3070 Final Review Questions

A client receiving chemotherapy is experiencing a low white blood cell count. The nurse should teach the client to avoid contact with which of the following family members? 9 year old grandchild with a recent exposure to chicken pox. 34 year old nephew with HIV infection. 31 year old daughter who is 4 months pregnant. 68 year old husband with a history of TB exposure as a child.

9 year old grandchild with a recent exposure to chicken pox.

Which client is at greatest risk of coronary artery disease: -A 43 year old with a family history of CAD and a total cholesterol of 150. -A 65 year old who is obese with an LDL of 200 -A 32 year old with mitral valve prolapse who quit smoking 10 years ago. -A 56 year old with an HDL of 63 who takes simvastatin (Zocor).

A 65 year old who is obese with an LDL of 200

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? -Difficulty moving the upper extremities -A reddened area over the sacrum -Stiffness in the lower extremities -Difficulty hearing some types of sounds

A reddened area over the sacrum

A nurse is teaching a client who has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching? -I will take my bronchodilators after meals. -I will eat five or six small meals each day. -I will choose foods that are not gas-forming. -I will rest for at least 30 minutes before eating.

I will take my bronchodilators after meals.

The nurse is teaching a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching? -I carry my medicine around in a clear plastic bag in my pocket so that I can get to it easily if I have chest pain. -Even if I have not used any of the nitroglycerin from one refill, I should get another refill one the other refill expires. -When my nitroglygerin tingles under my tongue, I know that it is strong enough to work. -If I have chest pain that isn't relieved by rest or nitroglycerin, I will call an ambulance.

"I carry my medicine around in a clear plastic bag in my pocket so that I can get to it easily if I have chest pain."

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate (Select all that apply)? -Implement turning schedule every 4 hours -Keep the client's skin clean and dry -Minimize exposure to moisture -Massage over reddened bony prominences -Use pillows to keep heels off the bed surface

-Keep the client's skin clean and dry -Minimize exposure to moisture -Use pillows to keep heels off the bed surface

Which of the following should be included in the teaching plan for a client with cancer who is experiencing thrombocytopenia (Select all that apply)? -Report bleeding to your health care provider immediately. -Use a soft-bristled toothbrush. -Use aspirin for pain control. -Monitor temperature daily. -Floss aggressively every day. -Use an electric razor.

-Report bleeding to your health care provider immediately. -Use a soft-bristled toothbrush. -Use an electric razor.

The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease (CAD) does the nurse include in the education (Select all that apply)? -obesity -smoking -hypertension -depression -insomnia

-obesity -smoking -hypertension

Bonus Question: A patient is to receive furosemide (Lasix) 60mg IVP now. The pharmacy gives you furosemide 40mg/2mL. How many mL will you administer (round to the nearest tenth)?

3mL

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? -Clean and dress the wounds -Administer a tetanus booster -Administer IV fluids -Administer pain medications

Administer IV fluids

A client has been diagnosed with hypervolemia and is confused. Which intervention is a priority to relieve the confusion? -Administer a diuretic as prescribed. -Slowing the IV flow rate to 50mL/hr -Placing the client in Trendelenburg position -Measuring intake and output every shift.

Administer a diuretic as prescribed.

A client is being discharged and needs to monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client? -Ensuring an oral intake of at least 3L/day -Assessing the radial pulse for a full minute twice a day -Weighing themselves at the same time every day -Restricting sodium and potassium intake

Assessing the radial pulse for a full minute twice a day

The nurse notes the following rhythm on a client's telemetry monitor. How does the nurse interpret these findings? Atrial fibrillation. Sinus rhythm. Ventricular fibrillation. Asystole.

Atrial fibrillation.

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? Perform nasotracheal suctioning of the client. Auscultate the client's heart and lung sounds. Place the client on a 1000 mL fluid restriction. Place the client in low fowler's position.

Auscultate the client's heart and lung sounds.

