Adult Health 2 Final

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The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? a. An area of bruising over the mastoid bone b. A bloodstain surrounded by a yellowish stain on the head dressing c. Escape of cerebrospinal fluid from the client's ear d. Escape of cerebrospinal fluid from the client's nose

a. An area of bruising over the mastoid bone

A nurse is developing a plan of care for a client who has a new ileal conduit. The nurse should include that the client is at risk for which of the following? (Select all that apply.) a. Anxiety b. Infection c. Impaired skin integrity d. Fluid volume deficit e. Disturbed body image

a. Anxiety b. Infection c. Impaired skin integrity e. Disturbed body image

A nurse receives a unit of packed RBCs from a blood bank and notes that the time is 1130. The nurse should begin the infusion at which of the following times? a. As soon as the nurse can prepare the client and the administration set b. 2 hr after obtaining blood from the blood bank c. When the client states he is ready to start the infusion d. When the client has finished eating lunch

a. As soon as the nurse can prepare the client and the administration set

A seasoned nurse is caring for a postoperative patient following lung surgery. The patient has a shallow, monotonous respiratory pattern and is reluctant to cough. What may the patient may be at an increased risk for? a. Atelectasis b. Aspiration c. Malnutrition d. Increased oxygen saturation

a. Atelectasis

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? a. Early ambulation b. Increased dietary intake of protein c. Administering aspirin with warfarin d. Maintaining the client in a supine position

a. Early ambulation

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education? a. Iron will cause the stools to darken in color. b. Take the iron with dairy products to enhance absorption. c. Limit foods high in fiber due to the risk for diarrhea. d. Increase the intake of vitamin E to enhance absorption.

a. Iron will cause the stools to darken in color.

Bell's palsy is a paralysis of which of the following cranial nerves? a. Otic b. Facial c. Optic d. Trigeminal

b. Facial

Which Glasgow Coma Scale score is indicative of a severe head injury? a. 11 b. 13 c. 7 d. 9

c. 7

The nurse provides care for several clients who have obesity. Which client's obesity is most likely to resolve with medication? a. A client whose obesity is characterized as android rather than gynoid b. A client with long-standing obesity who has recently been diagnosed with type 2 diabetes c. A client whose obesity has been attributed to hypothyroidism d. An obese client whose parents and siblings are not obese

c. A client whose obesity has been attributed to hypothyroidism

Which nursing intervention is appropriate for a client with double vision in the right eye due to MS? a. Exercise the right eye twice a day. b. Place needed items on the right side. c. Apply an eye patch to the right eye. d. Administer eye drops as needed

c. Apply an eye patch to the right eye.

Which complication of cardiac surgery occurs when fluid and clots accumulate in the pericardial sac, which compresses the heart, preventing blood from filling the ventricles? a. Hypothermia b. Hypertension c. Cardiac tamponade d. Fluid overload

c. Cardiac tamponade

A 69 year-old client has maintained a consistent diet and activity level throughout adulthood. Over the past few years, however, the client has reported a gradual increase in adipose tissue. When providing health education, the nurse should address what topic? a. Weight gain as a natural, age-related change b. Loss of skeletal muscle with aging c. Changes in metabolism that accompany the aging process d. Changes in food cravings that are common in older adults

c. Changes in metabolism that accompany the aging process

Which is a modifiable risk factor for coronary artery disease (CAD)? a. Gender b. Increasing age c. Diabetes mellitus d. Race

c. Diabetes mellitus

A client with chronic arterial occlusive disease undergoes percutaneous transluminal coronary angioplasty (PTCA) for mechanical dilation of the right femoral artery. After the procedure, the client will be prescribed long-term administration of which drug? a. penicillin V or erythromycin. b. aspirin or acetaminophen. c. aspirin or clopidogrel. d. pentoxifylline or acetaminophen

c. aspirin or clopidogrel.

The nurse is caring for a client postoperative day 4 following a kidney transplant. When assessing for potential signs and symptoms of rejection, what assessment should the nurse prioritize? a. Assessment of the client's incision b. Assessment for flank or abdominal pain c. Assessment of the client's abdominal girth d. Assessment of the quantity of the client's urine output

d. Assessment of the quantity of the client's urine output

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? a. Hyperkalemia b. Elevated blood glucose level c. Urinary tract infection (UTI) d. Atelectasis

d. Atelectasis

A client with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the client's cardiac and neurologic status, the nurse monitors the client for signs of what complication? a. Acute pain b. Septicemia c. Seizures d. Bleeding

d. Bleeding

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? a. Gangrene of the gallbladder and hyperglycemia b. Acidosis and hypoglycemia c. Pain and peritonitis d. Bleeding and perforation

d. Bleeding and perforation

A client with systemic lupus erythematosus (SLE) has the classic rash of lesions on the cheeks and bridge of the nose. What term should the nurse use to describe this characteristic pattern? a. Bull's eye rash b. Papular rash c. Pustular rash d. Butterfly rash

d. Butterfly rash

The nurse should advise a client with iron deficiency anema to take which action in order to prevent staining of the teeth? a. Do not combine iron with other prescribed or over-the-counter medications b. Take iron with or immediately after meals c. Avoid taking iron simultaneously with an antacid d. Dilute liquid preparations of iron with juice and drink with a straw

d. Dilute liquid preparations of iron with juice and drink with a straw

You are assessing a patient suspected of having right-sided heart failure. What assessment finding may indicate right-sided heart failure? a. Dry cough b. Orthopnea c. Pulmonary edema d. Distended neck veins

d. Distended neck veins

A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client? a. Void at least every 6 to 8 hours. b. Avoid voiding immediately after sexual intercourse. c. Bathe daily and keep the perineal region clean. d. Drink liberal amounts of fluids.

d. Drink liberal amounts of fluids.

Mr. K has been admitted with a potential diagnosis of Nephritic Syndrome. Prednisone is prescribed for Mr. K. The nurse can evaluate its effectiveness by which of the following interventions? a. Observing him for behavioral changes b. Checking his BP every 4 hours c. Checking his urine for increased protein d. Weighing him each morning before breakfast

d. Weighing him each morning before breakfast

A nurse is caring for a client with left-sided heart failure. What should the nurse anticipate using to reduce fluid volume excess? a. anticoagulants. b. antiembolism stockings. c. oxygen. d. diuretics.

d. diuretics.

Thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? a. 6 hours b. 9 hours c. 12 hours d. 3 hours

d. 3 hours

Which particular area(s) should be examined to assess peripheral edema? a. Under the sacrum b. Lips, earlobes c. Uppper arms d. Feet, ankles

d. Feet, ankles

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? a. Adherence to recommended immunization schedules b. Regular blood pressure monitoring c. Annual screening colonoscopies d. Frequent screening for osteoporosis

d. Frequent screening for osteoporosis

The community health nurse is performing a home visit to a client who has obesity, peripheral vascular disease, and type 2 diabetes. The client has expressed a desire to lose weight. What is the nurse's best initial action? a. Review the client's most recent blood glucose and hemoglobin A1c results b. Teach the client exercises that are physically achievable and easy to perform c. Teach the client about the relationship between lifestyle and body weight d. Identify the client's desired goals for weight loss

d. Identify the client's desired goals for weight loss

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? a. Bilateral wheezes b. Shallow respirations c. Bradypnea d. Increased anterior-posterior (AP) diameter

d. Increased anterior-posterior (AP) diameter

During a client's scheduled home visit, an older adult client has stated to the community health nurse that she has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? a. Daily use of OTC glycerin suppositories b. Use of an NSAID to reduce inflammation c. Regular application of an OTC antibiotic ointment d. Increased fluid and fiber intake

d. Increased fluid and fiber intake

The nurse is preparing to assess a new client who has class III obesity. In order to provide empathic and holistic care for this client, the nurse should first: a. remind himself or herself that obesity is a treatable health problem. b. anticipate having some discomfort or anxiety when assessing the client. c. seek advice from a colleague who is known to provide empathic care. d. examine their own preconceptions and beliefs about obesity.

d. examine their own preconceptions and beliefs about obesity.

Which of the following would best describe the sputum of a patient experiencing pulmonary edema? a. white viscous b. pink viscous c. white frothy d. pink frothy

d. pink frothy

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm . What term should the nurse use to describe this low platelet count? a. Thrombocytopenia b. Leukopenia c. Anemia d. Neutropenia

a. Thrombocytopenia

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? a. "If a pin becomes detached, I'll notify the surgeon." b. "I can apply powder under the liner to help with sweating." c. "I'll check under the liner for blisters and redness." d. "I will change the vest liner periodically."

b. "I can apply powder under the liner to help with sweating."

A client has a glomerular filtration rate (GFR) of 43 mL/min/1.73 m . Based on this GFR, the nurse interprets that the client's chronic kidney disease is at what stage? a. Stage 1 b. Stage 3 c. Stage 4 d. Stage 2

b. Stage 3

The nurse is caring for a client who is having chest pain associated with a myocardial infarction (MI). What medication will the nurse administer intravenously to reduce pain and anxiety? a. codeine sulfate b. morphine sulfate c. fentanyl d. hydromorphone hydrochloride

b. morphine sulfate

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? a. 1) pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg b. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg c. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg d. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg

a. 1) pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? a. Strategies for avoiding irritating foods and beverages b. Strategies for maintaining an alkaline gastric environment c. Techniques for positioning correctly to promote gastric healing d. Safe technique for self-suctioning

a. Strategies for avoiding irritating foods and beverages

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? a. Emphasize the fact that the colostomy is temporary measure and is not permanent. b. Engage the client in dialogue about the implications of having the colostomy. c. Encourage the client to conduct online research into colostomies. d. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem.

b. Engage the client in dialogue about the implications of having the colostomy.

The nurse is assessing a client admitted with renal stones. During the admission assessment, what parameters should the nurse address? Select all that apply. a. Surgical history b. Family history of renal stones c. Vaccination history d. Medication history e. Dietary history

b. Family history of renal stones d. Medication history e. Dietary history

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. a. Systemic infection b. Fat embolism c. Complex regional pain syndrome d. Deep vein thrombosis e. Compartment syndrome

b. Fat embolism d. Deep vein thrombosis e. Compartment syndrome

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do? a. Lie in a low Fowler or supine position. b. Increase oral fluids unless contraindicated c. Call the nurse for oral suctioning, as needed. d. Increase activity.

b. Increase oral fluids unless contraindicated

A patient with acute myeloid leukemia (AML) has a neutrophil count that persists at less than 100/mm3. What should the nurse cautiously monitor this patient for? a. Hypotension b. Infection c. Abdominal cramps d. Seizure activity

b. Infection

The most important nursing priority of treatment for a patient with an altered LOC is to: a. Position the patient to prevent injury and ensure dignity. b. Maintain a clear airway to ensure adequate ventilation. c. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. d. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain.

b. Maintain a clear airway to ensure adequate ventilation.

A nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified? a. Phlebotomist b. Oncology nurse c. Senior nursing student d. Assistive personnel

b. Oncology nurse

A nurse is monitoring a client who reports having chills and back pain during a blood transfusion. Which of the following actions is nurse's priority? a. Covering the client with a blanket b. Stopping the transfusion c. Assessing the client's skin for a rash d. Notifying the provider

b. Stopping the transfusion

A client is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what? a. Nephritic syndrome b. Pyelonephritis c. Hydronephrosis d. Nephrotoxicity

c. Hydronephrosis

Which terms describes the backward flow of blood through a heart valve? a. Prolapse b. Hypertrophy c. Regurgitation d. Stenosis

c. Regurgitation

The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite? a. Men of all ages are less prone to UTIs, but typically experience more severe symptoms. b. Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. c. The prevalence of UTIs in older men approaches that of women in the same age group. d. The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.

c. The prevalence of UTIs in older men approaches that of women in the same age group.

A patient has been diagnosed with an allergy to peanuts. What is a priority for this patient to carry at all times? a. A medical alert bracelet b. An EpiPen c. An oral airway d. An H1 blocker

b. An EpiPen

A client has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? a. Half the width of the stoma b. The narrowest part of the stoma c. The circumference of the stoma d. The widest part of the stoma

d. The widest part of the stoma

A client with an acute myocardial infarction is receiving nitroglycerin by continuous I.V. infusion. Which client statement indicates that this drug is producing its therapeutic effect? a. "My vision is blurred, so my blood pressure must be up." b. "My chest pain is decreasing." c. "I feel a tingling sensation around my mouth." d. "I have a bad headache.

b. "My chest pain is decreasing."

An elderly patient is being monitored for evidence of heart failure. To detect early signs of CHF, the nurse would instruct the CNA to perform which of the following during patient care? a. Assist client with ambulation three times per shift b. Observe electrocardiogram readings and report deviations to the nurse c. Accurately weigh the patient and report and document the findings d. Monitor VS every 15 minutes and report readings to the nurse

c. Accurately weigh the patient and report and document the findings

A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? a. Compartment syndrome is associated with third-degree strains. b. Nerve damage is associated with third-degree strains. c. Avulsion fractures are associated with third-degree strains. d. Greenstick fractures are associated with third-degree strains.

c. Avulsion fractures are associated with third-degree strains.

A medicine cup has _____ ml, or _____ fluid ounce capacity: a. 10, 3 b. 30, 3 c. 30, 1 d. 10, 1

c. 30, 1

The nurse is caring for a patient who has been diagnosed with an elevated cholesterol level. The nurse is aware that plaque on the inner lumen of arteries is composed chiefly of what? a. Lipids and fibrous tissue b. WBCs c. High-density cholesterol d. Lipoproteins

a. Lipids and fibrous tissue

A client with early-stage rheumatoid arthritis asks the nurse what he can do to help ease the symptoms of his disease. What would be the best response by the nurse? a. "The doctor could prescribe anti-inflammatory drugs." b. "The doctor could prescribe antipyretic drugs." c. "The doctor could prescribe antineoplastic drugs." d. "The doctor could prescribe antihypertensive drugs."

a. "The doctor could prescribe anti-inflammatory drugs."

