Adult Health Final Exam Nclex -Review for weeks 4-7

b

After dinner time, during hourly rounding, a patient awakes to report they feel like "food is coming up" in the back of their throat and that there is a bitter taste in their mouth. What nursing intervention will you perform next? A. Perform deep suctioning B. Assist the patient into the Semi-Fowler's position C. Keep the patient NPO D. Instruct the patient to avoid milk products

3

Client is experiencing vaso-occlusive sickle cell crisis secondary to infection. which medical tx should the nurse anticipate 1. administer demerol 2. admit the client to a private room 3. Infuse D5W 4. Insert a 22-french foley

FYI

the best rational for using heparin early in DIC is to block the formation of thrombin? FYI the whole point of DIC is that your trying to block the formation of the thrombin -the conversion so it doesnt used up. if you have a depletion clotting factors in the body - you will just bleed.

a

the nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before the beginning transfusion, the nurse assesses which of the following items? A. Vital signs B. Skin Color C. Urine output D. Latest hematocrit level.

a (Red blood cells contain antigens and antibodies that must be matched between donor and recipient. The blood products in options 2-4 do not contain red cells. Thus, they require no cross-match.)

"Cris asks the nurse whether all donor blood products are cross-matched with the recipient to prevent a transfusion reaction. Which of the following always require cross-matching? a. packed red blood cells b. platelets c. plasma d. granulocytes"

c (he initial nursing action should be assessment of the neurovascular status of the injured leg. After assessment, the nurse may need to splint and elevate the leg, based on the assessment data. Information about tetanus immunizations should be done if there is an open wound.)

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to a.splint the lower leg. b.elevate the left leg. c.check the popliteal, dorsalis pedis, and posterior tibial pulses. d.obtain information about the patient's tetanus immunization status.

C

A patient is taking Bethanechol "Urecholine" for treatment of GERD. This is known as what type of drug? A. Proton-pump inhibitor B. Histamine receptor blocker C. Prokinetic D. Mucosal Healing Agent

fyi

FYI management of a client is sickle crisis: 1. Management of Pain2. Administration of oxygen3. Promoting Hydration to decrease blood viscocity

c ( Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.)

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to a.apply a heating pad to reduce muscle spasms. b.wear an elastic compression bandage continuously. c.use pillows to keep the arm elevated above the heart. d.gently exercise the joint to prevent muscle shortening.

3

The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 1) Bacteriemia. 2) Hypovolemia. 3) Fluid overload 4) Transfusion reaction

2 (The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole-wheat bread, egg yolks, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.)

The nurse has conducted dietary teaching with a client diagnosed with iron deficiency anemia. The nurse instructs the client that which food item is a good dietary source of iron? 1.Oranges 2.Apricots 3.Egg whites 4.Refined white bread

Baked foods such as chicken or fish are all right to eat

The nurse has provided dietary instructions to a client with a diagnosis of peptic ulcer disease. Which client statement indicates that education was effective? A. "Baked foods such as chicken or fish are all right to eat. "B. "Citrus fruits and raw vegetables need to be included in my daily diet." C. "I can drink beer as long as I consume only a moderate amount each day." D. "I can drink coffee or tea as long as I limit the amount to 2 cups daily."

d

The nurse obtains an admission history for a client with suspected peptic ulcer disease (PUD). Which client factor documented by the nurse would increase the risk for PUD? A. Recently retired from a job B. Significant other has a gastric ulcer C. Occasionally drinks 1 cup of coffee in the morning D. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for osteoarthritis

A (IBS is a functional gastrointestinal disorder that causes chronic or recurrent diarrhea, constipation, and/or abdominal pain and bloating. Dietary fiber and bulk help to produce bulky, soft stools and establish regular bowel elimination habits. Therefore, the client should consume a high-fiber diet.)

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? A. "I need to limit my intake of dietary fiber. "B. "I need to drink plenty, at least 8 to 10 cups daily. "C. "I need to eat regular meals and chew my food well. "D. "I will take the prescribed medications because they will regulate my bowel patterns."

c

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat? --A. Peaches --B. Cottage cheese --C. Popsicles --D. Lima beans

rest, compress, elevate ( do them in order)

a nurse is caring for a client with an ankle sprain which action should the nurse take?

" I will ice my leg today and tmrw"

an er nurse is preparing to provide discharge education to a client who has ankle sprain, which statement by the client indicates the education has been effective?

a (The fresh frozen plasma should be administered as rapidly as possibleand should be used within 2 hours of thawing. Fresh frozen plasma isinfused using any straight-line infusion set. Any existing IV should beinterrupted while the fresh frozen plasma is infused, unless a second IVline has been started for the transfusion.")

"The nurse receives a physician's order to transfuse fresh frozen plasmato a patient suffering from an acute blood loss. Which of the followingprocedures is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hand the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl."

2 (The administration of antipyretics and antihistamines before initiation of the transfusion in the frequently transfused client can decrease the incidence of febrile reactions. Febrile reactions are immune-mediated and are caused by antibodies in the recipient that are directed against antigens present on the granulocytes, platelets, and lymphocytes in the transfused component. They are the most common transfusion reaction and may occur with onset, during transfusion, or hours after transfusion is completed.)

A 28-year old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following? 1) Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient. 2) Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion. 3) Febrile reactions are rarely immune-mediated reactions and can be a sign of hemolytic transfusion. 4) Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and occur during the blood transfusion.

3

A 52-year-old woman is admitted with a new diagnosis of gastrointestinal (GI) bleed. The physician has ordered the client to receive 2 units of packed red blood cells (PRBCs) for a hemoglobin (Hgb) of 6.8g/dL. The nurse begins the infusion of the first unit at 100mL/hr. Firfteen minutes after the start of the infusion, the client complains that she is feeling chilled, is short of breath, and is experiencing lumbar pain rated 8 on a 1-10 scale. Whic of the following should be the nurse's FIRST action. "1. Obtain vital signs and notify the physician of potential reaction 2. Slow the infusion to 75mL/hr and reassess in 15 minutes 3. Stop the infusion and run normal saline (NS) to keep the vein open (KVO) 4. Administer PRN pain medication as ordered, apply oxygen at 2 L/min, and provide an additional blanket"

C ( The patient's occupation and the inflammation, pain, and weakness in the elbow and hand suggest a repetitive strain injury. Muscle spasms would be characterized by a palpable, firm muscle mass during the spasm. Meniscus injury would affect the knee. Carpal tunnel syndrome is characterized by weakness and numbness of the hand.)

A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to a.muscle spasms. b.meniscus injury. c.repetitive strain injury. d.carpal tunnel syndrome.

Reticulocyte count (The reticulocyte count will be increased because the life span of sickled red blood cells is shortened. Hemoglobin, hematocrit, and platelet levels will be decreased.)

A child with suspected sickle cell disease (SCD) is in the clinic for laboratory studies. The parents ask the nurse what results will tell the physician that their child has SCD. The nurse responds that which of the following is increased in this disease?

b ( Appendicitis should be suspected in a client with an elevated WBC count complaining of acute right lower abdominal quadrant pain. Laxatives are never prescribed because if appendicitis is present, the effect of the laxative may cause a rupture with resultant peritonitis. Cold packs may be prescribed for comfort. The client would be NPO and given IV fluids in preparation for possible surgery.)