The patient with COPD states that he feels "full after eating just a little food." What will the nurse teach the patient to assist with this problem? -Avoid drinking fluids just before and during meals -Use a bronchodilator inhaler 30 minutes before meals -Practice diaphragmatic breathing 4 times/day

Avoid drinking fluids just before and during meals

A nurse is caring for several clients. Which client does the nurse assess most carefully for the development of hyperkalemia? -Client taking NSAIDs -Client taking furosemide (lasix) for HTN -Client with type 2 diabetes taking an oral hypoglycemic agent -Client with HF using a salt substitute

Client with HF using a salt substitute

The nurse is seeing clients in a clinic. Which of the following assessment findings prompts the nurse to assess further for cancer? Client with a 10-pound weight gain. Client whose mother died of lung cancer. Woman whose last mammogram was 3 years ago. Client with a cough that has lasted for 4 months.

Client with a cough that has lasted for 4 months.

After receiving change of shift report, which client does the nurse assess first? Client with breast cancer scheduled for external beam radiation. Client with xerostomia associated with laryngeal cancer. Client with neutropenia who has just been admitted with a possible infection. Client with leukemia who needs an antiemetic before chemotherapy.

Client with neutropenia who has just been admitted with a possible infection.

A nurse is assessing a patient with respiratory acidosis. Which of the following findings does the nurse anticipate? -Facial flushing -Hyperactive reflexes -Peripheral edema -Confusion

Confusion

The nurse has completed an assessment on a client with a decreased cardiac output after an MI. Which finding should receive the highest priority? -Weight gain of 1 kg in 4 days, BP 130/80, mild dyspnea with exercise. -SpO2 93% on 2L of oxygen via nasal cannula, respirations 20, 1+ edema of bilateral lower extremities. -BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. -Confusion, urine output 15 mL over the last 2 hours, orthopnea, cool extremities.

Confusion, urine output 15 mL over the last 2 hours, orthopnea, cool extremities.

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a drainage system with suction. The nurse should intervene for which of the following: -Continuous bubbling in the water-seal chamber. -Fluid-level fluctuation in the water-seal chamber with inspiration and exhalation. -Bloody drainage in the collection chamber. -Continuous bubbling in the suction control chamber.

Continuous bubbling in the water-seal chamber.

The nurse is teaching a client who is receiving chemotherapy how to manage possible nausea and vomiting at home. The nurse should include information about: Eating small, frequent meals throughout the day. Eating only cold foods with strong flavors. Limiting the amount of fluid intake. Eating three normal meals a day.

Eating small, frequent meals throughout the day.

A nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? -Administering oxygen via nasal cannula at 2L/mins -Helping the client select a low-salt diet -Maintaining a semi-Fowler's position as often as possible -Encouraging the client to drink plenty of fluids every day.

Encouraging the client to drink plenty of fluids every day.

A client with acute chest pain is receiving IV morphine sulfate. Which of the following is not an intended effect of morphine in the treatment of chest pain: Decrease in respiratory rate. Reduction of myocardial oxygen demand. Reduction of circulating catecholamines. Reduction in pain.

Decrease in respiratory rate.

The emergency department nurse is assessing an 82 year old client for a potential myocardial infarction. Which clinical manifestations does the nurse monitor for? Right sided chest pain. Pain on inspiration. Numbness and tingling of the arm. Disorientation or confusion.

Disorientation or confusion.

The nurse is assessing a client who has a history of stable angina. The client describes a recent increase in the number of attacks and in the intensity of the pain. Which question does the nurse ask to assess the change in the client's condition? How many cigarettes do you smoke daily? Do you have abdominal pain or nausea? Do you have pain when you are resting? How frequently are you having chest pain?

Do you have pain when you are resting?

The client is taking an opioid pain medication at home after surgery. What instruction does the nurse give this client? -Drink plenty of water and eat foods high in fiber -Avoid taking aspirin while you are on the medication -Weigh yourself daily to determine whether you are retaining fluid -Stop this medication after 3 days whether there is still pain or not

Drink plenty of water and eat foods high in fiber

The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client? Dyspnea with activity. Hypertension. Warm, flushed skin. Bradycardia.

Dyspnea with activity.

The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating the client? Make sure the defibrillator is set to the synchronous mode. Deliver a precordial thump to the upper portion of the sternum. Ensure that all personnel are clear of contact with the patient and the bed. Test the equipment by delivering a smaller shock of 100 joules.

Ensure that all personnel are clear of contact with the patient and the bed.

