Adult Health 2 Textbook Mastery Questions

(Chapter 1) The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? A. Situation B. Background C. Assessment D. Recommendation

A

(Chapter 14) How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A

(Chapter 24) While responding to questions in a health history, the client reports that he usually expectorates about 2 ounces of thin, clear, colorless sputum daily, usually on getting up in the morning. What is the nurse's best action related to this finding? A. Document the report as the only action. B. Arrange for the client to have tuberculosis testing. C. Collect a sputum specimen for laboratory analysis. D. Alert the primary health care provider about this funding.

A

(Chapter 25) Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself." C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen." D. "If my shortness of breath becomes worse or if I have chest pain I will contact my primary health care provider immediately."

A

(Chapter 27) Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.

A

(Chapter 3) Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? A. Diabetes mellitus B. Hypotension C. Osteoarthritis D. Peptic ulcer disease

A

(Chapter 30) The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."

A

(Chapter 32) The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A

(Chapter 45) The nurse is teaching a client who has osteopenia about alendronate. Which statement by the client indicates a need for further teaching? A. "I will take this drug at night to prevent nausea." B. "I need a dental checkup before taking the drug." C. "I need to sit up for 30 minutes after taking the drug." D. "I will drink plenty of water after I take the drug."

A

(Chapter 46) The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? A. Joint pain B. ADL dependence C. Risk for falls D. Muscle stiffness

A

(Chapter 55) The nurse is caring for four clients who have been recommended to consider bariatric surgery. Which assessment data require immediate nursing intervention? A. BMI of 23 with gastrointestinal reflux B. BMI of 36 with hypertension C. BMI of 40 with type II diabetes D. BMI of 43 with sleep apnea

A

(Chapter 58) Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism? A. Measuring heart rate and rhythm B. Checking core body temperature C. Asking about previous allergic drug reactions D. Listening to bowel sounds in all four abdominal quadrants

A

(Chapter 60) Which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function? A. An 80-year-old man who has benign prostatic hyperplasia B. A 62-year-old woman with a known allergy to contrast media C. A 48-year-old woman with established urinary incontinence D. A 45-year-old man receiving oral and intravenous fluid therapy

A

(Chapter 45) The nurse is caring for a client who was admitted with a draining diabetic ulcer on the lower extremity. What personal protective equipment will the nurse teach the staff to use? Select all that apply. A. Gown B. Gloves C. Mask D. Foot covers E. Goggles

A B

(Chapter 39) A client experiences a seizure that is observed by the nurse. What will the nurse document in the client's medical record? Select all that apply. A. Time that seizure began and ended B. Whether the seizure was preceded by an aura C. What the client does after the seizure D. How long it takes for the client to return to pre seizure status E. The drugs that are administered during the seizure

A B C D

(Chapter 32) The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your healthcare provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A B C D E

(Chapter 39) The nurse is admitting a client with a probable diagnosis of meningitis. What signs and symptoms might the nurse expect when assessing this client? Select all that apply. A. Photophobia B. Nystagmus C. Decreased level of consciousness D. Decreased movement, such as hemiparesis E. Disorientation to person, place, and time

A B C D E

(Chapter 4) The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A B C D E

(Chapter 44) The nurse is preparing to teach a client about how to promote musculoskeletal health. Which statements will the nurse include in the teaching plan? Select all that apply. A. "If you smoke, you need a smoking cessation plan." B. "Avoid drinking excessive alcohol." C. "Be sure to take in enough calcium and vitamin D." D. "Avoid high-risk activities that could cause an accident." E. "Include weight-bearing exercise like walking on a regular basis."