A client arrives at the hospital emergency department complaining of acute right lower quadrant abdominal pain, and appendicitis is suspected. Laboratory tests are performed, and the nurse notes that the client's white blood cell (WBC) count is elevated. On the basis of these findings, the nurse should question which health care provider (HCP) prescription documented in the client's medical record? A. Apply a cold pack to the abdomen. B. Administer 30 mL of milk of magnesia (MOM). C. Maintain nothing by mouth (nil per os [NPO]) status. D. Initiate an intravenous (IV) line for the administration of IV fluids.

4

A client brought to the emergency department states that he hasaccidentally been taking two times his prescribed dose of warfarin(Coumadin) for the past week. After noting that the client has noevidence of obvious bleeding, the nurse plans to do which of thefollowing? 1. Prepare to administer an antidote. 2. Draw a sample for type and crossmatch and transfuse the client. 3. Draw a sample for an activated partial thromboplastin time (aPTT) level. 4. Draw a sample for prothrombin time (PT) and international normalized ratio (INR)."

a ( During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest.)

A client is admitted to the hospital with a diagnosis of acute diverticulitis. What should the nurse expect to be prescribed for this client? A. NPO (nothing by mouth) status B. Ambulation at least 4 times daily C. Cholinergic medications to reduce pain D. Coughing and deep breathing every 2 hours

a (septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and development of shock.)

A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 from a baseline of 125/78. Temp is 100.8 from baseline 99.2 orally. The nurse determines patient is experiencing which complication with blood transfusion? a. septicemia B. hyperkalemia. c. circulatory overload. D. Delayed tranfusion reaction.

D ( Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics and also by practicing relaxation techniques, applying local cold or heat to the abdomen, massaging the abdomen, and lying with the legs flexed. Lying with the legs extended is not useful because it increases the muscle tension in the abdomen, which could aggravate inflamed intestinal tissues as the abdominal muscles are stretched.)

A client with Crohn's disease is experiencing acute pain, and the nurse provides information about measures to alleviate the pain. Which statement by the client indicates the need for further teaching? A. "I know I can massage my abdomen." B. "I will continue using antispasmodic medication." C. "One of the best things I can do is use relaxation techniques." D. "The best position for me is to lie supine with my legs straight."

b ( A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. Clients should avoid high-fiber foods when experiencing acute diverticulitis. As the attack resolves, fiber can be added gradually to the diet.)

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse should anticipate a prescription from the health care provider for which type of diet for this client? A. A low-fat diet B. A low-fiber diet C. A high-protein diet D. A high-carbohydrate diet

c (Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization)

A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately?" a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion. b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter .c. The new RN primes the transfusion set using 5% dextrose in lactated Ringer's solution. d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction."

1 ( Asking the client about personal experience with tranfusion therapy provides a good starting point for client teaching about this procedure. Options 3 & 4 are not helpful because they may elicit a fearful response from the client.)

A nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse asks which initial questions? 1. Have you ever had a transfusion before? 2. Why do you think that you need the transfusion? 3. Have you ever gone into shock for any reason in the past? 4. Do you know the complications and risks of a transfusion?

erythema at incision site ( Redness, or erythema, at the incision site is an initial sign of a wound infection and requires intervention by the nurse.)

A nurse is caring for a client who is 2 days postop. which of the following findings should alert the nurse that the client is developing an infection? Temp of 100 Erythema at incision site WBC 9000 Pain reported as a 6 of 10

b (The nurse should anticipate the use of heat paraffin to be prescribed as a nonpharmacologic intervention. The elevated ESR indicates an acute inflammatory process due to client's rheumatoid arthritis. The use of the warm paraffin relives the stiffness of the client's joints and provides comfort.)

A nurse is caring for a client who is experiencing an acute exacerbation of Rheumatoid arthritis RA. the nurse should anticipate that the clients affected joints will require which of the following treatments? a An assistive device to use when the client is ambulating b Heat paraffin therapy applied to the client's joints c Gentle massage of the client's hands d Active range-of-motion exercises on the client's affected joints

Reduced joint stress (Rheumatoid arthritis in an autoimmune disease in which the cartilage and bone of the joints are destroyed resulting in increased pain and limited range of motion. The nurse should instruct the client that rest reduces stress on the joints and can be an effective intervention for relieving pain associated with rheumatoid arthritis

A nurse is teaching a client who has RA about increasing physical rest as part of her treatment plan. Which of the following outcomes of this intervention should the nurse document as a goal for this client?

b ( immediate care after a sprain or strain injury includes the application of cold and compression to the injury to minimize swelling. The other actions should be taken after the ankle is wrapped with a compression bandage and ice is applied.)

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first? a.Administer naproxen (Naprosyn) 500 mg PO. b.Wrap the ankle and apply an ice pack. c.Give acetaminophen with codeine (Tylenol #3). d.Take the patient to the radiology department for x-rays

b ( Until a plaster cast has dried, placing pressure on the cast should be avoided to prevent creating areas inside the cast that could place pressure on the arm. The left arm should be elevated to prevent swelling. The edges of the cast may be petaled once the cast is dry, but padding the edges before that may cause the cast to be misshapen. The cast should not be covered until it is dry because heat builds up during drying.)

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should a.keep the left arm in a dependent position. b.handle the cast with the palms of the hands. c.place gauze around the cast edge to pad any roughness. d.cover the cast with a small blanket to absorb the dampness.

a ( he first goal of collaborative management is realignment of the knee to its original anatomic position, which will require anesthesia or conscious sedation. Immobilization of the joint will be done after realignment. Later, gentle ROM exercises may be started if the joint is stable. Casting is not usually required for dislocations.)

A patient in the emergency department is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for a.conscious sedation. b.a knee immobilizer. c.gentle knee flexion. d.cast application.

c (The jaw will be wired for stabilization, and the patient should know what emergency situations require that the wires be cut to protect the airway. There are no dressing changes for this procedure. The diet is liquid, and patients are not able to chew high-fiber foods. Initially, the patient may receive nasogastric tube feedings, but by discharge the patient will swallow liquid through a straw.)

A patient is admitted with facial injuries after a bicycle accident and has a repair of a fractured mandible. When doing postoperative teaching, the nurse will include information about a.the use of sterile technique for dressing changes. b.the importance of including high-fiber foods in the diet .c.when the patient may need to cut the immobilizing wires. d.self-administration of nasogastric tube feedings

b ( A shorter limb after a fall indicates a possible dislocation, which is an orthopedic emergency. The nurse will expect bruising and pain at the area, even without an injury that requires surgery. The shoulder should be immobilized until it is evaluated by the health care provider)

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine? a whether there is bruising at the shoulder area. b. whether the right arm is shorter than the left. c. the amount of pain the patient is experiencing. d. how much range of motion (ROM) is present.

A, B, D. (These are signs and symptoms seen with GERD. Melena is seen with gastrointestinal bleeding as in peptic ulcer disease. Smooth, red tongue is seen with vitamin B12 deficiency, and Murphy's Signs is seen with cholecystitis)

A patient reports frequent heartburn twice a week for the past 4 months. What other symptoms reported by the patient may indicate the patient has GERD? SELECT-ALL-THAT-APPLY: A. Bitter taste in mouth B. Dry cough C. Melena D. Difficulty swallowing E. Smooth, red tongue F. Murphy's Sign

d ( MRI is most useful in assessing for soft tissue injuries. Bone scanning and standard radiographs are used to assess for injures or lesions of bone. Arthroscopy is used for visualizing the joints.)

A patient suffers an injury to the shoulder while playing football. To identify abnormalities of cartilage and soft tissue surrounding the joint, the nurse would expect the patient to be evaluated with a. radioisotope bone scanning. b. arthroscopy. c. standard x-rays. d. magnetic resonance imaging (MRI).

