my blood pressure while on this medication.

A nurse is caring for client with a leg cast and is returning demonstration on the proper use of crutches while climbing stairs the sequence the cleitn should follow. place in order the steps shift their weight from the crutches to the unaffected leg. bring the crutches and the affected leg up to the stair. place their body weight on the crutches. advance the unaffected leg onto the stair.

The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair.

A nurse is caring for a client who is having a seizure. Which intervention is the nurse priority?\ Loosen the clothing around the client's neck. Check the client's pupillary response. Turn the client to the side. Move furniture away from the client.

Turn the patient to the side. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

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? Take tub baths daily. Drink at least 1 L of fluid daily. Wear underwear made of nylon. Void before and after intercourse.

Urine specific gravity is 1.045

A nurse and an AP are caring for a client with bacterial meningitis. The nurse should give the AP which of the following instructions? Wear a mask. Wear a gown. Keep the client's room well-lit. Maintain the head of the bed at a 45° elevation.

Wear a mask

a nurse is planning care for a client who has extensive burn injuries and is immunocompromised. which of the following precautions should the nurse include in the plan of care to prevent pseudomonas aeruginosa infection?

avoid placing plants and flowers in the patients room.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the following is a priority assessment finding that te nurse should report to the provider? Restlessness T3 level 215 ng/dL Blood pressure 170/80 mm Hg Decreased weight

blood pressure 170/80

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 cushings triad. Hypotension Tachypnea Nuchal rigidity Bradycardia

bradycardia The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

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? Disease processes Laboratory findings Current medications Family history

current medications 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

a nurse is caring for a client who has HIV. which finding indicates a positive response to the prescribed HIV treatment? Decreased T cells Increased creatinine clearance Increased eosinophils Decreased viral load

decreased viral load

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 assessment. History of asthma Appendectomy 1 year ago Penicillin allergy Total knee arthroplasty 6 months ago

history of asthma greater risk of reacting to the contrast dye used during the procedure

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? Metabolic alkalosis Hyperkalemia Increased hemoglobin Hypophosphatemia

hyperkalemia

a nurse is caring for a client with a potassium level of 3. which of the following assessment findings should the nurse expect? Positive Trousseau's sign 4+ deep tendon reflexes Deep respirations Hypoactive bowel sounds

hypoactive bowel sounds.

a nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. the client is experiencing excessive stools. which of the following findings is an adverse effect of this medication? Hypokalemia Hypercalcemia Gastrointestinal bleeding Confusion

hypokalemia ...

a nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change? "It is just easier to let my partner administer my insulin." "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." "I'm concerned I won't be able to read my blood sugar level because the screen is so small." "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."

i used to never worry about my feet, now i inspect them every day with a mirror.

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 the teaching? "I should avoid walking as much as possible." "I should sit down and read for several hours a day." "I will wear clean graduated compression stockings every day." "I will keep my legs level with my body when I sleep at night."

i will wear a clean pair of graduated compression stockings each day

a nurse is providing teaching to a client who has IBS. which of the following instructions should the nurse include in the teaching? Take an antacid before meals and at bedtime. Increase fiber intake to at least 30 g per day. Drink ginger tea daily. Consume no more than 1 L of water per day.

increase fiber intake to 30G

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

increase fluid intake.

a nurse is caring for a client who has ALS and is being admitted to the hospital with pneumonia. Which of the following is the priority assessment finding? Temperature 38.4º C (101.1º F) Increased respiratory secretions Fluid intake of 200 mL in the prior 8 hr Limited range of motion

increased respiratory secretions.

a nurse is caring for a client who has anorexia, low grade fever, night sweats, and a productive cough. Which action should the nurse take first? Obtain a sputum sample. Administer antipyretics. Provide hand hygiene education. Initiate airborne precautions.

initiate airborne precautions

a nurse is caring for a client who is on bedrest and has a new prescription for enoxaparin subcutaneous. which of the following actions should the nurse take? Monitor the client's INR daily. Expel air bubbles when using a prefilled syringe. Inject the medication into the anterolateral abdominal wall. Massage the injection site after administration.

inject the medication into the anterolateral or posterolateral abdominal wall

a nurse is caring for a client who is recieving morphine for daily dressing changes. the client tells the nurse "I don't want anymore morphine because i don't want to become addicted". which of the following actions should the nurse take? Administer a placebo to the client without their knowledge. Instruct the client on alternative therapies for pain reduction. Tell the client not to worry about addiction to prescribed narcotics. Suggest the client receive a different opioid for pain reduction.

instruct the client on alternative therapies for pain reduction.