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? -Pull rather than push or carry items heavier than 5 pounds. -Gather everything you will need to complete a task before you begin. -Take a walk after dinner every day to build up your strength. -Walk until you become short of breath then walk back home.

Gather everything you will need to complete a task before you begin.

The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? Get a wheelchair and have the client sit down. Assist the client when ambulating. Apply oxygen via nasal cannula. Assess the client's lungs.

Get a wheelchair and have the client sit down.

What does the nurse prioritize teaching the client with COPD? -How to treat respiratory infections without antibiotics -How to assess the pulse and RR -How to recognize when a change is needed in oxygen therapy -How to prevent respiratory infections

How to prevent respiratory infections

A nurse is teaching a client who has emphysema about self-management strategies. Which of the following statements by the client indicates an understanding of the teaching? -I will inhale slowly through pursed lips to help me breathe better. -I will follow a daily diet high in calories and protein. -I will lie on my stomach to practice abdominal breathing every day. -I will avoid getting a flu shot.

I will follow a daily diet high in calories and protein.

A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates understanding of the teaching? -I will limit my fluid intake to 2-3 glasses of water a day -I should conserve my energy by limiting my activity -I will wait until my pain is at least a 6 out of 10 before I use my PCA button -I will use my incentive spirometer every hour while I am awake

I will use my incentive spirometer every hour while I am awake

A nurse is caring for a patient with metabolic alkalosis knows to assess for the primary compensatory mechanism of: -Decreased PCO2 -Decreased HCO3 -Increased PCO2 -Increased HCO3

Increased PCO2

The nurse and an unlicensed assistive personnel are caring for a group of clients. Which intervention should the nurse perform? Measure the client's output from the indwelling catheter. Refill the water pitcher for the patient with dehydration. Instruct the client on appropriate fluid restrictions. Record the client's intake and output on the I&O sheet.

Instruct the client on appropriate fluid restrictions.

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? -Have the client use the early morning hours to exercise and activity. -Provide the client with low protein diet. -Instruct the client to use pursed-lip breathing. -Restrict the client's fluid intake to less than 2L/day

Instruct the client to use pursed-lip breathing.

A client is admitted to the hospital with a serum potassium level of 2.8 mEq/L. Which of the following assessments would warrant immediate intervention by the nurse? -Respiratory rate of 18 with clear breath sounds and 2 loose stools this morning. -Irregular pulse and shallow respirations

Irregular pulse and shallow respirations

A client is ready to go home after a myocardial infarction (MI). The client is asking questions about his medications and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following? Metoprolol helps to increase blood flow to the heart by dilating the coronary arteries. Your heart was beating too slowly, and metoprolol increases your heart rate. It slows your heart rate and decreases the amount of work it has to do so it can heal. The medication makes your heart beat stronger to supply more blood to your body.

It slows your heart rate and decreases the amount of work it has to do so it can heal.

A nurse is caring for several clients at risk for hypovolemia. The nurse assess the older client with which finding first? -Has had diabetes mellitus for 12 years -Had abdominal surgery and has an NG tube -Just received 3 units of packed red blood cells -Uses antacids frequently

Just received 3 units of packed red blood cells

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the X-ray department. Which of the following actions should the nurse take? -Clamp the chest tube prior to transferring the client to a wheelchair. -Empty the collection chamber prior to transport. -Disconnect the chest tube from the drainage system during transport. -Keep the drainage system upright and below the level of the client's chest at all times.

Keep the drainage system upright and below the level of the client's chest at all times.

The nurse is performing a home visit to an 84 year old client recovering from hip surgery. The woman seems confused and has dry mucous membranes. When asked about her fluid intake, the patient states, "I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom." What would be the nurse's best response? -It is normal to be a little confused after surgery and it is not safe to urinate at night. -Limiting your fluids can create an imbalance that can result in confusion. Maybe we need to adjust the timing of your fluids. -If you build up too much urine in your bladder it can cause confusion, especially when your body is under stress. -I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup.

Limiting your fluids can create an imbalance that can result in confusion. Maybe we need to adjust the timing of your fluids.