C (The axilla can become excoriated when a sling is used to support the arm, and the nurse should check the axilla and apply absorbent dressings to prevent this. A patient with a sling would not have traction applied by hanging. The patient will be encouraged to move the fingers on the injured arm to maintain function and to help decrease swelling. The patient will do active ROM on the uninjured side.).

A patient who has a proximal humerus fracture that is immobilized with a left-sided long-arm cast, and a sling is admitted to the medical-surgical unit. Which nursing intervention will be included in the plan of care? a .Use surgical net dressing to hang the arm from an IV pole. b. Immobilize the fingers on the left hand with gauze dressings. c. Assess the left axilla and change absorbent dressings as needed. d. Assist the patient in passive range of motion (ROM) for the right arm.

b ( The patient's clinical manifestations and history are consistent with a pulmonary embolus, and the nurse's first action should be to ensure adequate oxygenation. The nurse should offer reassurance to the patient, but meeting the physiologic need for oxygen is a higher priority. The health care provider should be notified after the oxygen is started and pulse oximetry and assessment for deep vein thrombosis (DVT) are obtained)

A patient who has been hospitalized for 3 days with a hip fracture and Buck's traction has sudden onset shortness of breath and tachypnea. The patient tells the nurse, "I feel like I am going to die!" Which action should the nurse take first? a.Stay with the patient and offer reassurance. b.Administer oxygen at 4 L/min by a nasal cannula. c.Notify the health care provider about the patient's symptoms. d.Check the patient's legs for swelling or tenderness.

a ( The patient can lift the buttocks off the bed by using the left leg without changing the right-leg alignment. Turning the patient will tend to move the leg out of alignment. Disconnecting the traction will interrupt the weight needed to immobilize and align the fracture.)

A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should a.have the patient lift the buttocks by bending and pushing with the left leg. b.turn the patient partially to each side with the assistance of another nurse. c.place a pillow between the patient's legs and turn gently to each side. d.loosen the traction and have the patient turn onto the unaffected side

D (The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.)

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a.a blood pressure of 100/65 mm Hg. b.anxiety, restlessness, and confusion. c.warm, reddened areas in the calf. d.pinpoint red areas on the upper chest.

a ( he cast may be removed when callus ossification has occurred. It is not necessary to wait until radiologic union or complete bone fusion occurs. Bone healing starts immediately after the injury, but the cast will need to be worn at least 3 weeks.)

A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone a.is strong enough to stand mild stress. b.union is complete on the x-ray. c.fragments are fully fused. d.healing has started.

a ( The goal of hand surgery in RA is to restore function, not to correct for cosmetic deformity or treat the underlying process.)

A patient with severe ulnar drift caused by rheumatoid arthritis (RA) is scheduled for an arthroplasty of the right hand and fingers. The nurse determines that the patient has realistic expectations of the outcome of surgery when the patient says, a."I will be able to use my fingers to grasp objects better. "b."My fingers will appear normal in size and shape after this surgery. "c."This procedure will prevent further deformity in my hands and fingers. "d."I will not have to do as many hand exercises after the surgery."

D

After providing education to a patient with GERD. You ask the patient to list 4 things they can do to prevent or alleviate signs and symptoms of GERD. Which statement is INCORRECT? A. "It is best to try to consume small meals throughout the day than eat 3 large ones." B. "I'm disappointed that I will have to limit my intake of peppermint and spearmint because I love eating those types of hard candies." C. "It is important I avoid eating right before bedtime." D. "I will try to lie down after eating a meal to help decrease pressure on the lower esophageal sphincter."

c ( The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Diskography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic test for osteoporosis.)

During assessment of the musculoskeletal system of a 74-year-old woman, the nurse notes that the patient has lost 1 inch in height since the previous visit two years ago. The nurse will plan to teach the patient about a. diskography studies. b. magnetic resonance imaging (MRI). c. dual-energy x-ray absorptiometry (DEXA). d. myelographic testing.

A ( The blood must be stopped at once, and then normal saline should be infused to keep the line patent and maintain blood volume.)

Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should: a. Increase the flow of normal saline b. Assess the pain further c. Notify the blood bank d. Obtain vital signs.

4 (The most likely time for a blood transfusion reaction to occur is during the first 15 minutes or first 50 mL of the infusion. If a blood transfusion reaction does occur, it is imperative to keep an established I.V. line so that medication can be administered to prevent or treat cardiovascular collapse in case of anaphylaxis. PRBCs should be administered through a 19-gauge or larger needle; a peripherally inserted central catheter line is not recommended, in order to avoid a slow flow. RBCs will hemolyze in dextrose or lactated Ringer's solution and should be infused with only normal saline solution.)

The nurse is administering packed red blood cells (PRBCs) to a client. The nurse should first: "1. Discontinue the I.V. catheter if a blood transfusion reaction occurs. 2. Administer the PRBCs through a percutaneously inserted centralcatheter line with a 20-gauge needle. 3. Flush PRBCs with 5% dextroseand 0.45% normal saline solution. 4. Stay with the client during thefirst 15 minutes of infusion.

Delayed Growth and Development (Rationale:The child with sickle cell disease is often developmentally delayed due to the effects of physical disability, pain, and inpatient hospital stays. The nurse would plan activities that help maintain developmental levels the child has reached. The child in sickle cell crisis does not experience ineffective airway clearance, bleeding, or constipation as a result of sickle cell disease. The child may have an illness that could cause one of these symptoms, but they are not common to children with sickle cell disease.)

The nurse is admitting a 7-year-old client who is experiencing sickle cell crisis and plan of care is based on which of the following nursing diagnoses? 1 delayed growth and development 2 ineffective aw clearance 3 bleeding 4 constipation

c (The most typical finding with duodenal ulcer is pain that is relieved by food intake. The pain is often described as a burning, heavy, sharp, or "hunger pang" pain that often localizes in the midepigastric area. It does not radiate down the right arm. The client with duodenal ulcer does not usually experience weight loss or nausea and vomiting; these symptoms are more typical in the client with a gastric ulcer.)

The nurse is assessing a client with a duodenal ulcer. The nurse interprets that which sign or symptom is most consistent with the typical presentation of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain that is relieved by food intake D. Pain that radiates down the right arm

a (The client is exhibiting symptoms of fluid volume excess; slowing the rate is the proper action. The nurse would not stop the infusion of blood, as in answer C, and answers B and D would not help.)

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action? A. Slow the transfusion. B. Document the finding as the only action. C. Stop the blood transfusion and turn on the normal saline. D. Assess the client's pupils."

Treatment is aimed at pain control, oxygen therapy, and hydration, but does not provide a cure. (Rationale:Treatment for sickle cell crisis is pain control, oxygenation, and fluid resuscitation. There is no cure for sickle cell disease. The nurse teaches families how to prevent sickle cell crisis.)

The nurse is caring for a child who is in the hospital experiencing sickle cell crisis. The parents are asking the nurse which treatment will help cure the child. The nurse responds with which of the following?

b (Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appenditis.)

The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? A. Leukopenia with a shift to the left B. Leukocytosis with a shift to the left C. Leukopenia with a shift to the right D. Leukocytosis with a shift to the right

c ( Oral corticosteroids are used to treat the inflammation of Crohn's disease, so option 3 is the correct one. In addition to treating the GI inflammation of Crohn's disease with medications, it is also treated by resting the bowel. Therefore, option 1 is incorrect. Option 2 is incorrect, as clients with Crohn's disease typically have diarrhea and would not be on fluid restrictions. Option 4, activity restrictions, is not indicated. The client can do activities as tolerated but should avoid stress and strain.)