A B C D E

(Chapter 54) The nurse is planning care for a client who had a laparoscopic Whipple surgery. For which complications will the nurse assess? Select all that apply. A. Bleeding B. Wound infection C. Intestinal obstruction D. Diabetes mellitus E. Abdominal abscess

A B C D E

(Chapter 49) A client who had the Stretta procedure to treat severe GERD is being discharged. Which client statement requires further nursing teaching? Select all that apply. A. "Dysphagia after this procedure is normal." B. "It's important to stop my proton pump inhibitor." C. "I will not take NSAIDs and aspirin for at least 10 days." D. "I might cough up some blood following this procedure." E. "Today I will drink clear liquids and tomorrow I can eat soft food."

A B D

(Chapter 49) A nurse is caring for a 34-year-old client newly diagnosed with GERD. Which lifestyle change will the nurse suggest? Select all that apply. A. Lose weight if needed. B. Do not eat before bed. C. Elevate the foot of your bed by 6 to 12 inches. D. Avoid pants with a tight waistband or belt. E. Eat fatty foods to minimize ongoing hunger.

A B D

(Chapter 48) Which teaching will the nurse include when educating a client who is scheduled to have an esophagogastroduodenoscopy (EGD)? Select all that apply. A. "Anesthesia will be used for sedation." B. "The procedure takes about 20 to 30 minutes to complete." C. "Informed consent will be needed prior to the procedure." D. "A separate test will be required to obtain any needed biopsies." E. "You will need to refrain from eating for at least 6 to 8 hours before the EGD."

A B D E

(Chapter 50) What health teaching will the nurse include to promote gastric health for an adult client? Select all that apply. A. "Stop smoking or using tobacco of any form." B. "Do not drink excessive amounts of alcohol." C. "Consume high-fat foods and decrease carbohydrates." D. "Avoid excessive amounts of pickled or smoked food." E. "Avoid taking large amounts of NSAIDs."

A B D E

(Chapter 3) The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply. A. "Be sure to include plenty of fresh fruits and vegetables in your diet each day." B. "Eat lots of high fiber foods, including whole grains each day." C. "Be sure to take a laxative every day to clean out your bowels and prevent toxins." D. "Exercise several times a week to keep our bowels working for regular elimination." E. "Drink at least 3 caffeinated beverages every day to keep your bowels stimulated." F. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom."

A B D F

(Chapter 27) The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. Ambrisentan B. Bosentan C. Epoprostenol D. Iloprost E. Macitentan F. Riociguat G. Selexipag H. Sildenafil I. Tadalafil J. Treprostinil

A B E F

(Chapter 53) A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."

A C

(Chapter 59) Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lipogenesis F. Lipolysis

A C

(Chapter 9) The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left-arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A C D

(Chapter 37) Which new symptoms in a client who is being managed for sickle cell crisis does the nurse report immediately to prevent harm? Select all that apply. A. Decreased handgrip strength on one side B. Diffuse abdominal pain C. Fever of 102.2°F (39°C) D. Increased urine output E. Shortness of breath F. Sore throat

A C E

(Chapter 55) What discharge teaching will the nurse provide to a client who had gastric bypass surgery? Select all that apply. A. Be certain to stay hydrated by drinking water. B. Solid food can be introduced back into the diet in a week. C. Report any back, shoulder, or abdominal pain to the surgeon. D. You are likely to have little urine output for the first few weeks. E. Each of your meals should initially contain about 5 tablespoons of food.

A C E

(Chapter 29) A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply. A. Decreased SpO 2 B. Elevated temperature C. Crackles auscultated over the trachea D. Crackles auscultated in the lung periphery E. High-pressure ventilator alarm sounds F. Presence of fluid within the endotracheal tube G. Presence of fluid within the ventilator tubing

A C E F

(Chapter 30) The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A C E F

(Chapter 13) Which electrolytes are most detrimentally affected by low magnesium levels? Select all that apply. A. Calcium B. Chloride C. Hydrogen D. Potassium E. Sodium F. Sulfate

A D

(Chapter 1) The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? Select all that apply. A. Quality Improvement B. Ethics C. Health Care Disparities D. Systems Thinking E. Teamwork and Collaboration

A D E

(Chapter 20) The nurse is caring for a client with a sealed radiation implant for the treatment of cancer. Which nursing intervention is appropriate? Select all that apply. A. Place a caution sign on the door of the client's room. B. Wear a dosimeter badge for protection when providing care. C. Allow the client's spouse to stay with the client at least 6 feet away for 4 hours. D. Do not allow children to visit the client for any length of time. E. Keep the door to the client's room closed.