The nurse is caring for a client recently diagnosed with renal calculi. The nurse should instruct the client to increase fluid intake to a level where the client produces at least how much urine each day? a. 2000 mL b. 1250 mL c. 3500 mL d. 2750 mL

a. 2000 mL

The nurse is providing care for an adult client who has sought care for the treatment of obesity. When performing an assessment of this client, the nurse should address what potential contributing factors? Select all that apply. a. Endocrine factors b. Neurologic factors c. Microbiota d. Activity level e. Family history and genetics

a. Endocrine factors c. Microbiota d. Activity level e. Family history and genetics

A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? a. Excess Fluid Volume b. Adult Failure to Thrive c. Imbalanced Nutrition: More than body requirements d. Sedentary Lifestyle

a. Excess Fluid Volume

The nurse is caring for a patient at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? a. Incentive spirometry b. Bronchoscopy c. Positive end-expiratory pressure (PEEP) d. Intermittent positive-pressure breathing (IPPB)

a. Incentive spirometry

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. a. Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day b. Instructing the client to move the legs in a "pumping" exercise c. Using elastic stockings, especially when decreased mobility would promote venous stasis d. Instructing the client to move the legs in a "pumping" exercise e. Encouraging a liberal fluid intake

a. Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day b. Instructing the client to move the legs in a "pumping" exercise c. Using elastic stockings, especially when decreased mobility would promote venous stasis e. Encouraging a liberal fluid intake

a. Iron will cause the stools to darken in color.

Six weeks after an above-the-knee amputation (AKA), a client returns to the outpatient office for a routine postoperative checkup. During the nurse's assessment, the client reports symptoms of phantom pain. What should the nurse tell the client to do to reduce the discomfort of the phantom pain? a. Take opioid analgesics as prescribed b. Apply intermittent hot compresses to the area of the amputation c. Elevate the level of the amputation site d. Avoid activity until the pain subsides

a. Take opioid analgesics as prescribed

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing him the nurse notes that his right leg is shorter than his left leg; his right hip is noticeably deformed and he is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms? a. Traumatic hip dislocation b. Subluxated right hip c. Hip strain d. Right hip contusion

a. Traumatic hip dislocation

b. "My chest pain is decreasing."

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? a. 1.75 mL b. 1.6 mL c. 0.4 mL d. 0.6 mL

b. 1.6 mL

There are ____ ml in a teaspoon and ___ teaspoons in a tablespoon. a. 3, 6 b. 5, 3 c. 10, 2 d. 5, 5

b. 5, 3

Which patient does the nurse recognize as being most likely to be affected by sickle cell disease? a. An 18-year-old Chinese woman b. A 14-year-old African American boy c. A 28-year-old Israeli man d. A 26-year-old Eastern European Jewish woman

b. A 14-year-old African American boy

The nurse is evaluating a client's readiness for allergy skin testing. The nurse determines that the testing will need to be postponed when it is revealed that the client took which classification of medication the night before? a. Antidepressant b. Antihistamine c. Anticoagulant d. Anti-inflammatory

b. Antihistamine

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? a. Depressed b. Basilar c. Comminuted d. Simple

b. Basilar

You are caring for an adult patient who had symptoms of unstable angina during admission to the hospital. The most appropriate nursing diagnosis for the discomfort associated with angina is what? a. Noncompliance related to failure to accept necessary lifestyle changes b. Ineffective cardiopulmonary tissue perfusion secondary to CAD, as evidenced by chest pain c. Anxiety related to fear of death d. Deficient knowledge about underlying disease and methods for avoiding complications

b. Ineffective cardiopulmonary tissue perfusion secondary to CAD, as evidenced by chest pain

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? a. Infusion of hypotonic IV solution b. Insertion of an NG tube for decompression c. Administration of antiemetics d. Administration of proton pump inhibitors as prescribed

b. Insertion of an NG tube for decompression

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective? a. Relief from constipation b. Reduced muscle spasticity c. Increased ability to sleep d. Relief from pain

b. Reduced muscle spasticity

The nurse is caring for a client with a history of systemic lupus erythematosus who has been recently diagnosed with end-stage kidney disease (ESKD). The client has an elevated phosphorus level and has been prescribed calcium acetate to bind the phosphorus. The nurse should teach the client to take the prescribed medication at what time? a. First thing in the morning b. With each meal c. Only when needed d. Daily at bedtime

b. With each meal

A client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. Myasthenia gravis is confirmed by: a. Kernig's sign. b. a positive edrophonium (Tensilon) test c. a positive sweat chloride test. d. Brudzinski's sign.

b. a positive edrophonium (Tensilon) test

A client comes to the emergency department complaining of difficulty breathing and feeling strange after eating a shrimp cocktail. The client is leaning forward with a respiratory rate of 36 breaths per minute. The nurse suspects anaphylaxis. What is the nurse's priority action? a. providing pain relief measures b. maintaining an open airway c. encouraging activity d. decreasing anxiety

b. maintaining an open airway

A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of: a. vitamin A. b. vitamin B12. c. vitamin C. d. folic acid.

b. vitamin B12.

A client with gallstones has been prescribed ursodeoxycholic acid (UDCA). The nurse understands that additional teaching is needed regarding this medication when the client states: a. "It is important that I see my physician for scheduled follow-up appointments while taking this medication." b. "If I lose weight, the dose of the medication may need to be changed." c. "I will take this medication for 2 weeks and then gradually stop taking it." d. "This medication will help dissolve small gallstones made of cholesterol."

c. "I will take this medication for 2 weeks and then gradually stop taking it."

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? a. 0.4 mL b. 0.8 mL c. 0.5 mL d. 1.5 mL

c. 0.5 mL

A nurse is caring for a client diagnosed with human immunodeficiency virus (HIV). The client wants to know when medication for the disease will begin. What is the nurse's best response? a. When the client is coinfected with hepatitis C. b. If the client is diagnosed with HIV-associated liver disease. c. If the client has a CD4 T-cell count less than 350 cells/mm3 d. After the client has been cured of Kaposi's sarcoma.

c. If the client has a CD4 T-cell count less than 350 cells/mm3

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? a. Liaise with the primary provider to obtain an order for loperamide. b. Keep a food diary to determine the foods that exacerbate the client's symptoms. c. Toilet the client on a frequent, scheduled basis. d. Provide the client with a bland, low-residue diet.

c. Toilet the client on a frequent, scheduled basis.

A client with long-standing obesity has been prescribed phentermine/topiramate-ER. What statement by the client suggests that further health education is necessary? a. "It's hard to believe that there are actually medications that can treat obesity." b. "I'm going to have to do some rearranging of my finances to make sure I can afford this medication." c. "I'm a bit nervous to start this medication because I know I'll need blood tests sometimes." d. "I'm so relieved to start this medication. I really don't like having to exercise or change what I eat."

d. "I'm so relieved to start this medication. I really don't like having to exercise or change what I eat."