The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? -Respiratory acidosis -Metabolic acidosis -Metabolic alkalosis -Respiratory alkalosis

Metabolic acidosis

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the morning's blood work, the nurse notices that the client's potassium is below the reference range. The nurse should assess for signs and symptoms of what imbalance? -Respiratory alkalosis -Respiratory acidosis -Metabolic alkalosis -Metabolic acidosis

Metabolic alkalosis

A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? Mid-sternal chest pain. T wave touching the P wave. Mild orthostatic hypotension. Increased urine output.

Mid-sternal chest pain.

For a client admitted with severe hyponatremia, which should be the priority intervention to achieve the goal "client will remain free from injury"? -Adhere to the sodium restriction as prescribed -Perform daily weights at the same time each day -Monitor neurologic status and initiate seizure precautions -Maintain accurate intake and output records

Monitor neurologic status and initiate seizure precautions

Which assessment finding, obtained while taking a client history, alerts the nurse that the client should be assessed for fluid imbalance? -I am often cold and need to wear a sweater. -In the summer I feel thirsty more often. -My rings seem to be tighter this week. -I seem to urinate more when I drink coffee.

My rings seem to be tighter this week.

The nurse is assisting a client to walk in the hall on the third day after an MI. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity? Onset of chest pain. Heart rate increase of 10 bpm at completion of the activity. Systolic BP increase of 10 mmHg at completion of the activity. Facial flushing.

Onset of chest pain.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears restless. Which of the following values does the nurse anticipate to be outside the reference range? -Bicarb -PO2 -PCO2 -Sodium

PCO2

The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client's care? Assess the client's roommate for symptoms of infection. Wear a mask when entering the room. Evaluate the amount of protein the client eats. Perform effective hand hygiene frequently.

Perform effective hand hygiene frequently.

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue? Schedule for daily physicals and occupational therapy. Arrange for a family member to stay with the client. Plan care for times when the client has the most energy. Plan all activities to occur in the morning, allowing for afternoon naps.

Plan care for times when the client has the most energy.

A client is taking furosemide (Lasix) for heart failure. What assessment finding requires immediate action by the nurse? Potassium of 2.9 mEq/L. Cough. Pulse of 60 bpm. Headache.

Potassium of 2.9 mEq/L.

A nurse is assessing a client using a PCA following a hip surgery. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The ABG results are pH 7.52, PO2 89, PCO2 28, and HCO3 24. Which of the following actions does the nurse take initially? -Discontinue the PCA -Instruct the client to cough forcefully -Assist the client with ambulation -Provide calming interventions

Provide calming interventions

Which instruction is the most accurate for the nurse to give a client who has a PCA device after surgery? -Instruct your visitors to push the button for you when you are sleeping. -Try to go as long as you possibly can before you press the button -Push the button when you first feel pain instead of waiting until the pain is severe. -Push the button every 15 minutes whether you feel pain at that time or not.

Push the button when you first feel pain instead of waiting until the pain is severe.

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client for prevention? -Check your radial pulse twice a day. -Bake or grill meat rather than frying it. -Weight yourself every morning and night. -Read food labels to determine sodium content.

Read food labels to determine sodium content.

A nurse is caring for a client who has a stage 1 pressure ulcer. Which of the following dressings should the nurse plan to apply? -Alginate dressing -Hydrogel dressing -Wet to dry dressing -Transparent dressing

Transparent dressing

A nurse is caring for a client admitted with an exacerbation of a neuromuscular disease. Upon assessment of the client, the nurse notes that the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? -Respiratory alkalosis -Respiratory acidosis -Metabolic acidosis -Metabolic alkalosis

Respiratory acidosis

The nurse is caring for a client who experienced a traumatic injury in a workplace accident. The client is reporting dyspnea because of abdominal pain. An ABG reveals the following results: pH 7.28, pCO2 50, and HCO3 23. The nurse should recognize the likelihood of what acid-base disorder? -Metabolic acidosis -Respiratory acidosis -Metabolic alkalosis -Respiratory alkalosis

Respiratory acidosis

The nurse is administering the pneumonia and influenza vaccines to clients with COPD. A client asks why these vaccines are recommended. What is the nurse's best response? -Respiratory infections can be more serious in patients with COPD and should be prevented. -These vaccines help reduce the tachypnea that you experience -These vaccines are recommended for all clients -These vaccines promote bronchodilation and improve oxygenation

Respiratory infections can be more serious in patients with COPD and should be prevented.