A D E

(Chapter 51) The nurse is caring for a client with a complete large bowel obstruction. What assessment findings would the nurse expect? Select all that apply. A. Obstipation B. Dehydration C. Metabolic alkalosis D. Abdominal distention E. Abdominal pain F. Profuse vomiting

A D E

(Chapter 62) When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? Select all that apply. A. Urine output of 15 mL for the first hour and then diminishing B. Tenderness at the surgical site C. Pink-tinged urine draining from the nephrostomy D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 mm Hg that persists despite administration of pain medication

A D E F

(Chapter 37) A client who is 5 weeks post transplant after an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data support the nurse's suspicion of possible sinusoidal obstructive syndrome (SOS)? Select all that apply. A. Jaundiced skin and sclera B. Platelet count is 28,000/mm3 C. Skin peeling on the hands and feet D. Mixed chimerism by laboratory finding E. Body temperature slightly below normal F. Pain in the upper right abdominal quadrant

A F

(Chapter 13) A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? A. 12 mEq (mmol) B. 15 mEq (mmol) C. 18 mEq (mmol) D. 20 mEq (mmol)

B

(Chapter 13) Which assessment data is most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? A. Asking about the use of sugar substitutes B. Determining what drugs are taken daily C. Measuring the client's response to Chvostek testing D. Asking about a history of kidney disease

B

(Chapter 20) A client with chemotherapy-induced neutropenia is prescribed filgrastim. The client states, "The bones in my legs are aching so bad." What is the appropriate nursing response? A. "The pain in your legs is likely from the cancer." B. "Bone pain is a side effect of filgrastim that improves with time." C. "Increasing activity will help with the bone pain." D. "Have you had any fever or nausea?"

B

(Chapter 20) The nurse is teaching a client who has been prescribed an oral chemotherapy agent. What teaching will the nurse include? A. "Oral chemotherapy drugs are not as toxic as IV chemotherapy." B. "Do not crush, split, break, or chew the oral chemotherapy drug." C. "You may dispose of unused oral chemotherapy drugs in the trash." D. "Oral chemotherapy drugs are not absorbed through the skin."

B

(Chapter 27) A client newly diagnosed with stage I non small cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."

B

(Chapter 27) Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a healthcare professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.

B

(Chapter 28) A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

B

(Chapter 30) Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B

(Chapter 31) While suctioning a client with a tracheostomy, the client becomes diaphoretic and nauseous and the heart rate decreases to 37 beats/min. What is the priority nursing action? A. Continue to clear the airway. B. Stop suctioning the patient. C. Administer atropine. D. Call the health care provider immediately.

B

(Chapter 33) A client is admitted to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue mottling on feet and toes

B

(Chapter 33) The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to vomit blood. What action should the nurse be prepared to take? A. Administer vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube

B

(Chapter 36) Which statement regarding erythrocytes is true? A. Reticulocytes represent the final stage of mature erythrocytes. B. The lack of a nucleus in a mature erythrocyte increases its life span. C. Each erythrocyte can carry up to a maximum of four molecules of oxygen. D. The main trigger for erythrocyte production is the secretion of thrombopoietin.

B

(Chapter 38) The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider? A. Discomfort at the injection site B. Bleeding from the injection site C. Fatigue and weakness D. Mild headache

B

(Chapter 40) A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurological assessment.