The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD? a. A client with a history of polycystic kidney disease b. A client with severe chronic obstructive pulmonary disease c. A client who is morbidly obese with a history of vascular disorders d. A client with diabetes mellitus and poorly controlled hypertension

d. A client with diabetes mellitus and poorly controlled hypertension

d. Atelectasis

The nurse is caring for an acutely ill client. What assessment finding should prompt the nurse to inform the physician that the client may be exhibiting signs of acute kidney injury (AKI)? a. The client reports an inability to initiate voiding. b. The client's urine is cloudy with a foul odor. c. The client complains of acute flank pain. d. The client's average urine output has been 10 mL/hr for several hours.

d. The client's average urine output has been 10 mL/hr for several hours.

A nurse is teaching a client about heart failure. What will the nurse explain is causing the heart to fail? a. The heart is pumping too slow to disseminate nutrients to the body. b. The heart is fibrillating. c. The heart is pumping too fast to adequately meet the body's metabolic needs. d. The heart cannot pump sufficient blood to meet the body's metabolic needs.

d. The heart cannot pump sufficient blood to meet the body's metabolic needs.

A client with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin. The nurse should recognize the possible need for what antidote? a. Factor VIII b. Factor X c. IVIG d. Vitamin K

d. Vitamin K

The nurse is working on the renal transplant unit. To reduce the risk of infection in a client with a transplanted kidney, it is imperative for the nurse to do what? a. Bar visitors from the client's room. b. Ensure immediate function of the donated kidney. c. Instruct the client to wear a face mask. d. Wash hands carefully and frequently.

d. Wash hands carefully and frequently.

A physician orders aspirin, 325 mg P.O. daily for a client who has experienced a transient ischemic attack (TIA). The nurse should teach the client that the physician has ordered this medication to: a. prevent intracranial bleeding. b. control headache pain. c. enhance the immune response d. reduce the chance of blood clot formation.

d. reduce the chance of blood clot formation.

The nursing instructor is teaching a class of level I nursing students how to do a physical assessment on a patient with lung disease and chronic hyperinflation of the lungs. What would a nurse most likely assess in this type of patient? a. A barrel chest b. Dry, flaky skin c. Long, thin fingers d. Large, drooping eyes

a. A barrel chest

A nurse is planning the care of an older adult client who will soon be discharged home after treatment for a fractured hip. In an effort to prevent future fractures, the nurse should encourage what actions? Select all that apply. a. A high-calcium diet b. Regular bone density testing c. Weight-bearing exercise d. Use of corticosteroids as prescribed e. Use of falls prevention precautions

a. A high-calcium diet b. Regular bone density testing c. Weight-bearing exercise e. Use of falls prevention precautions

a. As soon as the nurse can prepare the client and the administration set

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? a. Bed rest lowers the metabolic rate and reduces enzyme production. b. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis. c. Reduced activity protects the physical integrity of pancreatic cells. d. Inactivity reduces caloric need and gastrointestinal motility.

a. Bed rest lowers the metabolic rate and reduces enzyme production.

A client's blood work reveals a platelet level of 17,000/mm . When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? a. Petechiae b. Urticaria c. Alopecia d. Dermatitis

a. Petechiae

A client returns for a follow-up visit to the cardiologist 4 days after a trip to the ED for sudden shortness of breath and abdominal pain. The nurse realizes the client had a myocardial infarction because the results from the blood work drawn in the hospital shows: a. elevated troponin levels. b. decreased LDH levels. c. decreased myoglobin levels. d. ncreased C-reactive protein levels.

a. elevated troponin levels.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a. L4 b. T6 c. T10 d. S2

b. T6

c. Accurately weigh the patient and report and document the findings

A client returns to the floor after a laparoscopic cholecystectomy. The nurse should assess the client for signs and symptoms of what serious potential complication of this surgery? a. Decubitus ulcer b. Wound evisceration c. Bile duct injury d. Diabetic coma

c. Bile duct injury

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? a. Tonic-clonic seizures b. Generalized pain c. Shortness of breath d. Alteration in level of consciousness (LOC)

d. Alteration in level of consciousness (LOC)

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? a. Assistance with self-care b. Monitoring vital signs c. Frequent reorientation d. Evaluation of gag reflex and ability to swallow

d. Evaluation of gag reflex and ability to swallow

The nurse is developing a plan of care for a client newly diagnosed with Bell's palsy. The nurse's plan of care should address what characteristic manifestation of this disease? a. Diplopia b. Pain at the base of the tongue c. Tinnitus d. Facial paralysis

d. Facial paralysis

You are receiving a patient with aortic regurgitation from the critical care unit into the step-down unit. You are aware that aortic regurgitation causes what? a. Blood to flow back from the aorta to the left ventricle b. Obstruction of blood flow from the left ventricle c. Obstruction of blood from the left atrium to left ventricle d. Blood to flow back from the left atrium to the left ventricle

a. Blood to flow back from the aorta to the left ventricle

A client is receiving education about his upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that he may experience which of the following adverse effects associated with this procedure? a. Diarrhea and feelings of fullness b. Persistent feelings of hunger and thirst c. Constipation or bowel incontinence d. Gastric reflux and belching

a. Diarrhea and feelings of fullness

Atherosclerosis can lead to coronary artery disease by causing: a. Reduced blood flow to the heart b. Reduced blood flow to the brain c. Congestive heart failure d. Heart valve failure

a. Reduced blood flow to the heart

A nurse is obtaining a history from a new client in the cardiovascular clinic. When investigating for childhood diseases and disorders associated with structural heart disease, which finding should the nurse consider significant? a. Medullary sponge kidney b. Rheumatic fever c. Croup d. Severe staphylococcal infection

b. Rheumatic fever

A client has just been diagnosed with Parkinson disease and the nurse is planning the client's subsequent care for the home setting. What nursing diagnosis should the nurse address when educating the client's family? a. Impaired spontaneous ventilation b. Risk for injury c. Risk for infection d. Unilateral neglect

b. Risk for injury

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? a. The need for blood glucose monitoring for the next week b. Signs and symptoms of intra-abdominal complications c. Management of fluid balance in the home setting d. Appropriate use of prescribed pancreatic enzymes

b. Signs and symptoms of intra-abdominal complications

A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence? a. Reflex incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence

b. Stress incontinence

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? a. Client will adhere to recommended guidelines for mobility and activity. b. Client will demonstrate appropriate use of standard infection control precautions. c. Client will accurately identify foods that trigger symptoms. d. Client will demonstrate appropriate care of his ileostomy.

c. Client will accurately identify foods that trigger symptoms.

A client has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the client about what topic? a. Psychosocial stressors b. Allergy status c. Current medication use d. Typical diet

c. Current medication use

The nurse is caring for a client in acute kidney injury. Which of the following complications would most clearly warrant the administration of polystyrene sulfonate? a. Hypomagnesemia b. Hypernatremia c. Hypercalcemia d. Hyperkalemia

d. Hyperkalemia

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? a. It refers to the permanent deficits seen after the rehabilitation process. b. t refers to the difficulties suffered by the client and family related to the changes in the client. c. It results from inadequate delivery of nutrients and oxygen to the cells. d. It results from initial damage to the brain from the traumatic event.

d. It results from initial damage to the brain from the traumatic event.

a. Early ambulation

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. a. Eye opening b. Muscle strength c. Intelligence d. Motor response e. Verbal response

a. Eye opening d. Motor response e. Verbal response

The nurse is working with a client whose health history includes occasional episodes of urinary retention. What assessment finding would suggest that the client is currently retaining urine? a. The client's suprapubic region is dull on percussion. b. The client takes a beta-adrenergic blocker for the treatment of hypertension. c. The client claims to void large amounts of urine two to three times daily. d. The client is uncharacteristically drowsy.

a. The client's suprapubic region is dull on percussion.