The nurse is caring for a client experiencing an exacerbation of Crohn's disease. Which intervention should the nurse anticipate the health care provider prescribing? A. Enteral feedings B. Fluid restrictions C. Oral corticosteroids D. Activity restrictions

4

The nurse is caring for a client in a sickle cell crisis. which is the pain regiment of choice to relieve the pain? 1. Frequent aspirin2. Motrin3. Demerol4. Morphine

c

The nurse is caring for a client with gastroesophageal reflux disease (GERD) and provides client education on measures to decrease GERD. Which statement made by the client indicates a need for further teaching? A. "I plan to eat 4 to 6 small meals a day." B. "I should sleep in the right side-lying position." C."I plan to have a snack 1 hour before going to bed." D. "I will stop having a glass of wine each evening with dinner."

D (Because of the loss of blood, clients with ulcerative colitis commonly have decreased hemoglobin and hematocrit levels. Clients with ulcerative colitis have bloody diarrhea, not steatorrhea (fatty, frothy, foul-smelling stools).

The nurse is caring for a client with ulcerative colitis. Which finding does the nurse determine is consistent with this diagnosis? A. Hypercalcemia B. Hypernatremia C. Frothy, fatty stools D. Decreased hemoglobin

D

The nurse is caring for a group of clients on the surgical nursing unit. The nurse anticipates that the client who underwent which procedure is most likely to have some long-term residual difficulty with absorption of nutrients? A. Colectomy B. Appendectomy C. Ascending colostomy D. Small bowel resection

C ( Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the HCP.)

The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, should the nurse report to the health care provider (HCP)? A. Hypotension B. Bloody diarrhea C. Rebound tenderness D. A hemoglobin level of 12 mg/dL (120 mmol/L)

C

The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result? A. The client reports some pain before meals. B. The client frequently is awakened at 2 a.m. with heartburn. C. The client has eliminated any irritating foods from the diet. D. The client's pain is minimal with histamine H2-receptor antagonists.

4 ( side note: even if you read somewhere to check clients vitals every 30 mns for example it doesnt mean you shouldnt pick this one because this is the BEST answer)

The nurse is prepping to initiate transfusion of PRBC's to a patient with anemia which action should the nurse take first? 1. Leave client after 5 mns of start of transfusion 2. infuse transfusion within 2 hours 3. flush tubing with D5w 4. Check patients vitals every hour during the transfusion

b (The client with irritable bowel should take in a diet that consists of 30 to 40 g of fiber daily because dietary fiber will help produce bulky, soft stools and establish regular bowel habits. The client should also drink 8 to 10 glasses of fluid daily and chew food slowly to promote normal bowel function. Foods that are irritating to the intestines need to be avoided. Corn is high in fiber but can be very irritating to the intestines and should be avoided. The food items in the other options are acceptable to eat.)

The nurse is providing dietary instructions to a client with a diagnosis of irritable bowel syndrome. The nurse determines that education was effective if the client states the need to avoid which food? A. Rice B. Corn C. Broiled chicken D. Cream of wheat

a (you need to lower fiber intake

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction? A. "I should increase the fiber in my diet. "B. "I will need to avoid caffeinated beverages. "C. "I'm going to learn some stress reduction techniques. "D. "I can have exacerbations and remissions with Crohn's disease."

a b c d ( IBS is a common, chronic functional disorder, meaning that no organic cause is currently known. Treatment is directed at psychological and dietary factors and medications to regulate stool output. Options 1, 2, 3, and 4 are correct, as clients diagnosed with IBS whose primary symptoms are abdominal distention and flatulence should be advised to avoid common gas-producing foods such as broccoli and cabbage and to consume yogurt, as it may be better tolerated than milk. In addition, the probiotics found in yogurt may be beneficial because alterations in intestinal bacteria are believed to exacerbate IBS. The client should be advised to take loperamide, a synthetic opioid that slows intestinal transit and treats diarrhea when it occurs. Also, psychological stressors are associated with development and exacerbation of IBS, so stress management techniques are important. Option 5, decrease fiber intake, is incorrect, as clients should be encouraged to have a dietary fiber intake of at least 20 g/day. )

The nurse is providing instructions to a client diagnosed with irritable bowel syndrome (IBS) who is experiencing abdominal distention, flatulence, and diarrhea. What interventions should the nurse include in the instructions? Select all that apply. A. Eat yogurt. B. Take loperamide to treat diarrhea. C. Use stress management techniques. D. Avoid foods such as cabbage and broccoli. E. Decrease fiber intake to less than 15 g/day.

3 (The client cannot donate blood for 6months after a pregnancy because of thenutritional demands on the mother.)

The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1.The client who had wisdom teeth removed a week ago. 2.The nursing student who received a measles immunization 2 months ago. 3. The mother with a six (6)-week-old newborn. 4.The client who developed an allergy to aspirin in childhood

b ( Leaning over would flex the hip at greater than 90 degrees and predispose the patient to hip dislocation. The other patient actions are appropriate and do not require any immediate action by the nurse to protect the patient.)

The nurse observes a patient doing all these activities after having a hip-replacement surgery. Which patient action requires that the nurse intervene immediately? a.The patient sits straight up on the edge of the bed. b.The patient leans over to pull shoes and socks on. c.The patient bends over the sink while brushing the teeth. d.The patient uses crutches with a swing-to gait.

d

The nurse recognizes the following symptoms as a sign of duodenal ulcer: a. consistent pain b. appearing mid morning, the pain is relieved by food but recurs 2-3 hours after a meal, and often awakens a patient at night. c. an infancy and early childhood, repeated vomiting, abdominal pain and or hemorrhage may be the first sings d. all of the above

b ( he defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs.)

The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings?" a. Schilling's test, elevated b. Intrinsic factor, absent. c. Sedimentation rate, 16 mm/hour d. RBCs 5.0 million

a

The nurse who is about to give a blood transfusion knows that blood cells start to deteriorate after a certain period of time. Which of the following itens is important to check regarding the age of blood cells before the transfusion is begun? A. Expiration date B. Presence of clots C. Blood group and type D. Blood identification number"

2 (ON QUIZ UNLESS it has a question regarding high heart rate then that would be the answer thats an early clinical manisfestation that would show up first- and to report to MD.

What is the earliest clinical manifestation in a client with acute disseminated intravascular coagulation (DIC)? 1.Severe shortness of breath. 2.Bleeding without history or cause. 3.Orthopnea. 4.Hematuria.

b ( ncreased swelling or numbness may indicate increased pressure at the injury, and the health care provider should be notified immediately to avoid damage to nerves and other tissues. The patient should be encouraged to move the joints above and below the cast to avoid stiffness. There is no need to elevate the shoulder, although the forearm should be elevated to reduce swelling. NSAIDs are appropriate to treat pain after a fracture.)

When giving home-care instructions to a patient who has multiple forearm fractures and a long-arm cast on the right arm, which information should the nurse include? a.Keep the hand immobile to prevent soft tissue swelling. b.Call the health care provider for increased swelling or numbness. c.Keep the right shoulder elevated on a pillow or cushion. d.Avoid the use of NSAIDs for the first 48 hours after the injury.

a ( The patient should be adequately medicated for pain before any attempt to ambulate. Instructions about the benefits of ambulation may increase the patient's willingness to ambulate, but decreasing pain with ambulation is more important. The presence of an incisional drain or timing of dressing change will not impact on ambulation.)