B

(Chapter 47) The nurse is assigned to care for a postoperative client who had an open reduction, internal fixation of the right tibia yesterday. The client reports increased right leg pain, numbness, and tingling. What would be the nurse's first action at this time? A. Elevate the surgical leg on a pillow. B. Perform a neurovascular assessment. C. Administer pain medication. D. Call the primary health care provider.

B

(Chapter 49) A public health nurse is assessing community clients for oral health disorders. Which client is identified at highest risk? A. 23-year-old with three dental fillings B. 34-year-old with schizophrenia C. 55-year-old with stable angina D. 62-year-old with irritable bowel syndrome

B

(Chapter 50) The primary health care provider prescribes bismuth subsalicylate for a client as part of treating H. pylori infection. What health teaching will the nurse include for the client about this drug? A. "Do not crush this drug before taking." B. "The drug may cause your tongue and stool to turn black." C. "Take the drug at night only." D. "The drug may cause you to have diarrhea."

B

(Chapter 52) The nurse is caring for a client with peritonitis from a perforated appendix. Which abdominal assessment finding will the nurse most likely expect? A. Soft abdomen B. Board-like abdomen C. Slightly distended abdomen D. Absent bowel sounds

B

(Chapter 56) Which instruction/precaution does the nurse teach a client to prevent harm during a 24-hour urine specimen collection? A. Be sure to keep the specimen cool for the entire collection period. B. Avoid splashing urine in the container when a preservative is present. C. Add the preservative to the collection container before adding any urine. D. Discard the first specimen that marks the beginning of the 24-hour test period.

B

(Chapter 59) While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon. B. Immediately give the client 30 g of glucose orally. C. Start an IV and administer a small amount of a concentrated dextrose solution. D. Recheck the blood glucose level and call the Rapid Response Team.

B

(Chapter 60) Which client assessment data is essential for the nurse to report to the health care provider before a renal scan is performed? A. Pink-tinged urine B. Reports pregnancy C. Reports claustrophobia D. History of an aneurysm clip

B

(Chapter 62) When assessing a client with acute glomerulonephritis, which question will the nurse ask to determine if the client is following best practices to slow progression of kidney damage? A. "Do you avoid contact sports while you are taking cyclosporine?" B. "How are you evaluating the amount of daily fluid you drink?" C. "Have you contacted anyone from our dialysis support services?" D. "Have you increased your protein intake to promote healing of the damaged nephrons?"

B

(Chapter 62) Which question will the nurse ask the client who has a urinary tract infection to assess the risk for pyelonephritis? A. "What drugs do you take for asthma?" B. "How long have you had diabetes?" C. "How much fluid do you drink daily?" D. "Do you take your antihypertensive drugs at night or in the morning?"

B

(Chapter 67) A client with a history of BPH calls the telehealth nurse reporting the sudden onset of testicular pain after moving heavy furniture. What is the appropriate nursing response? A. "Taking ibuprofen may help alleviate the pain." B. "Please go to your closest emergency department right away." C. "This is a common reaction when performing labor; the pain will go away." D. "Your BPH is probably giving you difficulty because you were moving furniture."

B

(Chapter 67) The nurse is teaching a client with erectile dysfunction about taking sildenafil to achieve an erection. Which client statement demonstrates an understanding of this drug? A. "I can have sex up to 8 hours after taking the drug." B. "I might get a headache or stuffy nose when this drug is used." C. "Taking this with a drink or two of alcohol will enhance my performance." D. "If one pill doesn't work, it is acceptable for me to quickly take another pill."

B

(Chapter 8) A client receiving palliative care for a terminal cancer diagnosis asks the nurse, "Why is this happening to me?" What is the best nursing response? A. "I don't know. God knows when your time is up on this earth." B. "I'm sorry. I know that this is a very difficult time for you." C. "It's going to be OK; at least you aren't leaving any family behind." D. "We'll make sure that all of your needs are met, so don't worry."

B

(Chapter 8) The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse's best response? A. "We can start fluids to help ease the dehydration." B. "Intravenous fluids can increase discomfort for the client." C. "Intravenous fluids will likely prolong life." D. "Terminal dehydration can be managed better with pain medication."