The nurse on a urology unit is working with a client who has been diagnosed with oxalate renal calculi. When planning this client's health education, what nutritional guidelines should the nurse provide? a. Increase intake of potassium-rich foods. b. Restrict protein intake as prescribed. c. Follow a low-calcium diet. d. Encourage intake of food containing oxalates.

b. Restrict protein intake as prescribed.

Which of the following is the most accurate indicator of fluid loss or gain? a. Urine output b. Weight c. Caloric intake d. Body temperature

b. Weight

A nurse is assessing an elderly client with gallstones. The nurse is aware that the client may not exhibit typical symptoms, and that particular symptoms that may be exhibited in the elderly client may include what? a. Nausea and vomiting b. Chills and jaundice c. Signs and symptoms of septic shock d. Fever and pain

c. Signs and symptoms of septic shock

The nurse is caring for a client with a cerebral aneurysm. Why does the nurse limit the interaction of visitors or family members with the client who has an aneurysm? a. The interaction may cause migraine in the client. b. The client may become emotional and lose interest in the treatment. c. The stimulation can increase intracranial pressure (ICP) or trigger a seizure. d. The interaction may cause the client to become violent.

c. The stimulation can increase intracranial pressure (ICP) or trigger a seizure.

The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? a. cerebral bleeding b. I.M. injection c. myocardial necrosis d. skeletal muscle damage due to a recent fall

c. myocardial necrosis

The nurse is preparing to provide care for a client diagnosed with myasthenia gravis. The nurse should know that the signs and symptoms of the disease are the result of what? a. Genetic dysfunction b. Decreased conduction of impulses in an upper motor neuron lesion c. Upper and lower motor neuron lesions d. A lower motor neuron lesion

d. A lower motor neuron lesion

A male client who has undergone a cervical discectomy is being discharged with a cervical collar. Which of the following would be most appropriate to include the client's discharge plan? a. Wearing the cervical collar when sleeping b. Moving the neck from side to side when the collar is off c. Removing the entire collar when shaving d. Keeping the head in a neutral position

d. Keeping the head in a neutral position

The nurse explains to the client with projectile vomiting and severe headache that a medication is being prescribed to reduced edema surrounding the brain and lessen these symptoms. What medication is the nurse preparing to administer? a. Temozolomide b. Bevacizumab c. Everolimus d. Mannitol

d. Mannitol

d. The heart cannot pump sufficient blood to meet the body's metabolic needs.

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information? a. The benefits of weight loss and exercise as tolerated during recovery b. The good prognosis for clients who are treated for gastric cancer c. The possibility of needing a short-term or long-term colostomy d. The possibility of surgery, chemotherapy and radiotherapy

d. The possibility of surgery, chemotherapy and radiotherapy

Nursing students are studying the cardiovascular system. One student asks the instructor what happens when the amount of fluid in the pericardial sac increases. What should the instructor tell the students? a. Raises the pressure inside the pericardial sac, compressing the heart. b. Raises the pressure inside the pericardial sac, causing fluid to leak through. c. Raises the pressure inside the pericardial sac, compressing the lungs. d. Raises the pressure inside the pericardial sac, causing it to rupture.

a. Raises the pressure inside the pericardial sac, compressing the heart.

A 15 year old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? a. Hypersensitivity to an immunization b. Psychosocial stress c. Streptococcal infection d. Menarche

c. Streptococcal infection

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? a. Respiratory failure b. Lung cancer c. Hemothorax d. Pneumothorax

d. Pneumothorax

a. Blood to flow back from the aorta to the left ventricle

A nurse is caring for a client who has been admitted to the hospital with diverticulitis. What would be appropriate nursing diagnoses for this client? Select all that apply. a. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea b. Bowel Incontinence Related to Increased Intestinal Peristalsis c. Activity Intolerance Related to Generalized Weakness d. Impaired Urinary Elimination Related to GI Pressure on the Bladder e. Acute Pain Related to Increased Peristalsis and GI Inflammation

a. Deficient Fluid Volume Related to Anorexia, Nausea, and Diarrhea c. Activity Intolerance Related to Generalized Weakness e. Acute Pain Related to Increased Peristalsis and GI Inflammation

The nurse is caring for a client with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a client with an indwelling catheter? a. Empty the drainage bag at least every 8 hours. b. Vigorously clean the meatus area daily. c. Irrigate the catheter every 8 hours with normal saline. d. Apply powder to the perineal area twice daily.

a. Empty the drainage bag at least every 8 hours.

A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? a. Excess fluid volume related to generalized edema b. Hyperthermia related to the inflammatory process c. Constipation related to immobility d. Risk for injury related to altered thought processes

a. Excess fluid volume related to generalized edema

The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication? a. Face the client and establish eye contact. b. Help the client complete their sentences as needed c. Speak in a loud and deliberate voice to the client d. Have the client speak to loved ones on the phone daily

a. Face the client and establish eye contact.

The nurse is performing an initial assessment on a client with suspected Bell's palsy. Which of the following findings would the nurse be most focused on related to this medical diagnosis? a. Facial distortion and pain b. Ptosis and diplopia c. Hyporeflexia and weakness of the lower extremities d. Fatigue and depression

a. Facial distortion and pain

A client with pancreatic cancer has been scheduled for a pancreaticoduodenectomy (Whipple procedure). During health education, the client should be informed that this procedure will involve the removal of which of the following? Select all that apply. a. Gallbladder b. Part of the stomach c. Duodenum d. Part of the common bile duct e. Part of the rectum

a. Gallbladder b. Part of the stomach c. Duodenum d. Part of the common bile duct

The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones? a. Humerus b. Radial head c. Femur d. Clavicle

a. Humerus

a. Incentive spirometry

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti- inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? a. It protects the stomach's lining b. It reduces the stomach's volume of hydrochloric acid c. It increases the speed of gastric emptying d. It increases lower esophageal sphincter pressure

a. It protects the stomach's lining

The nurse is providing care for a client with high cholesterol and triglyceride values. In teaching the client about therapeutic lifestyle changes such as diet and exercise, the nurse realizes that the desired goal for cholesterol levels is which of the following? a. Low LDL values and high HDL values b. Elevated blood lipids, fasting glucose less than 100 c. High HDL values and high triglyceride values d. Absence of detectable total cholesterol levels

a. Low LDL values and high HDL values

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? a. Measure the client's abdominal girth daily. b. Monitor the client for signs of dysphagia. c. Encourage activity as tolerated. d. Limit the use of opioid analgesics.

a. Measure the client's abdominal girth daily.