The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? Dyspnea with activity. Fatigue. Sinus tachycardia. Speech alterations.

Speech alterations.

The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching? Chicken Oranges Tomatoes Steak

Steak

The nurse is caring for a patient with an advanced stage of lung cancer. The nurse enters the room and finds the patient struggling to breathe and the nurse's rapid assessment reveals that the patient's jugular veins are distended and there is significant facial swelling. The nurse should suspect the development of what oncologic emergency? Superior vena cava syndrome (SVCS) Tumor Lysis Syndrome Increased intracranial pressure Spinal cord compression

Superior vena cava syndrome (SVCS)

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? Respiratory rate change from 20 to 26 breaths/min. Decrease in oxygen saturation from 98% to 95%. Increase in heart rate from 86 to 100 beats/min Systolic BP change from 136 to 96 mmHg.

Systolic BP change from 136 to 96 mmHg.

The nurse notices that the client's heart rate is 50 bpm on the telemetry monitor. Which of the following should the nurse do first? Auscultate for abnormal heart sounds. Take the client's blood pressure. Administer 0.5 mg of atropine IV push. Prepare for transcutatneous pacing.

Take the client's blood pressure.

The nurse is planning discharge education for a client after coronary artery bypass graft (CABG) surgery. Which instruction does the nurse include in this client's teaching? Remember to drink at least 3 liters of fluid daily. You should abstain from sexual activity for 6 months. Stop taking your antihyperlipidemic medication at this time. Take your pulse before, midway through, and after exercising.

Take your pulse before, midway through, and after exercising.

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? -Talk with the client during wound care -Keep family members aware of his condition -Assign assistive personnel to keep his room neat and clean -Rotate nursing staff so he can have varied interactions

Talk with the client during wound care

The nurse is interested in primary prevention for cancer. Which activity will allow the nurse to provide this level of prevention? -Teaching junior high school students the impact of using tobacco on the body. -Distributing fecal occult blood test kits to people at the shopping mall. -Educating adolescent girls about getting an annual Pap smear. -Arranging transportation volunteers for clients undergoing radiation therapy.

Teaching junior high school students the impact of using tobacco on the body.

The nurse is assessing a client wit COPD. Which symptoms is a priority for the nurse's intervention? -The client has new bilateral dependent leg edema -The client has pale, pink skin -The client's anterior/posterior to transverse ratio is 1:1 -The client has clubbing of the fingernails

The client has new bilateral dependent leg edema

A nurse is caring for 4 hospitalized clients. Which of the following clients should the nurse identify as being at risk of fluid volume deficit? -The client who has left-sided HF and has a BNP of 600pg/mL. -The client who has end stage renal failure and is scheduled for dialysis today. -The client who has gastroenteritis and has a fever. -The client who has been NPO since midnight for an endoscopy.

The client who has gastroenteritis and has a fever.

Which client is at greatest risk for developing hypercalcemia? -The client with hyperparathyroidism -the client taking furosemide (Lasix) -The woman who is pregnant with twins -The client with long-standing osteoarthritis

The client with hyperparathyroidism

Which of the following does the nurse expect as an outcome of pursed lip breathing for patients with COPD? -To strengthen the intercostals -To promote oxygen intake -To promote carbon dioxide elimination -To strengthen the diaphragm

To promote carbon dioxide elimination

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? -Elevate the head of the bed no more than 45 degrees -Massage the skin over bony prominences -Apply cornstarch to keep sensitive skin areas dry -Use a transfer device to lift the client up in bed

Use a transfer device to life the client up in bed

A client has a history of chronic hypocalcemia. What intervention is most important for the nurse to add to this client's plan of care? -Encourage fluid intake of 2L/day -Strain all urine output -Use of nonslip footwear to get out of bed -Position the client supine twice a day

Use of nonslip footwear to get out of bed

A client's radiation implant has become dislodged overnight, and the nurse finds it in the client's bed. What does the nurse do first? Don gloves and attempt to replace the implant. Assess the client's skin for radiation burns. Notify the safety officer and move the client to a different room. Use the tongs to put the implant into the radiation container.

Use the tongs to put the implant into the radiation container.