When preparing a patient to ambulate the day after an ORIF for a hip fracture, which action is most important for the nurse to take? a.Administering the ordered oral opioid pain medication b.Instructing the patient about the benefits of ambulation c.Ensuring that the incisional drain has been discontinued d.Changing the hip dressing and document the appearance of the site

a ( A family history of height loss with aging may indicate osteoporosis, and the patient may need to consider preventative actions, such as calcium supplements. A sprained ankle 2 years previously will not cause any current or future musculoskeletal problems. A family history of tuberculosis is not a risk factor. Occasional nonsteroidal antiinflammatory drug (NSAID) use does not indicate any increased musculoskeletal risk.)

When taking a patient history during assessment of the musculoskeletal system, the nurse identifies an increased risk for the patient who reports a. that a parent became much shorter with aging. b. a sprained ankle 2 years previously. c. a family history of tuberculosis. d. taking over-the-counter (OTC) ibuprofen (Advil) for occasional aches.

3 ( Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets)

Which collaborative treatment would the nurse anticipate in the client diagnosed with DIC? 1. Administer oral anticoagulants 2. Prepare for plasmapheresis 3. Administer fresh frozen plasma 4. Calculate the intake and output

D

Which of the following does NOT play a role in the development of GERD? A. Pregnancy B. Hiatal hernia C. Usage of antihistamines or calcium channel blockers D. All the above play a role in GERD

3 (As blood collects in the peritoneal cavity, it causes dilation and distention, which is reflected in increased abdominal girth. The client would be tachycardic and hypotensive. Petechiae reflect bleeding in the skin.)

Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation? 1.Bradycardia. 2.Hypertension. 3.Increasing abdominal girth. 4.Petechiae.

C (for all causes of hemolysis, a major focus of treatment is to maintain renal function. When RBCs are hemolyzed, the hemoglobin molecule is released and filtered by the kidneys. The accumulation of hemoglobin molecules can obstruct the renal tubules and lead to acute tubular necrosis).

Which organ is at greatest risk due to the effects of hemolytic anemia?" A. Heart B. Spleen C. Kidney D. Liver

3 ( Vaso-occlusive crisis, the most frequent crisis, is characterized by organ infarction, which will result in bloody urine secondary to kidney infarction.)

Which s/s will the nurse expect to assess in the client diagnosed with a vaso-occlusive sickle cell crisis 1. lordosis 2.epistaxis 3. hematuria 4. petechia

2 (Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled)

Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? "1. The blood will coagulate if left out of the refrigerator for >four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure."

A. (Options B is a proton-pump Inhibitors (PPIs) and it decreases stomach acid and helps the esophagus heal. Option C is a type of prokinetic drug and prevents delayed gastric emptying by improving pressure in lower esophageal sphincter and it improves peristalsis of the GI tract. Option D is a histamine receptor blocker and it blocks histamine. When histamine is released it causes the parietal cells to release HCL but this response will be blocked so gastric acid secretion will be decreased. Option A is a drug used in gallbladder disease.)

You're collecting a patient's medication history that has GERD. Which medication below is NOT typically used to treat GERD? A. Colesevelam "Welchol" B. Omeprazole "Prilosec" C. Metoclopramide "Reglan" D. Ranitidine HCL "Zantac"

b ( An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures. -An EGD is performed while the client receives moderate sedation. -A colonoscopy is performed to detect colon cancer.)

a This procedure is performed to measure the presence of acid in your esophagus." b "This procedure can determine how well the lower part of your esophagus works." c "This procedure is performed while you are under general anesthesia." d "This procedure can determine if you have colon cancer."

b ( The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels.)

a nurse in the ER is assessing a client who was in a MVA 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a sao2 of 87%, and the nurse notes generalized petechiae on the clients skin. which of the following complications should the nurse suspect? a Hypovolemic shock b Fat embolism syndrome c Thrombophlebitis d Avascular bone necrosis

d ( Cold minimizes swelling and erythema to the affected area. Therefore, the nurse should instruct the client to apply cold compresses for no more than 20 min at a time.)

a nurse in the er is preparing to discharge a client following a grade II ankle sprain. Which of the following instructions should the nurse plan to give? a Perform passive range-of-motion exercises of the ankle hourly. b Keep the affected extremity in a dependent position. c Wrap a loose dressing around the affected ankle. d Apply cold compresses to the extremity intermittently.

d

a nurse is assessing a client that rcvd crutches in the er following a foot injury which of the following statements should the nurse identify as an indication that the client needs further instructions? a I will bear the weight of my body on my hands b I will keep spare crutches c I will inspect my crutches for signs of wear d I have a set of my brothers crutches that I can use

reddish-purple skin lesions (Kaposi's sarcoma is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.)

a nurse is assessing a client who has Kaposis's sarcoma, which of the follwoing findings should the nurse expect?

c ( Abdominal tenderness and rigidity occur with a bowel perforation. As fluid escapes into the peritoneal cavity, there is a reduction in circulating blood volume and a lowered blood pressure, or hypotension, results. -A client who has experienced a bowel perforation will not display an elevated blood pressure. However, hypotension or shock can be present. -Vomiting is frequent and copious with a small bowel obstruction. This does not indicate a bowel perforation)

a nurse is assessing a client who has admitted with a with a SBO. the client reports severe abdominal pain. Which of the following findings should indicate to the nurse that a possible bowel perforation has occured. a. elevated bp b. bowel sounds increased frequency and pitch c. rigid abdomen d. emesis of undigested food

a ( The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. The first level consists of physiological needs; the second level consists of safety and security needs; the third level consists of love and belonging needs; the fourth level consists of personal achievement and self-esteem needs; and the fifth level consists of achieving full potential and the ability to problem solve and cope with life situations. When applying Maslow's hierarchy of needs priority-setting framework, the nurse should review physiological needs first. The nurse should then address the client's needs by following the remaining four hierarchal levels. It is important, however, for the nurse to consider all contributing client factors, as higher levels of the pyramid can compete with those at the lower levels, depending on the specific client situation. The fourth level of Maslow's hierarchy of needs includes usefulness, self-worth, and self-confidence in fulfilling self-esteem needs. Therefore, the nurse should identify the report of muscle spasms, a physiological need, as the priority client finding.)

a nurse is assessing a client who is 24 hr posoperative following an above the elbow amputation. WHich of the of the following findings should the nurse identify as priority? a report of muscle spasms b Inability to get dressed without assistance c Report of feelings of anger d Refusal to look at the affected limb.

d ( The nurse should expect the client who is experiencing perforation of a peptic ulcer to exhibit manifestations of a boardlike abdomen and severe pain in the abdomen or back that radiates to the right shoulder. Vomiting of blood and shock can occur if the perforation causes hemorrhaging.

a nurse is assessing a client who is experiencing perforation of a peptic ulcer which of the following manifestations should the nurse expect? a increased blood pressure b Decreased heart rate c Yellowing of the skin d Boardlike abdomen

b

a nurse is assessing a client with carpel tunnel syndrome the nurse should expect which finding? a. positive choveck sign b. positive phallens sign c. decrease radial pulse

d

a nurse is assessing a client with compartment syndrome which assessment finding indicates an improvement in the condition? a. multiple petechiae in areas of the body b. capillary refill >3 c. numbness and tingling d. pain relief with medication.

b ( The nurse should identify paresthesias as a finding of compartment syndrome. Compartment syndrome involves the compression of nerves and blood vessels in an enclosed space, leading to impaired blood flow and nerve damage. Other findings include numbness, tingling, weakness, and pain that does not respond to medication.)