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." "This sharp pain in my eye started 2 hours ago." "I've been having more and more difficulty seeing over the last few weeks." "I seem to have more problems seeing different colors."

its like a curtain closed over my eye.

a nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. which of the following interventions should the nurse include in the plan. Monitor the client's temperature every 4 hr. Insert an indwelling urinary catheter for the client. Request the client's bathroom to be cleaned three times each week. Place a box of latex gloves just outside the client's room.

monitor the clients temp every 4 hours.

a nurse in a providers offive is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew. Metoprolol Bupropion Naproxen Atorvastatin

naproxen

a nurse is caring for a client who has viral pneumonia. the clients pulse ox readings have fluctuated between 79% and 88% for the last 30 minutes. which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen. Nonrebreather mask Venturi mask Simple face mask Partial rebreather mask

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 portal hypertension. the client is vomiting blood mixed with food after a meal. which of the following actions should the nurse take first? Check laboratory values for recent hemoglobin and hematocrit levels. Establish a peripheral IV line for possible transfusion. Call the laboratory to obtain a stat platelet count. Obtain vital signs.

obtain vital signs

a nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. which of the following prescriptions should the nurse expect? Apply ice to the client's puncture wounds. Initiate corticosteroid therapy for the client. Keep the client's leg above heart level. Administer an opioid analgesic to the client.

opioid analgesic to promote comfort following a rattlesnake bite.

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? Bradycardia Tremors Orthostatic hypotension Drowsiness

orthostatic hypotension

A nurse is caring for a client who has bilateral pneumonia and a KaO2 of 85%. the client has dyspnea with a productive cough and is using accessory muscles to breath. Which of the following actions should the nurse take first.? Obtain a prescription for ABGs. Administer IV antibiotics to the client. Instruct the client to use the incentive spirometer. Place the client in high-Fowler's position.

place the patient in high fowlers.

a nurse is preparing to administer a unit of packed red blood cells to a client. which of the following actions should the nurse take? Remain with the client for the first 15 min of the infusion. Prime the blood administration IV tubing with lactated Ringer's solution. Verify the client's identity by using the client's room number prior to starting the transfusion. Infuse the unit of packed RBCs within 8 hr.

remain with the client for the first 15 to 30 min of the infusion

a nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. which of the following instructions should the nurse include? Keep the client's personal care items in the bathroom. Keep the overhead lights on in the client's bedroom while the client is sleeping. Remind the client to scan their complete range of vision during ambulation. Secure the client's extension cords under carpeting.

remind the patient to scan to look over their complete range of vision during ambulation.

A nurse in a providers office is assessing a client who has hypertension and takes propanolol. Which finding should indicate an adverse reaction to this medicine. Report of a night cough Report of tinnitus Report of excessive tearing Report of increased salivation

report of a night cough - indication of heart failure.

a nurse is preparing to admit a client with dysphagia. which item should be at the patients bedside? Suction machine Wire cutters Padded clamp Communication board

suction machine

a nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? Anorexia Abdominal pain radiating to the right shoulder Tachycardia Rebound abdominal tenderness

tachycardia

a nurse is providing teaching to a female client who has a history of urinary tract infection. which of the following information should the nurse include in the teaching? Avoid foods that are high in ascorbic acid. Add oatmeal to the water when taking a tub bath. Urinate every 6 hr. Take daily cranberry supplements.

take daily cranberry supplements

a nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. which of the following interventions should the nurse include in the plan? Remind the client that dialysis treatments are not difficult to incorporate into daily life. Inform the client that dialysis will result in a cure. Tell the client that it is possible to return to similar previous levels of activity. Begin health promotion teaching during the first dialysis treatment.

tell the client it is possible to return to similar previous levels of activity.

a nurse has recieved change of shift report for a group of clients. which of the following should the nurse assess first. A client who is 1 day postoperative following abdominal surgery and reports pain of 4 on a scale of 0 to 10 A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and reports severe itching A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds

the client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet

a nurse is caring for a client who has a stage III pressure injury. which of the following findings contributes to delayed wound healing? WBC count 6,000/mm3 BMI 24 Urine output 25 mL/hr Albumin 4 g/dL

urine output of 25ml

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? Take tub baths daily. Drink at least 1 L of fluid daily. Wear underwear made of nylon. Void before and after intercourse.

void before and after intercourse.

A nurse is caring for a client who has a closed head injuryand an intraventricular catheter placed. which finding indicates the client is experiencing increased intracranial pressure? Flat jugular veins A Glasgow Coma Scale score of 15 Sleepiness exhibited by the client Widening pulse pressure Decerebrate posturing

**Sleepiness exhibited by the client is correct. **Widening pulse pressure is correct. **Decerebrate posturing is correct

a nurse is caring for a client who has pancreatitis. the nurse should expect which of the following laboratory results to be below the expectation.