The nurse is educating a client with myasthenia gravis about medications. The nurse is sure to include which of the following? a. Medications must be taken on time. b. Medications can be taken whenever convenient. c. Medications are best taken while the client is in a reclining position. d. There is no conflict with the disorder and dental work.

a. Medications must be taken on time.

The nurse is caring for a client who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the client? a. Notify the health care provider about cloudy or foul-smelling urine. b. Report the presence of fine, sand-like particles through the nephrostomy tube. c. Limit oral fluid intake for 1 to 2 days. d. Report any pink-tinged urine within 24 hours after the procedure.

a. Notify the health care provider about cloudy or foul-smelling urine.

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? a. Notify the health care provider. b. Provide the client with ice water to slow any GI bleeding. c. Prepare for the insertion of an NG tube. d. Place the client in a prone position.

a. Notify the health care provider.

The nurse is completing a family history for a client who is admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The nurse should include questions that address which of the following health problems? Select all that apply. a. Obesity b. Hypervitaminosis c. Alcoholism d. Psoriasis e. Allergies

a. Obesity c. Alcoholism e. Allergies

A cardiac surgery client's new onset of signs and symptoms is suggestive of cardiac tamponade. As a member of the interdisciplinary team, what is the nurse's most appropriate action? a. Prepare to assist with pericardiocentesis. b. Reposition the client into a prone position c. Administer a dose of metoprolol as prescribed. d. Administer a bolus of normal saline as prescribed.

a. Prepare to assist with pericardiocentesis.

What intervention by the nurse is most effective for reducing hospital-acquired infections? a. Proper hand-washing techniques b. Administration of prophylactic antibiotics c. Control of upper respiratory tract infections d. Aseptic wound care

a. Proper hand-washing techniques

The nurse notes that a patient has developed a cough productive for pink frothy sputum, is short of breath, has cyanotic hands, and has noisy, moist-sounding, rapid breathing. These symptoms indicate: a. Pulmonary edema b. Right ventricular hypertrophy c. Pericarditis d. Cor Pulmonale

a. Pulmonary edema

A nurse is assessing a client who is receiving a blood transfusion. Which of the following findings is a manifestation of a hemolytic transfusion reaction? a. Report of low-back pain b. Pallor c. Hypertension d. Report of metallic taste

a. Report of low-back pain

The nurse is performing an initial assessment on a client admitted to rule out Guillain-Barre syndrome. On which of the following areas will the nurse focus most heavily? a. Respiratory b. Urinary c. Gastrointestinal d. Skin

a. Respiratory

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? a. Rigid abdomen b. Frequent bowel movements c. Increased urinary output d. Hyperactive bowel sounds

a. Rigid abdomen

A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take to identify the client? (Select all that apply.) a. Scan the barcode on the client's identification band. b. Ask the client to verbalize if blood type is Rh-negative or positive c. Confirm that the room number matches the medical record. d. Verify the provider's prescription with another RN. e. Compare client identification number to the blood component tag number.

a. Scan the barcode on the client's identification band. d. Verify the provider's prescription with another RN.

A patient comes to the clinic with the complaint, "I think I have an ulcer." What is a characteristic associated with peptic ulcer pain that the nurse should inquire about? Select all that apply. a. Severe gnawing pain that increases in severity as the day progresses b. Pain that radiates to the shoulder or jaw c. Feeling of emptiness that precedes meals from 1 to 3 hours d. Vomiting without associated nausea e. Burning sensation localized in the back or mid-epigastrium

a. Severe gnawing pain that increases in severity as the day progresses c. Feeling of emptiness that precedes meals from 1 to 3 hours e. Burning sensation localized in the back or mid-epigastrium

The nurse is educating the patient about administering nitroglycerin prior to discharge from the hospital. What information should the nurse include in the instructions? a. Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system. b. Take a nitroglycerin and if the pain is not relieved, drive to the nearest emergency department. c. Take 2 nitroglycerins and if the pain is not relieved, go to the emergency department. d. Take 2 nitroglycerins every 10 minutes until a total of 6 pills are taken. If pain is not relieved, activate the emergency medical system.

a. Take a nitroglycerin and repeat every 5 minutes if the pain is not relieved until a total of 3 are taken. If pain is not relieved, activate the emergency medical system.

The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? a. Vitamin B12 b. Vitamin A c. Vitamin C d. Vitamin E

a. Vitamin B12

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a: a. contusion. b. dislocation. c. strain. d. sprain.

a. contusion.

A nurse is providing care for a client who is postoperative day 2 following gastric surgery. The nurse's assessment should be planned in light of the possibility of what potential complications? Select all that apply. a. Malignant hyperthermia b. Atelectasis c. Hemorrhage d. Chronic gastritis e. Pneumonia

b. Atelectasis c. Hemorrhage e. Pneumonia

The nurse has implemented a bladder retraining program for an older adult client. The nurse places the client on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the client typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding? a. Perform a straight catheterization on this client. b. Avoid further interventions at this time, as this is an acceptable finding. c. Press on the client's bladder in an attempt to encourage complete emptying. d. Place an indwelling urinary catheter.

b. Avoid further interventions at this time, as this is an acceptable finding.

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client? a. Take opioid analgesics. b. Avoid heavy lifting. c. Take an herbal form of feverfew. d. Include peanut butter, bread, or tart foods in the diet.

b. Avoid heavy lifting.

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? a. Performing 15 minutes of physical activity at least three times per week b. Avoid taking aspirin to treat pain or fever c. Taking multivitamins as prescribed and eating organic foods whenever possible d. Maintaining a healthy body weight

b. Avoid taking aspirin to treat pain or fever

The nurse is assessing a client with a bleeding gastric ulcer. When examining the client's stool, which of the following characteristics would the nurse be most likely to find? a. Clay like quality b. Black and tarry appearance c. Bright red blood in stool d. Green color and texture

b. Black and tarry appearance

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment? a. Chest x-ray b. Brain CT scan or MRI c. Prothrombin level d. Lumbar puncture

b. Brain CT scan or MRI

A client is admitted to the ICU after a motor vehicle accident. On the second day of the hospital admission, the client develops acute kidney injury. The client is hemodynamically unstable, but renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia. Which of the following therapies will the client's hemodynamic status best tolerate? a. Hemodialysis b. Continuous venovenous hemodialysis (CVVHD) c. Peritoneal dialysis d. Plasmapheresis

b. Continuous venovenous hemodialysis (CVVHD)

A 52-year-old client is scheduled to undergo ileal conduit surgery. When planning this client's discharge education, what is the most plausible nursing diagnosis that the nurse should address? a. Impaired mobility related to limitations posed by the ileal conduit b. Deficient knowledge related to care of the ileal conduit c. Risk for autonomic dysreflexia related to disruption of the sacral plexus d. Risk for deficient fluid volume related to urinary diversion

b. Deficient knowledge related to care of the ileal conduit

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? a. Recurrent constipation coupled with weight loss b. Foul-smelling diarrhea that contains fat c. Bloody bowel movements accompanied by fecal incontinence d. Fever accompanied by a rigid, tender abdomen

b. Foul-smelling diarrhea that contains fat

A client has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study? a. Administer the radioactive agent intravenously the evening before the study. b. Have the client refrain from food and fluids after midnight. c. Administer the contrast agent orally 10 to 12 hours before the study. d. Encourage the intake of 64 ounces of water 8 hours before the study.

b. Have the client refrain from food and fluids after midnight.

b. Increase oral fluids unless contraindicated

b. Ineffective cardiopulmonary tissue perfusion secondary to CAD, as evidenced by chest pain

The nurse is working with a client who is newly diagnosed with MS. What basic information should the nurse provide to the client? a. MS usually occurs more frequently in men. b. MS is a progressive demyelinating disease of the nervous system. c. MS typically has an acute onset. d. MS is sometimes caused by a bacterial infection.

b. MS is a progressive demyelinating disease of the nervous system.