a nurse is caring for a client immediately following application of a plaster cast. The nurse should monitor for and report which of the following findings as an indication of compartment syndrome? a sensation of heat on the surface of the cast b Paresthesias of the extremity c Pruritus of the extremity d Musty odor noted from cast materials

a ( The nurse should provide relief for the report of itching by blowing cool air into the cast using a hair dryer on a cool setting or an empty 60-mL plunger syringe.)

a nurse is caring for a client who had a fiberglass cast placed on her left arm several hours ago and now reports itching under the cast. Which of the following actions should the nurse plan to take? a. Use a hair dryer on a cool setting to blow air into the cast. b. Ask the provider to bivalve the cast. c. Provide the client with a sterile cotton swab to rub the affected skin. d. Wrap the extremity with a dry heating pad.

b ( Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately.)

a nurse is caring for a client who has a pelvic fracture. the client reports sudden SOB, stabbing chest pain and feelings of doom. the nurse should identify that the client is experiencing which of the following complications? a Pneumonia b Pulmonary embolus c Tension d pneumothorax e Tuberculosis

c ( keep it moist and use unscented lotions)

a nurse is caring for a client who has systemic lupus and is concerned about the skin lesions on her face and neck. the client asks the nurse, "what hsould I do about these spots"? what is the following response the nurse should give? a. keep lesions covered with a light sterile dressing when going outdoors b. rub lesions covered with a light sterile dressing when going outdoors. c apply moisturizer after bathing the lesions with warm water d. apply antibiotic cream twice per day until scabs form on the lesions.

b ( The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally.)

a nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. the nurse should assess the client for which of the following manifestations of discoloration of the hip prosthesis? a Bulging in the area over the surgical incision B Shortening of the right leg C Sensation of warmth over the surgical incision D Pallor following elevation of the right leg

d ( The head of the bed should be elevated at least 30° (semi-Fowler's position) while the tube feeding is administered. This position uses gravity to help the feeding move down through the digestive system and lessens the possibility of regurgitation -The nurse should monitor the client's intake and output and should observe the client for manifestations of dehydration, such as dry mucous membranes, thirst, and decreased urinary output. A pitcher of water at the client's bedside does not require intervention by the nurse..)

a nurse is caring for a client who is dehydrated and is receiving cont. tube feeding through a pump at 75ml/hr. when the nurse assesses the client at 0800, which of the following findings requires intervention by the nurse? a A full pitcher of water is sitting on the client's bedside table within the client's reach. b The disposable feeding bag is from the previous day at 1000 and contains 200 mL of feeding. c The client is lying on the right side with a visible dependent loop in the feeding tube. d The head of the bed is elevated 20°.

b ( The nurse should not remove the weight without a prescription, because this could interfere with the correct alignment of the extremity. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely.MY ANSWERThe nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed, or the nurse can assist the client up, making sure to maintain proper alignment of the extremity. Lift the rope off the pulley while the client rocks back and forth to reposition.The nurse should ensure the traction ropes are on the pulley. Lifting the rope displaces the weight and can interfere with the correct alignment of the extremity. Lift the weight manually while another staff member moves the client up in bed.The nurse should not lift the weight without a prescription because this could interfere with the correct alignment of the extremity.)

a nurse is caring for a client who is in skeletal traction following femur fracture. the nurse finds the client has slid down toward the foot of the bed and traction weight is resting on the floor. which of the following actions should the nurse take? a. Remove the weight temporarily to reposition the client to the correct alignment in bed. b Have the client use a trapeze to pull himself up while ensuring the weight hangs freely. C Lift the rope off the pulley while the client rocks back and forth to reposition. D Lift the weight manually while another staff member moves the client up in bed.

C ( Answering this item requires application of the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first action the nurse should take is to acquire further data by asking the client to describe the characteristics of the pain.)

a nurse is caring for a client who is postop following a Total knee arthroplasty and is prescribed a cont passive motion machine and PCA. the client tells the nurse. I am in so much pain which of the following should the nurse take first? a Remind the client to push the button for the PCA device. b Discuss activities the client may use to distract from the pain. c Ask the client to describe the characteristics of the pain. d Pause the CPM machine briefly to apply a cold pack to the client's knee.

d ( The nurse should recognize that the client has the potential for the development of hypoglycemia due to the sudden withdrawal of the TPN solution. In addition to diaphoresis, other potential manifestations of hypoglycemia can include weakness, anxiety, confusion, and hunger.)

a nurse is caring for a client who is receiving TPN and has just returned to the room following physical therapy. the nurse notes that the infusion pump for the clients TPN is turned off? after restarting the infusion pump, the nurse should monitor the client for which of the following findings? a Hypertension b Excessive thirst c Fever d Diaphoresis

b ( A sigmoidoscopy or barium enema is used to visualize the lower gastrointestinal tract, where polyps are found. The measurement of free air, which is a gas, is obtained using fluoroscopy or an x-ray, not an EGD. An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.)

a nurse is caring for a client whos scheduled for an EGD the nurse should identify that this procedure is used to do which of the following? a To visualize polyps in the colon b To detect an ulceration in the stomach c To identify an obstruction in the biliary tract d To determine the presence of free air in the abdomen

b ( A client who is receiving PEG tube feedings should be positioned with the head of the bed elevated at least 30° during and after feedings to decrease the risk of aspiration. Therefore, this is the priority action by the nurse. -A client receiving PEG tube feedings should have the tube thoroughly flushed. However, there is another action the nurse should take first. -A client receiving PEG tube feedings should have the tube thoroughly flushed. However, there is another action the nurse should take first.)

a nurse is caring for a client with PEG and is recieving intermittent feedings. prior to initiating the feeding, which of the following actions should the nurse take first? a Flush the tube with water. b Place the client in semi-Fowler's position. c Cleanse the skin around the tube site. d Aspirate the tube for residual contents.

D ( The nurse should identify unilateral joint involvement as a finding of osteoarthritis. A client who has RA experiences symmetrical joint impairment. and for the ESR its leads to INCREASED esr NOT decreased.

a nurse is discussing the difference between RA and OA with a newly licensed nurse. WHich of the following information should the nurse include about OA? a Osteoarthritis is caused by autoimmune processes." b "Osteoarthritis leads to a decreased erythrocyte sedimentation rate." c "Osteoarthritis affects other organ systems." d "Osteoarthritis can impair a joint on a single side of the body."

D ( Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy.)

a nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? a You will need to apply a cold pack to the site three times a day." b "Your provider might ask you to walk frequently to increase circulation to the area." c "You will need to limit consumption of high-protein foods." d "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

eat less red meat, organ meat and shellfish

a nurse is instructing a client with a new diagnosis of gout about managing the disorder which instructions should the nurse use in the client teaching?