B

(Chapter 9) The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B

(Chapter 59) Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B C

(Chapter 28) Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B C D E

(Chapter 47) The nurse is caring for a client who was admitted to the emergency department (ED) with a report of left knee pain and swelling after playing baseball with friends. Which nursing actions are appropriate when caring for the client? Select all that apply. A. Apply heat to the affected area. B. Assess the severity and quality of pain. C. Perform a neurovascular assessment. D. Elevate the affected extremity. E. Immobilize the injured knee joint.

B C D E

(Chapter 47) The nurse is caring for a client who was admitted to the emergency department (ED) with report of left knee pain and swelling after playing baseball with friends. Which nursing actions are appropriate when caring for the client? Select all that apply. A. Apply heat to the affected area. B. Assess the severity and quality of pain. C. Perform a neurovascular assessment. D. Elevate the affected extremity. E. Immobilize the injured knee joint.

B C D E

(Chapter 61) Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? Select all that apply. A. Insomnia B. Blurred vision C. Constipation D. Dry mouth E. Loss of sphincter control F. Increased sweating G. Worsening mental function

B C D G

(Chapter 46) The nurse is assessing a client who has late-stage rheumatoid arthritis. Which assessment findings would the nurse expect for this client? Select all that apply. A. Joint inflammation B. Severe weight loss C. Bony nodules D. Joint deformities E. SjÖgren syndrome

B D E

(Chapter 56) Which statement regarding trophic (tropic) hormones is true? A. All are categorized as catecholamines. B. Responses are independent of target tissue receptors. C. Their target tissues are always another endocrine gland. D. They represent the final hormone secreted in a complex negative feedback pathway.

C

(Chapter 26) In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Bloody and purulent sinus drainage D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities G. Gastroesophageal reflux H. A persistent blue tinge to the skin and mucous membranes around the mouth

B D F

(Chapter 60) Which lab finding is indicative of renal function alterations and not dehydration? Select all that apply. A. BUN 20 mL/dL B. Creatinine 2.3 mL/dL C. Hemoglobin 14 g/dL D. Cystatin-c 105 mg/mL E. BUN/creatinine ratio 10 F. Creatinine clearance 175 mL/min

B D F

(Chapter 58) Which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger of thyroid storm? Select all that apply. A. Increased salivation B. Client report of increased palmar sweating C. Decreased pulse pressure from 40 mm Hg to 36 mm Hg D. Diminished bowel sounds in all four abdominal quadrants E. An increase in temperature from 99.5°F (37.5°C) to 101.3°F (38.5°C) F. Serum sodium level increase from 136 mEq/L (mmol/L) to 139 mEq/L (mmol/L) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

B E G

(Chapter 14) The hand grasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

C

(Chapter 15) An older adult client receiving an infusion of 5% dextrose in 0.9% normal saline at 150 mL/hour has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? A. Notify the health care provider B. Place the client on oxygen C. Sit the client upright in bed D. Assess the client's lung sounds

C

(Chapter 24) Which respiratory side effect does the nurse teach the client who is now prescribed an angiotensin-converting enzyme (ACE) inhibitor to expect? A. Wheezing on exertion B. Increased secretions C. Persistent dry cough D. Orthopnea

C

(Chapter 25) Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion

C

(Chapter 26) A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? A. Nasal CPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation

C

(Chapter 27) A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. Paco2 from 45 mm Hg to 68 mm Hg D. Pao2 from 88 mm Hg to 86 mm Hg

C

(Chapter 28) A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

C

(Chapter 31) The primary health care provider prescribes warfarin for a client with atrial fibrillation. Which client statement indicates that additional education is needed? A. "I need to go to the clinic once a week to have my blood level checked." B. "If my stools turn black, I will be sure to call my primary health care provider." C. "I'm glad I don't need to change my diet. Salads are my favorite food." D. "I need to stop taking my herbal supplement."