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? a. Provide the client with educational materials that match the client's learning style. b. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse. c. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. d. Encourage the client to write down these concerns and questions to bring forward to the surgeon.

b. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? a. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. b. Standard precautions should be used with all patients to reduce the risk of transmission of blood-borne pathogens. c. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time. d. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus.

b. Standard precautions should be used with all patients to reduce the risk of transmission of blood-borne pathogens.

A new nursing graduate is working at the hospital in the medical-surgical unit. The preceptor observes the nurse emptying a patient's wound drain without gloves on. What important information should the preceptor share with the new graduate about standard precautions? a. It is only necessary to use gloves when you are emptying reservoirs that have body fluids in them. b. Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens. c. If you are careful and do not expose yourself to blood or body fluids, it is not necessary to use gloves all of the time. d. Standard precautions should only be used with patients who are HIV positive to reduce the risk of transmission of the HIV virus.

b. Standard precautions should be used with all patients to reduce the risk of transmission of bloodborne pathogens.

The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? a. Using a stethoscope for auscultating the fistula is contraindicated. b. Taking a BP reading on the affected arm can damage the fistula. c. The client should not feel pain during initiation of dialysis. d. The client feels best immediately after the dialysis treatment.

b. Taking a BP reading on the affected arm can damage the fistula.

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment? a. Potassium 5.2 mEq/L b. Urine specific gravity 1.020 c. Hct 62% d. Sodium 165 mEq/L

b. Urine specific gravity 1.020

A nurse is preparing to discharge an emergency department client who has been fitted with a sling to support her arm after a clavicle fracture. What should the nurse instruct the client to do? a. Elevate the arm above the shoulder three to four times daily b. Use the arm for light activities within the range of motion c. Engage in active range of motion using the affected arm d. Avoid moving the elbow, wrist, and fingers until bone remodeling is complete

b. Use the arm for light activities within the range of motion

A nurse is caring for a female client whose urinary retention has not responded to conservative treatment. When educating this client about self-catheterization, the nurse should encourage what practice? a. Assuming a supine position for self-catheterization b. Using clean technique at home to catheterize c. Self-catheterizing every 2 hours at home d. Inserting the catheter 1 to 2 inches (2.5 to 5 cm) into the urethra

b. Using clean technique at home to catheterize

A client with end-stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes? a. Filgrastim b. Pegfilgrastim c. Epoetin alfa d. Interleukin 2

c. Epoetin alfa

The client with a brain tumor may be at increased risk for aspiration. What does the nurse determine is the most important nursing intervention? a. Monitoring vital signs b. Assistance with self-care c. Evaluation of gag reflex and ability to swallow d. Frequent reorientation

c. Evaluation of gag reflex and ability to swallow

A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? a. Avascular necrosis of bone b. Complex regional pain syndrome c. Fat embolism syndrome d. Compartment syndrome

c. Fat embolism syndrome

Radiographs of a boy's upper arm show that the humerus appears to be fractured on one side and slightly bent on the other. This diagnostic result suggests what type of fracture? a. Compression b. Impacted c. Greenstick d. Compound

c. Greenstick

The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? a. Hypotension unresolved by fluid administration b. Precipitous decrease in serum creatinine levels c. Hematuria d. Glucosuria

c. Hematuria

A nurse administers furosemide to treat a client with heart failure. Which adverse effect must the nurse watch for most carefully? a. Increase in blood pressure b. Increase in blood volume c. Low serum potassium level d. High serum sodium level

c. Low serum potassium level

A client is being treated on the acute medical unit for acute pancreatitis. The nurse has identified a diagnosis of Ineffective Breathing Pattern Related to Pain. What intervention should the nurse perform in order to best address this diagnosis? a. Position the client supine to facilitate diaphragm movement. b. Administer corticosteroids by nebulizer as prescribed. c. Maintain the client in a semi-Fowler position whenever possible. d. Perform oral suctioning as needed to remove secretions.

c. Maintain the client in a semi-Fowler position whenever possible.

A home health nurse is caring for a client discharged home after pancreatic surgery. The nurse documents the nursing diagnosis Risk for Imbalanced Nutrition: Less than Body Requirements on the care plan based on the potential complications that may occur after surgery. What are the most likely complications for the client who has had pancreatic surgery? a. Hemorrhage and hypercalcemia b. Weight loss and hypoglycemia c. Malabsorption and hyperglycemia d. Proteinuria and hyperkalemia

c. Malabsorption and hyperglycemia

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? a. Administering zolpidem tartrate (Ambien) b. Placing the client in Trendelenburg's position c. Monitoring the patency of an indwelling urinary catheter d. Assessing laboratory test results as ordered

c. Monitoring the patency of an indwelling urinary catheter

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? a. Maintain prone positioning at all times b. Administer analgesics as required c. Place a pillow between the client's legs when turning d. Encourage internal and external rotation of the affected leg

c. Place a pillow between the client's legs when turning

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? a. Helping the client weigh treatment options b. Teaching the client about the etiology of gastritis c. Providing the client with physical and emotional support d. Teaching the client about necessary nutritional modification

c. Providing the client with physical and emotional support

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has had not ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? a. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. b. Encourage the client to mobilize in order to enhance motility. c. Report signs and symptoms of obstruction to the health care provider. d. Contact the physician and obtain a swab of the stoma for culture.

c. Report signs and symptoms of obstruction to the health care provider.

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? a. Notify the laboratory. b. Obtain a urine specimen. c. Stop the infusion of blood. d. Inform the provider.

c. Stop the infusion of blood.

The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? a. Provide medication teaching related to pseudoephedrine sulfate. b. Prepare the client for an anterior vaginal repair procedure. c. Teach the client to perform pelvic floor muscle exercises. d. Provide information on periurethral bulking.

c. Teach the client to perform pelvic floor muscle exercises.

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem? a. The client should be assured that these are a normal, age-related physiologic change. b. Adherence to a high-fiber diet will help the polyps resolve. c. The client's polyps constitute a risk factor for cancer. d. The presence of polyps is associated with an increased risk of bowel obstruction.

c. The client's polyps constitute a risk factor for cancer.