Raised Rash

a nurse is preparing a presentation at a community center about SLE a nurse should plan to include which finding as manifestation of SLE?

c ( The result of long-term, low-fiber eating habits along with increased intracolonic pressure lead to straining during bowel movements, causing the development of diverticula. High-fiber foods help strengthen and maintain active motility of the gastrointestinal tract. -Vitamin C functions as an antioxidant as well as a coenzyme. It can be associated with prevention of cancer of the stomach, esophagus, and colon. However, it does not improve or prevent acute diverticulitis attacks.)

a nurse is providing dietary teaching to a client who has diverticulitis about preventing acute attacks which of the following foods should the nurse recommend? a Foods high in vitamin C b Foods low in fat c Foods high in fiber d Foods low in calories

a ( The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended. Toothbrush should be cleaned once a WEEK by running through dishwasher OR with bleach. Clients should avoid raw fruits and veggies due to bacteria they carry).

a nurse is providing discharge teaching to a client who has aids about preventing infection while at home. which of the following instructions should hte nurse including in the teaching? a Wash your genitalia using an antimicrobial soap." b "Rinse your dishes with cold water." c "Clean your toothbrush once per month." d "Incorporate raw fruits and vegetables into your diet.

b ( The client's partner should clean blood or potentially contaminated body substances with a bleach solution and wear gloves when coming into contact with blood products. A rational - any items that cant be flushed should be kept separate and kept ina CLOSED plastic bag until disposal)

a nurse is providing discharge teaching to the partner of a client who has AIDS. which of the following statements by the clients partner indicates the need for further teaching? a "I will dispose soiled tissues in separate plastic bags." b I'll clean up blood spills immediately with hot water." c "I know that hand washing is an important preventive measure." d "I will wash soiled clothes in hot water."

sedentary lifestyle, aging, caffeine intake, secondhand smoke , jobs with repetitive motions.

a nurse is providing education to a client about the risk factors of OA which risk factor should the nurse include in the information?

Eat 4 to 6 meals per day

a nurse is providing education to a client with GERD which instructions should the nurse include with the education?

FYI

a nurse is providing education to client about risk factors regarding osteoporosis the client understands the instructions when they identify which risk factors can lead to osteoporosis? * Remember ACCESS FYI alcohol use, corticosteroid, calcium (low), estrogen (low), smoking, and sedentary lifestyle SATA- age, hereditary, obesity

I will sleep with my head elevated

a nurse is providing education to client with GERD which information by the client indicates an understanding of the education?

c ( The purpose of elastic stockings is to prevent venous thromboembolism, which is a common complication following orthopedic surgery. Therefore, the nurse should identify this statement as understanding of the teaching. a is incorrect because CPM is usually prescribed for a few hours at a time several times a day and not ALL clients are prescribed CPM therapy following a knee arthroplasty.)

a nurse is providing preop teaching for a client who is scheduled for a Total knee arthroplasty. Which of the following statements by the client should the nurse identify as understanding of the teaching? a "I will wear a continuous movement machine on my knee for 24 hours a day." b "I should avoid taking NSAID medications for pain after surgery." c "I should wear elastic stockings on both of my legs." d "I will begin exercising my legs the day after surgery."

c ( The nurse should instruct the client to avoid taking this medication with any other NSAIDs, such as aspirin, because this can increase the risk for bleeding and gastrointestinal ulceration. - enteric coated pills or have sustained release properties cannot be crushed)

a nurse is providing teaching to a client who has a recent diagnosis of RA and a has an new prescription for naproxen tablets. Which of the following statements requires further teaching? a "This medication will take 4 weeks for me to notice relief in my joints." B "I can take an antacid with this medication for indigestion." C "I can take this medication with aspirin." D "The naproxen goes down easier when I crush it and put it in applesauce

b ( An increase in the client's rheumatoid factor can indicate rheumatoid arthritis or other connective tissue diseases.)

a nurse is reviewing the lab results for a client who reports bilateral pain and swelling in her finger joints, with stiffness in the morning. the nurse should recognize that an increase in which of the following lab tests can indicate arthritis? a Reticulocyte count b Rheumatoid factor c Direct Coombs' test d Platelet count

D ( The nurse should identify anorexia nervosa as a risk factor for osteoporosis. Inadequate protein intake can lead to a decreased bone density, increasing the risk for fractures.)

a nurse is reviewing the medical record of a female client. which of the following should the nurse identify as a risk factor for osteoporosis? a. decreased intake of phosphate-containing foods b. spending several hours in the sun daily c increased estrogen levels d history of anorexia

c

a nurse is teaching a client who ha AIDS about the transmission of pnemocystis jiroveci pna (PCP), which of the following information should the nurse include in the teaching? a PCP is sexually transmitted from person to person." b "You were most likely exposed to a contaminated surface, such as a drinking glass." c "PCP results from an impaired immune system." d "You may have contracted PCP from a family pet."

b ( The concentration of the virus is highest in blood but also has been isolated in other body fluids, including sputum, saliva, cerebrospinal fluid, urine, and semen. Clients who have HIV are cautioned to practice safe sex, avoid donating blood, and abstain from sharing needles with others.)

a nurse is teaching a client who has HIV about how the virus is transmitted. which of the following statements should the nurse include in the teaching? a. HIV can be transmitted as soon as a person develops manifestations b Hiv can be transmitted to anyone who has had contact with the infected blood c HIV is transmitted through the respiratory route through droplets

a ( Clients who have AIDS can have persistent fever, swollen glands, diarrhea, weight loss, and fatigue. These manifestations indicate the onset of AIDS. - clients with aids usually have a low WBC as a result of the HIV virus destroying the CD4-T cells.)

a nurse is teaching a client who has HIV about the early manifestation of AIDS. which of the following statements should the nurse include in the teaching? a You can expect a persistent fever and swollen glands." b "You can expect an elevated white blood cell count." c "You can expect an increase in blood pressure and edema." D "You can expect weight gain."

exercise ( This attack results in generalized inflammation and the manifestations associated with the specific involved tissues. Most clients who have SLE can follow an exercise program to increase the aerobic capacity of cells and improve immune function, and the client should develop such a program with her provider's assistance. - all others a factors that exacerbate SLE).

a nurse teaching a femal client who has a new diagnosis of SLE (Lupus) about factors that can trigger an exacerbation of SLE. the nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? a Exercise b Pregnancy c Infection d Sunlight

apply pressure

a patient comes in the ED and he is bleeding perfusely with a deep laceration on the left lower forearm and after observing standard precaution which of the following should perform first?

b (Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing)

"Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 minutes B. 15 minutes C. 60 minutes D. 30 minutes"

d (Infectious viruses, such as human immunodeficiency virus (HIV), human herpesvirus, hepatitis B and C type 6 (HSV-6), Epstein-Barr virus (EBV), human T-cell leukemia virus type 1 (HTLV-1), and cytomegalovirus (CMV), and other agents, such as the agent that causes malaria, can be transmitted by blood transfusion. Leukocyte-reduced blood products drastically reduce the risk of blood transfusion-associated viral infections, including CMV.

"Complications of transfusions that can be decreased by the use of leukocyte depletion or reduction of RBC transfusion area. a chills and hemolysis. b. leukostasis and neutrophilia. c. fluid overload and pulmonary edema. d. transmission of cytomegalovirus and fever

b (If the client has a temperature higher than 100 degrees, the unit of blood should not be hung until the physician is notified and has the opportunity to give further prescriptions. The physician will likely prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurses's scope of practice to make.)

"Packed red blood cells have been prescribed for a client with a low hemoglobin and hematocrit levels. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6 degrees orally. Which of the following is the appropriate nursing action? A) Begin the transfusion as prescribed B) Delay hanging blood and notify the physician C) Administer an antihistamine and begin the transfusion D) Administer two tablets of Tylenol and begin the transfusion"

d ( The diet for the client with ulcerative colitis should be low fiber (low residue). The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol.)