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? -Weigh yourself at the same time each day in the same amount of clothing. -When you feel short of breath, take an additional diuretic. -Eat six small meals daily instead of three larger meals. -Avoid drinking more than 3 quarts of liquids each day.

Weigh yourself at the same time each day in the same amount of clothing.

An older adult client with heart failure state, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? Would you like to talk about this some more? You must feel as though you are a burden. You're lucky to have such a devoted daughter. Would you like an antidepressant medication?

Would you like to talk about this some more?

The nurse has identified risk for infection as a diagnosis for a patient diagnosed with leukemia. Which interventions should the nurse implement (Select all that apply)? -Assess the client's vital signs, including temperature, every 4 hours. -Ask the family to take the patient's fresh flowers home. -Place the client on droplet isolation. -Monitor the client's white blood cell count daily. -Ask that visitors with infections do not visit at this time. -Facilitate daily bone marrow biopsies.

-Assess the client's vital signs, including temperature, every 4 hours. -Ask the family to take the patient's fresh flowers home. -Monitor the client's white blood cell count daily. -Ask that visitors with infections do not visit at this time.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching (Select all that apply)? -Becoming increasingly short of breath at rest. -Having to sleep sitting up in a reclining chair. -High intake of sodium for breakfast. -Weight loss of 2 pounds in 1 day. -Weight gain of 2 pounds or more in 1 day.

-Becoming increasingly short of breath at rest. -Having to sleep sitting up in a reclining chair. -Weight gain of 2 pounds or more in 1 day.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for (Select all that apply)? -Crackles -Decreased oxygen saturation -Edema in lower extremities -Jugular Venous Distention -Dyspnea

-Crackles -Decreased oxygen saturation -Dyspnea

A nursing student is providing education on the signs of hypovolemia to a group at a senior center. Which of the following does the student include? (SATA) -Dizziness -Elevated pulse -Elevated BP -Dry mucous membranes -Confusion

-Dizziness -Elevated pulse -Dry mucous membranes -Confusion

The nurse is admitting an intravenous opioid medication to a client. Which interventions should the nurse implement for client safety? (SATA) -Reassess vitals 15-30 minutes after administration of medications -Clarify every pain medication order with prescriber -Assess the client's vitals prior to administration -Ask the client's name and DOB comparing it to the ID bracelet -Have a witness verify the wasted portion of the opioid after administration -Determine if the client has any allergies to medications

-Reassess vitals 15-30 minutes after administration of medications -Assess the client's vitals prior to administration -Ask the client's name and DOB comparing it to the ID bracelet -Determine if the client has any allergies to medications

A highway construction worker is concerned about her cancer risks. She has been married for 18 years, has two children, smokes one pack of cigarettes a day, and drinks one to two beers each week. She is 30 lbs overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and and aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. Which of the following changes does the nurse encourage this patient to make to decrease her cancer risk (Select all that apply)? -Change her job to work inside. -Stop smoking. -Use sunscreen daily. -Decrease alcohol consumption. -Improve her nutrition. -Lose weight.

-Stop smoking. -Use sunscreen daily. -Improve her nutrition. -Lose weight.

The client with which conditions requires immediate nursing intervention? (SATA) -Stridor -RR of 4 bpm -Arterial blood gas pH 7.36 -Occasional expiratory wheeze -Retractions of the sternum -Pulse ox reading of 95%

-Stridor -RR of 4 bpm -Retractions of the sternum

Which laboratory results should the nurse report to the oncologist before the next does of chemotherapy is administered (Select all that apply)? -Hemoglobin of 14.5 g/dL -Temperature of 101.2 F -BUN of 12 mg/dL -Urine output of 60 mL for the last hour -Platelet count of 40,000/mm3 -White blood cell count of 2,300/mm3

-Temperature of 101.2 F -Platelet count of 40,000/mm3 -White blood cell count of 2,300/mm3

The clinic nurse is caring for an oncology patient complaining of extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure the patient? -These symptoms usually result from radiation therapy, however, we will continue to monitor your lab and X-ray results. -Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy. -Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying. -These symptoms are part of your disease and unfortunately an inevitable part of living with cancer.

-These symptoms usually result from radiation therapy, however, we will continue to monitor your lab and X-ray results.