CALCIUM A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

a nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. which of the following prescribed medications should the nurse instruct the client to withhold for 48 hours prior to cardioversion. Enoxaparin Metformin Diazepam Digoxin

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 caring for a client who is postoperative following a total hip arthroplasty. which of the following laboratory values should the nurse report to the provider? Potassium 4 mEq/L WBC count 10,000/mm3 Hct 45% Hgb 8 g/dL

Hgb 8

Anurse 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. "I am taking my progesterone daily." "I am dieting to lose weight." "I am limiting my daily fluid intake." "I have switched my morning cups of coffee to hot tea."

I am dieting to lose weight.

a nurse in an emergency department is caring for a client who has full thickness burns covering 20% of their total body surface area. after ensuring patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? IV fluids Analgesia Antibiotics Tetanus toxoid

IV fluids

a nurse is teaching a class about client rights. which of the following instructions should the nurse include? A client should sign an informed consent before receiving a placebo during a research trial. A client cannot refuse to sign a consent form for a life-saving treatment. A client who has a mental illness is unable to give informed consent. An unemancipated minor needs guardian consent for substance use disorder treatment.

a client should sign an informed consent before recieving a placebo

a nurse is assessing a group of clients for indications of role changes. the nurse should identify that which of the following clients is at risk for experiencing a role change. A client who has type 1 diabetes mellitus and is starting to self-monitor blood glucose A client who had a cholecystectomy and is starting on a modified-fat diet A client who has Crohn's disease and is experiencing diarrhea three times a day A client who has multiple sclerosis and is experiencing progressive difficulty ambulating

a client with MS that is having difficulty ambulating

a nurse is teaching a client who has a family history of colorectal cancer. to help mitigate this risk, which of the following dietary alterations should he nurse recommend? Add full-fat yogurt to the diet. Add cabbage to the diet. Replace butter with coconut oil. Replace shellfish with red meat.

add cabbage to the diet. high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

a nurse is caring for a client 1 hour 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? Initiate oxygen at 2 L/min via nasal cannula. Apply firm pressure to the insertion site. Take the client's vital signs. Obtain a stat order for an aPTT.

apply firm pressure to the insertion site.

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 supplements can interfere with the effectiveness of this medication? Ginkgo biloba Glucosamine Calcium Vitamin C

calcium

a nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. the client reports muscle cramps and a tingling sensation in their hands, which of the following medications should the nurse plan to administer. Epoetin alfa Furosemide Captopril Calcium carbonate

calcium carbonate hypocalcemia is a manifestation of end stage kidney disease.

a nurse is performing a dressing change for a client who is recovering from a hemicolectomy. when removing the dressing, 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? Place the client in a supine position. Measure vital signs. Cover the wound with a sterile, saline-moistened dressing. Call for help.

call for help

a nurse is assessing a client who has had a plaster cast applied to their left leg 2 hours ago. which of the following actions should the nurse take? Inspect the cast for drainage once every 24 hr. Check that one finger fits between the cast and the leg. Perform neurovascular checks every 2 to 3 hr. Make sure the client has a warm blanket covering the cast.

check that one finger fits between the cast and the leg.

a nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. which of the following statements should the nurse include in the teaching? "You will still have the urge to void." "You can apply an aspirin tablet to the pouch to reduce odor." "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." "You should use a moisturizing soap when washing the skin around the stoma."

cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

a nurse is providing preoperative teaching to a client who is scheduled for a open cholecystectomy. which of the following actions should the nurse take? Teach the importance of a clear liquid diet after discharge. Tell the client to remove the incisional adhesive strips 3 days after discharge. Demonstrate ways to deep breathe and cough. Instruct the client to maintain bed rest for 48 hr.

demonstrate ways to deep breath and cough.

a nurse is caring for a client who is recieving TPN. A new bag is not available when the current infusion is nearly completed. which of the following actions should the nurse take? Keep the line open with 0.9% sodium chloride until the new bag arrives. Administer dextrose 10% in water until the new bag arrives. Flush the line and cap the port until the new bag arrives. Decrease the infusion rate until the new bag arrives.

dextrose 10% in water

a nurse is reviewing the laboratory results of a client who has cirrhosis. which of the following lab values should the nurse expect? Decreased prothrombin time Elevated bilirubin level Decreased ammonia level Elevated albumin level

elevated bili 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 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? Place a padded tongue blade at the client's bedside. Keep the side rails lowered on the client's bed. Maintain the client's bed at hip level or above. Ensure that the client has a patent IV.