C

(Chapter 32) The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C

(Chapter 36) Which precaution has the highest priority for prevention of harm when the nurse teaches the client about home care after a bone marrow aspiration? A. Clean the suture line daily with soap and water. B. Drink at least 4 L of fluid to ensure adequate hydration. C. Avoid taking any aspirin or aspirin-containing products. D. Stay in bed and get up only to use the bathroom for the next 2 days.

C

(Chapter 38) The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased level of consciousness D. Report of headache

C

(Chapter 47) The nurse teaches assistive personnel (AP) how to position a client who had an above-the-knee amputation (AKA) last week. Which statement by the AP indicates understanding of the teaching? A. "We should keep the surgical leg elevated on two pillows at all times." B. "We should keep the client in a sitting position as long as possible." C. "We should keep the surgical leg as flat on the bed as possible." D. "We should keep the client in a prone position most of the day."

C

(Chapter 51) A client has a new diagnosis of irritable bowel syndrome (IBS) with diarrhea. What health teaching by the nurse is appropriate for this client? A. "Take a stool softener every day to ease defecation." B. "Avoid high-fiber foods in your diet." C. "Avoid dairy products and caffeinated beverages." D. "Ask your primary health care provider for an antidepressant."

C

(Chapter 52) A client had a colectomy with creation of an ileo-anal pouch and temporary ileostomy yesterday morning. The nurse assesses the ostomy and its functioning. Which assessment finding will the nurse report to the primary health care provider? A. Client's report of abdominal pain of 3 on a 0 to 10 pain intensity scale B. Slight abdominal distention C. No drainage from the ileostomy D. Serosanguinous effluent from the drain

C

(Chapter 53) The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

C

(Chapter 58) The nurse reviewing the laboratory values of a client with hypoparathyroidism finds a serum calcium level of 7.9 mg/dL (1.76 mmol/L). Which parameter is most important for the nurse to assess to prevent harm? A. Temperature B. Heart rate and rhythm C. Deep tendon reflexes D. Level of consciousness

C

(Chapter 59) Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

C

(Chapter 48) Immediately following a colonoscopy, which client behavior will the nurse report to the health care provider? Select all that apply. A. Passing of flatus B. Blood pressure 128/80 mm Hg C. Abdominal guarding D. Change in mental status E. Report of mild abdominal cramping

C D

(Chapter 29) Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply. A. Assessing temperature every 4 hours B. Checking ventilator settings every 4 hours C. Getting the patient out of bed as soon as prescribed D. Keeping the head of the bed elevated to 30 degrees or above E. Maintaining the client in the prone position F. Providing adequate humidification G. Providing meticulous mouth care every 12 hours H. Suggesting that the pneumonia vaccine be prescribed

C D G

(Chapter 61) A 28-year-old female client states, "I don't know why I get cystitis every year. I don't drink much at work so that I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.

C E F G

(Chapter 13) Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? A. The client has calf muscle cramping. B. The serum chloride level is low. C. The urine-specific gravity is high. D. The hematocrit is 52%.

D

(Chapter 15) A client receiving gentamicin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? A. Contact the primary health care provider B. Document findings in the electronic health record C. Change the IV site to a new location D. Stop the infusion of the drug

D

(Chapter 25) Which assessment finding for a client receiving oxygen therapy with a non-rebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/min. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.

D

(Chapter 26) A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed antiemetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. D. Reposition the client to the side and suction the mouth with a large-bore catheter.

D

(Chapter 26) When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula. B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. C. Determine which assistive personnel (AP) provided this client's morning care today. D. Immediately provide complete oral care to this client.