Which of the following nursing diagnoses would be a priority for the teenage male client with acute leukemia? Risk of activity intolerance related to fatigue. Risk for injury related to thrombocytopenia. Risk for ineffective coping related to disease process. Risk for impaired skin integrity related to purpura.

Risk for injury related to thrombocytopenia.

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? -Request the prescription for the insertion of an indwelling urinary catheter -Apply a moisture barrier ointment to the client's skin -Check the client's skin every 8 hours for signs of breakdown -Clean the client's skin and perineum with hot water after each episode of incontinence

Apply a moisture barrier ointment to the client's skin

Which intervention in a client with hypovolemia-induced confusion is most likely to relieve the confusion? -Applying oxygen by mask or nasal cannula -Measuring intake and output every 4 hours -Placing the client in high-fowler's position -Decreasing the IV flow rate

Applying oxygen by mask or nasal cannula

You are making a home visit to a client receiving external radiation therapy. Further teaching is necessary when you observe the client doing which of the following? Protecting the skin with soft, loose clothing. Washing the site with plain water and patting it dry. Regularly inspecting the skin for damage. Applying perfumed lotion to the irritated site.

Applying perfumed lotion to the irritated site.

The client is receiving an IV infusion at 150 mL/hr as prescribed. After 4 hours of the infusion, the client reports SOB and develops a cough. Which intervention should be the nurse's first action? -Elevate client's legs -Notify prescriber -Continue to monitor the patient -Assess the client's lungs

Assess the client's lungs

A home health nurse visits a client who has COPD and receives oxygen at 2L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? -Increase oxygen flow to 3L/min -Assess the client's respiratory status -Call emergency services for the client -Have the client cough and expectorate secretions

Assess the client's respiratory status

A client who is post percutaneous transluminal coronary angioplasty (PTCA) with stent placement reports severe chest pain. Which action does the nurse take first? Perform an immediate 12 lead ECG. Assess the vital signs and notify the healthcare provider. Administer the prescribed sublingual nitroglycerin. Administer the prescribed IV morphine.

Assess the vital signs and notify the healthcare provider.

The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, " The pain has not gotten any better." What does the nurse do next? Administer IV nitroglycerin. Place the client in a semi-Fowler's position. Notify the healthcare provider. Begin supplemental oxygen at 5 L/min.

Notify the healthcare provider.

Which client is at a greatest risk for hypovolemia? -Younger adult client on bedrest -Younger adult client receiving hypertonic IV fluid -Older adult with cognitive impairment -Older adult receiving hypotonic IV fluids

Older adult with cognitive impairment

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which organs are responsible for regulatory processes and compensation? -Heart and liver -Heart and lungs -Lungs and kidneys -Pancreas and stomach

Lungs and kidneys

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? I wake up coughing every night. My shoes fit really tight lately. I have trouble catching my breath. I sleep on four pillows at night.

My shoes fit really tight lately.

The healthcare provider is preparing a patient on the med-surg unit for thoracentesis. Which of the following is the most appropriate position for the patient during the procedure? -Prone with arms extended above the head -The HOB elevated 45 degrees with patient lying on unaffected side -Sitting up, leaning over bedside table and feet supported on ground

Sitting up, leaning over bedside table and feet supported on ground

The nurse is assessing the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client? Blueberry muffin, orange juice, decaffeinated coffee. Whole wheat french toast, a side of bacon, coffee. Skim milk, oatmeal, banana, orange juice, coffee. Cheese omelet, skim milk, whole wheat toast, coffee.

Skim milk, oatmeal, banana, orange juice, coffee.

The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client's discharge teaching? Avoid blowing your nose. Use a soft-bristled toothbrush. Use only aspirin when having pain. Drink at least 3 liters of fluid a day.

Use a soft-bristled toothbrush.

A nurse is caring for a client receiving nasogastric suctioning. Which of the following ABG values does the nurse anticipate? -pH 7.48 pO2 89 pCO2 30 HCO3 26 -pH 7.26 pO2 84 pCO2 38 HCO3 20 -pH 7.51 pO2 94 pCO2 36 HCO3 31 -pH 7.31 pO2 77 pCO2 52 HCO3 23

pH 7.51 pO2 94 pCO2 36 HCO3 31