ensure the client has a patent IV

A nurse is caring for a client who is 12 hr postop following total hip arthroplasty. Which of the following actions should the nurse take? Maintain adduction of the client's legs. Encourage range of motion of the hip up to a 120° angle. Place a pillow between the client's legs. Keep the client's hip internally rotated.

had to add this one

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 110/min Blood pressure 138/90 mm Hg Urine specific gravity 1.020 BUN 15 mg/dL

heart rate 110

a nurse is caring for a client who presents to a clinic for a 1 week follow up visit after hospitalization for heart failure. based on the info in the clients chart, which of the following findings should the nurse report to the provider? Potassium 4.1 mEq/L Heart rate 55/min SaO2 92% Weight 67.1 kg (148 lb)

heart rate 55

a nurse is caring for a client who has emphysema and is recieving 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. Obtain ABGs. Administer propofol to the client. Instruct the client to allow the machine to breathe for them. Disconnect the machine and manually ventilate the client.

instruct the client to allow the machine to breath for them.

a nurse is caring for a client who is experiencing a tonic clonic seizure. which of the following actions should the nurse take? Insert a padded tongue blade. Apply oxygen. Restrain the client. Loosen restrictive clothing.

loosen restrictive clothing

a nurse is caring for a group of clients. the nurse should plan to make a referral to physical therapy for which of the following clients? A client who is receiving preoperative teaching for a right knee arthroplasty A client who states they will have difficulty obtaining a walker for home use A client who reports an increase in pain following a left hip arthroplasty A client who is having emotional difficulty accepting that they have a prosthetic leg

patient recieving preoperative teaching for a knee arthroplasty

a nurse is caring for a client who is experiencing SVT. upon assessing the client, the nurse observes the following findings: heart rate 200 / min, blood pressure 78/40, and respiratory rate 30/min. which of the following actions should the nurse take. Defibrillate the client's heart. Perform synchronized cardioversion. Begin cardiopulmonary resuscitation. Administer lidocaine IV bolus.

perform synchronized cardioversion

a nurse is caring for a client who is 8 hours postoperative following a craniotomy. which of the following actions should the nurse take? i think this is the wrong questions for the answer

place a pillow between the clients legs.

a nurse is assessing a client following the administration of magnesium sulfate 1 G IV bolus. for which of the following adverse effects should the nurse monitor? Hyperreflexia Increased blood pressure Respiratory paralysis Tachycardia

respiratory paralysis

a nurse is teaching a young adult male how to performtesticular self examination(TSE). which of the following instructions should the nurse include? Compare both testicles by examining them simultaneously. Roll each testicle between the thumb and fingers. Perform testicular self-examination before a warm bath or shower. Perform self-examination of the testicles every 2 weeks.

roll each testicle between the thumb and fingers.

a nurse is assessing a client who had extracorporeal shock wave lithotripsy 6 hours ago. which of the following findings should the nurse expect? Stone fragments in the urine Fever Decreased urine output Bruising on the lower abdomen

stone fragments in the urine

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. Neutralizing gastric acid Reducing the growth of ulcer-causing bacteria Coating the stomach lining Suppressing gastric acid production

suppressing gastric acid production.

a nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium sparing diuretic. which of the following information should the nurse include in teaching. Try to walk at least three times per week for exercise. To increase stamina, walk for 5 min after fatigue begins. Take over-the-counter cough medicine for persistent cough. Use a salt substitute to reduce sodium intake.

try to walk at least 3 times per week for exercise.

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 Apply a wet-to-dry gauze dressing. Irrigate with hydrogen peroxide solution. Use a 30-mL syringe. Attach a 24-gauge angiocatheter to the syringe.

use a 30ml 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 planing care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. which of the following actions should the nurse include in the clients plan of care. Collect and place the client's urine or feces in a biohazard bag. Limit the client's ambulation to their own room. Wear a lead apron while providing care to the client. Limit each visitor to 1 hr per day.

wear a lead apron while providing care.

a nurse in a providers office is caring for a client who request sildenafil to treat erectile dysfunction. which of the following statements should the nurse make? "You might need to take a stool softener while taking this medication." "You will not be able to use sildenafil if you have diabetes." "You will need to limit your caffeine intake if you start taking sildenafil." "You will not be able to use sildenafil if you are taking nitroglycerin."

you can not use this if you are taking nitroglycerin.

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? "It is an expected effect to sleep through the day when taking this medication." "Your constipation will be lessened as you develop a tolerance to the medication." "You should void every 4 hours to decrease the risk of urinary retention." "If you experience ringing in your ears, your dose will need to be reduced."

you should void every 4 hours to decrease the risk of urinary retention.