D

(Chapter 29) An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse's priority action? A. Placing a nasotracheal tube B. Assessing for bilateral breath sounds C. Assessing oxygen saturation by pulse oximetry D. Applying oxygen with a bag-valve-mask device

D

(Chapter 31) A client in the telemetry unit is on a cardiac monitor. The monitor technician alerts the nurse that there are no ECG complexes, and the alarm is sounding. What is the first action by the nurse? A. Suspend the alarm. B. Call the emergency response team. C. Press the record button to get an ECG strip. D. Assess the client and check lead placement.

D

(Chapter 33) The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day." B. "I will restrict my intake of daily dietary lean protein." C. "I am only going to drink one cup of coffee to start my day." D. "I will drink a glass of low-fat milk with my breakfast."

D

(Chapter 36) Which response or health problem does the nurse expect to be present in a client who has a lifelong deficiency of antithrombin III? A. Chronic fatigue resulting from reduced production of normal hemoglobin B. Failure to produce and maintain normal circulating levels of platelets C. Prolonged bleeding and hematoma formation at sites of tissue injury D. Increased risk for clot formation and disruption of perfusion

D

(Chapter 37) Which intervention is a priority for the nurse to teach the client with polycythemia vera to prevent harm related to injury as a result of impaired platelet function? A. Wear gloves and socks outdoors in cool weather. B. Elevate your feet whenever you are seated. C. Drink at least 3 L of liquids per day. D. Use a soft-bristle toothbrush.

D

(Chapter 39) The nurse is caring for a client who is diagnosed with early-stage Alzheimer's disease who has periods of lucidity. What is the best principle for the nurse to use when communicating with this client? A. Use validation therapy to prevent upsetting the client. B. Encourage pet therapy to help allay the client's anxiety. C. Use aromatherapy and other integrative therapies to relax the client. D. Reorient the client frequently to foster reality.

D

(Chapter 4) The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D

(Chapter 40) The primary health care provider started a client with multiple sclerosis on mitoxantrone therapy. Which statement will the nurse include in teaching the client about this drug? A. "Report changes in urinary and bowel elimination immediately." B. "Follow up for annual lab testing to monitor for liver toxicity." C. "Rotate the sites for your self-administered injections." D. "Avoid crowded places such as malls and large public gatherings."

D

(Chapter 40) Which statement by the client indicates a need for further teaching by the nurse about preventing back injuries? A. "I need to lose weight because I'm too big." B. "I should not stand or sit for a long period of time." C. "It would be best if I could get ergonomic office furniture." D. "Exercise is not going to help my back very much."

D

(Chapter 44) Which serum laboratory finding is of concern for the nurse and should be reported to the primary health care provider? A. Calcium = 9 mg/dL (2.10 mmol/L) B. Phosphorus = 4.5 mg/dL (1.45 mmol/L) C. Lactate dehydrogenase = 150 units/L (150 IU/L) D. Alkaline phosphatase = 210 units/L (210 IU/L)

D

(Chapter 46) The nurse is caring for a client who had an anterior total hip arthroplasty yesterday. For which commonly occurring postoperative complication will the nurse monitor for this client? A. Pneumonia B. Paralytic ileus C. Wound dehiscence D. Venous thromboembolism

D

(Chapter 54) Which statement by the client who is prescribed to take pancreatic enzyme replacements indicates a need for further teaching by the nurse? A. "I need to take the enzymes at every meal and with snacks." B. "After taking the enzymes, I should drink a glass of water." C. "I should wipe my mouth in case any of the enzyme got on my lips." D. "I should chew each capsule carefully so that it works in my stomach."

D

(Chapter 59) When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

D

(Chapter 60) Which symptom(s) in a client during the first 12 hours after a kidney biopsy indicates to the nurse a possible complication from the procedure? A. The client experiences nausea and vomiting after drinking juice. B. The biopsy site is tender to light palpation. C. The abdomen is distended, and the client reports abdominal discomfort. D. The heart rate is 118, blood pressure is 108/50, and peripheral pulses are thready.

D

(Chapter 61) A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.

D

(Chapter 61) For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

D