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education? Select all that apply. a. The client is likely to require long-term total parenteral nutrition (TPN) b. Part of the client's stomach and colon will be removed c. The procedure carries a risk for dumping syndrome d. The client's vagus nerve may be altered e. The client can resume a usual diet in 3 to 5 weeks

c. The procedure carries a risk for dumping syndrome d. The client's vagus nerve may be altered

Family members bring a patient to the emergency department with pale cool skin, midsternal chest pain unrelieved with rest, and a history of CAD. What is the nurse aware of? a. The symptoms indicate angina and should be treated as such. b. The symptoms indicate anxiety and should be treated as such. c. The symptoms indicate an acute coronary episode and should be treated as such. d. Treatment should be held until an ECG is completed.

c. The symptoms indicate an acute coronary episode and should be treated as such.

A female client's most recent urinalysis results are suggestive of bacteriuria. When assessing this client, the nurse's data analysis should be informed by what principle? a. A diagnosis of bacteriuria requires three consecutive positive results. b. Most UTIs in female clients are caused by viruses and do not cause obvious symptoms. c. Urine samples are frequently contaminated by bacteria normally present in the urethral area. d. Urine contains varying levels of healthy bacterial flora.

c. Urine samples are frequently contaminated by bacteria normally present in the urethral area.

The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse? a. Administer the medications and then notify the physician. b. Administer atropine to speed the heart rate and then administer the digoxin. c. Withhold the medication and notify the physician of the heart rate. d. Administer the medication and inform the charge nurse about the rate.

c. Withhold the medication and notify the physician of the heart rate.

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by: a. avoiding the use of pillows to position the client. b. making a referral to physical therapy. c. cleaning and drying regularly within the client's skin folds. d. ensuring the client receives a high-calorie, high-protein diet.

c. cleaning and drying regularly within the client's skin folds.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a. muffled or distant heart sounds. b. tracheal deviation to the unaffected side. c. diminished or absent breath sounds on the affected side. d. paradoxical chest wall movement with respirations

c. diminished or absent breath sounds on the affected side.

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis? a. Disturbed sleep pattern related to external stimuli b. Imbalanced nutrition: Less than body requirements related to poor intake c. Impaired skin integrity related to pruritus d. Acute pain related to sickle cell crisis

d. Acute pain related to sickle cell crisis

A community health nurse is preparing for an initial home visit to a client discharged following a total gastrectomy for treatment of gastric cancer. What would the nurse anticipate that the plan of care is most likely to include? a. Gastrointestinal decompression by nasogastric tube b. Periodic assessment for esophageal distension c. Enteral feeding via gastrostomy tube (G tube) d. Administration of injections of vitamin B12

d. Administration of injections of vitamin B12

An 84-year-old woman diagnosed with cancer is admitted to the oncology unit for surgical treatment. The client has been on chemotherapeutic agents to decrease the tumor size prior to the planned surgery. The nurse caring for the client is aware that what precipitating factors in this client may contribute to AKI? Select all that apply. a. NPO status b. Anxiety c. Low BMI d. Age-related physiologic changes e. Chronic systemic disease

d. Age-related physiologic changes e. Chronic systemic disease

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? a. Beta adrenergic blockers to reduce bowel motility b. Antiemetics on a PRN basis c. Vitamin B12 injections to prevent pernicious anemia d. Antidiarrheal medications 30 minutes before a meal

d. Antidiarrheal medications 30 minutes before a meal

A client diagnosed with Bell's palsy is being cared for on an outpatient basis. During health education, the nurse should promote which of the following actions? a. Avoiding the use of analgesics whenever possible b. Avoiding brushing the teeth c. Chewing on the affected side to prevent unilateral neglect d. Applying a protective eye shield at night

d. Applying a protective eye shield at night

A young client is being treated for a femoral fracture suffered in a snowboarding accident. The nurse's most recent assessment reveals that the client is uncharacteristically confused. What diagnostic test should be performed on this client? a. Electrolyte assessment b. Electrocardiogram c. Abdominal ultrasound d. Arterial blood gases

d. Arterial blood gases

The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. a. Assess the client's orientation and judgment. b. Percuss for pain in the right lower abdominal quadrant. c. Auscultate the client's apical heart rate for dysrhythmias. d. Assess for the presence of peripheral edema. e. Assess the client's BP.

d. Assess for the presence of peripheral edema. e. Assess the client's BP.

Which nursing intervention is the priority for a client in myasthenic crisis? a. Administering intravenous immunoglobin (IVIG) per orders b. Preparing for plasmapheresis c. Ensuring adequate nutritional support d. Assessing respiratory effort

d. Assessing respiratory effort

Which of the following diagnostic studies provides visualization of cerebral blood vessels? a. Cytologic studies of cerebrospinal fluid (CSF) b. Positron emission tomography (PET) c. Computer-assisted stereotactic biopsy d. Cerebral angiography

d. Cerebral angiography

d. Dilute liquid preparations of iron with juice and drink with a straw

A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential adverse effect? a. Abdominal pain b. Bowel incontinence c. Heat intolerance d. Drug-drug interactions

d. Drug-drug interactions

The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client? a. Sit upright when eating and for 30 minutes afterward. b. Choose foods that are high in simple carbohydrates. c. Drink a minimum of 12 ounces of fluid with each meal. d. Eat several small meals daily spaced at equal intervals.

d. Eat several small meals daily spaced at equal intervals.

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? a. Encouraging the client to sit in a chair for at least 8 hours a day b. Minimizing movement of the flexor muscles of the hip c. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation d. Encouraging the client to turn from side to side and to assume a prone position

d. Encouraging the client to turn from side to side and to assume a prone position

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? a. Chronic referred pain in the lower abdomen b. Gastric hyperacidity related to excessive gastrin secretion c. Uncontrolled proliferation of H. pylori d. Esophageal or pyloric obstruction related to scarring

d. Esophageal or pyloric obstruction related to scarring

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? a. Avoid range of motion exercises for the client because of spasms. b. Watch closely for signs of urinary tract infection. c. Keep accurate intake and output. d. Maintain a diet for the client that is high in protein, vitamins, and calories.

d. Maintain a diet for the client that is high in protein, vitamins, and calories.

d. Pneumothorax

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? a. Chronic Pain Related to Appendicitis b. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake c. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake d. Risk for Infection Related to Possible Rupture of Appendix

d. Risk for Infection Related to Possible Rupture of Appendix

A nurse is planning discharge for a client who experienced right-sided weakness caused by a stroke. During his hospitalization, the client has been receiving physical therapy, occupational therapy, and speech therapy daily. The family voices concern about rehabilitation after discharge. How should the nurse intervene? a. Inform the case manager of the family's concern and provide information about the client's current clinical status so appropriate resources can be provided after discharge b. The nurse should do nothing because she is responsible only for inpatient care. c. Contact the appropriate agencies so that they can provide care after discharge. d. Suggest that the family members speak with the physician about their concerns.

d. Suggest that the family members speak with the physician about their concerns.

A client has recently received a diagnosis of gastric cancer; the nurse is aware of the importance of assessing the client's level of anxiety. Which of the following actions is most likely to accomplish this? a. The nurse closely observes the client's body language. b. The nurse provides detailed and accurate information about the disease. c. The nurse gauges the client's response to hypothetical outcomes. d. The client is encouraged to express fears openly.

Adult Health 2 Final

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