A client with acute ulcerative colitis requests a snack. Which is the most appropriate snack for this client? A. Carrots and ranch dip B. Whole-grain cereal and milk C. A cup of popcorn and a cola drink D. Applesauce and a graham cracker

d

A 14 year old girl has been hospitalized with Sickle Cell Anemia in vasoocclusive crisis. Which of these Nursing diagnoses should receive priority in the Nursing plan of care? -- A. Impaired social interaction -- B. Alteration in body image -- C. Pain -- D. Alteration in tissue perfusion

b

A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client? A. Taking hourly blood pressures with mechanical cuff B. Encouraging fluid intake of at least 200mL per hour C. Position in high Fowler's with knee gatch raised D. Administering Tylenol as ordered

c

A client with gastritis asks the nurse at a screening clinic about analgesics that will not cause epigastric distress. The nurse should tell the client that which medication is unlikely to cause epigastric distress? A. Ibuprofen B. Indomethacin C. Acetaminophen D. Naproxen sodium

c

A newly admitted client has sickle cell crisis. The nurse is planning care based on assessment of the client. The client is complaining of severe pain in his feet and hands. The pulse oximetry is 89. Which of the following interventions would be implemented first? Assume that there are orders for each intervention. a. Adjust the room temperature b. Give a bolus of IV fluids c. Start O2 d. Administer meperidine (Demerol) 75mg IV push

a (The nurse should return the blood to the blood bank because the gas bubbles in the bag indicate possible contamination)

A nurse check a unit of blood received from the blood bank and notes the presence of gas bubbles in the bag. Which should the nurse implement? A. Return the bag to the blood bank. B. Infuse the blood using the filter tubing. C. Add 10ml of NS to the bag. D. Agitate the bag to mix contents gently.

4

About ten minutes after the nurse begins an infusion of packed RBCs, the patient complains of chills, chest and back pain, and nausea. His face is flushed, and he's anxious. Which is the priority nursing action? 1. Administering antihistamines STAT for an allergic reaction. 2. Notifying the physician of a possible transfusion reaction. 3. Obtaining a urine and serum specimen to send to the lab immediately. 4. Stopping hte transfusion and maintaining a patent IV catheter."

a (he pain medication should be given so that it has time to take effect before the patient is ambulated. The other medications will not affect whether the patient can ambulate or not, although the antibiotic and anticoagulant medications should be given as soon as possible in order to maintain therapeutic blood levels.)

All these medications are ordered at 9:00 AM for a patient who has had a right-hip replacement the previous day and is scheduled to ambulate with the physical therapist for the first time at 9:45. Which medication should be given first? a.Oxycodone (Roxicodone) 5 mg PO b.Ceftriaxone (Rocephin) 500 mg IV c.Enoxaparin (Lovenox) 30 mg SC d.Psyllium (Metamucil) 1 tsp PO

d ( it is both a and c because you know that c are all the factors for peptic ulcer BUT along with NSAIDS this medication causes mucosal irritation, inflam., and a decrease of COX enzyme )

Causative factors for peptic ulcer disease include: a. mucosal irritation and inflammation of COX enzyme. b. acute illness, trauma or sepsis c. h pylori, nsaids and cigarette smoking d. both a and c e. all of the above

A, B, D, E, G. (Patients with GERD should avoid foods that relax the lower esophageal sphincter such as greasy/fatty foods (Hot and Spicy Pork Rinds), peppermint (peppermint patties), acidic or citrus foods/juice (tomato soup and oranges), chocolate (chocolate fondue), along with coffee and soft drinks.)

During a home health visit, you are helping a patient develop a list of foods they should avoid due to GERD. Which items in the patient's pantry should be avoided? SELECT-ALL-THAT-APPLY: A. Hot and Spicy Pork Rinds B. Peppermint Patties C. Green Beans D. Tomato Soup E. Chocolate Fondue F. Almonds G. Oranges

D ( The initial action by the nurse will be to assess the circulation to the leg and to observe for any evidence of injury such as fractures or dislocations. After the initial assessment, the other actions may be appropriate based on what is observed during the assessment.)

Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg swelling. Which action will the nurse take first? a. Elevate the leg on pillows. b. Apply a compression bandage. c. Place ice packs on the lower leg. d. Check leg pulses and sensation.

a ( Phantom limb pain is treated like any other type of postoperative pain would be treated. Explanations of the reason for the pain may be given, but the nurse should still medicate the patient. The compression bandage is left in place except during physical therapy or bathing. Although the pain may decrease over time, it still requires treatment now.)

On the first postoperative day, a patient with a below-the-knee amputation complains of pain in the amputated limb. An appropriate action by the nurse is to a.administer prescribed opioids to relieve the pain. b.explain the reasons for phantom limb pain. c.loosen the compression bandage to decrease incisional pressure. d.remind the patient that this phantom pain will diminish over time.

1 ( This is major surgery but has a predictable course with no complications identified in the stem and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this patient.)

The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the 3 month orientation? 1. The client with an abnormal peritoneal resection who has a colostomy 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome 3. The client with a head injury developing disseminated intravascular coagulation 4. The client admitted with a gunshot wound who has an H&H of 7 and 22

1,3,4

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP hasordered two (2) units of packed red blood cells to be transfused. Which interventionsshould the nurse implement? Select all that apply 1. Obtain a signed consent. 2.Initiate a 22-gauge IV. 3.Assess the client's lungs. 4.Check for allergies. 5.Hang a keep-open IV of D5W

2 ( The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible (CORRECT). 1.) This should be done, but the client requires the IV fluids first because they are at risk for shock (omit #1).

The client is admitted to the ED after a MVA. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1.) Type and crossmatch for RBCs immediately (STAT). 2.) Initiate an IV with an 18-gauge needle and hang normal saline. 3.) Have the client sign a consent for an exploratory laparotomy. 4.) Notify the significant other of the client's admission.

4 (The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding should be given prior to delegating the procedure. (CORRECT)

The nurse and unlicensed nursing assistant are caring for clients on an oncology floor.Which nursing task would be delegated to the unlicensed nursing assistant?" 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received ten (10) units of platelets in brushing teeth.

4

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu? 1.Nuts and milk 2.Coffee and tea 3.Cooked rolled oats and fish 4.Oranges and dark green leafy vegetables

d

The nurse should anticipate that the health care provider (HCP) will prescribe which treatment for a client with pernicious anemia? A. Oral iron tablets B. Blood transfusions C. Gastric tube feedings D. Vitamin B12 injections

c

The physician orders 2 units of packed RBCs to be administered to the client. At 0600 the night shift nurse initiates the first unit's transfusion before going off shift. At 1000 the day shift nurse notes the IV line has clotted off and the transfusion has not been completed. The nursing assessment revealed the transfusion was only approximately 75% complete. Which of the actions by the nurse is most appropriate? A. Advise the blood bank about the delay for the next unit. B. Restart another peripheral line with 0.9% NS and restart the blood transfusion with the remaining blood unit. C. Discontinue the transfusion. D. Document the amount infused thus far and continue the transfusion."

d (Comfortable shoes with good support will help to decrease the risk for falls. Scatter rugs should be eliminated, not just tacked down. Regular weight-bearing exercise will improve strength, but occasional exercise is not helpful in improving strength. Falls inside the home are responsible for many injuries.)

When counseling an older patient about ways to prevent fractures, which information will the nurse include? a. Tacking down scatter rugs in the home is recommended. b. Occasional weight-bearing exercise will improve muscle and bone strength. c .Most falls happen outside the home. d. Buying shoes that provide good support and are comfortable to wear is recommended.

c ( When using crutches, patients are usually taught to move the assistive device and the injured leg forward at the same time and then to move the unaffected leg. Patients are discouraged from using furniture to assist with ambulation. The patient is taught to place weight on the hands, not in the axilla, to avoid nerve damage. If the 2- or 4-point gaits are to be used, the crutch and leg on opposite sides move forward, not the crutch and same-side leg.)

When evaluating the crutch-walking technique of a patient with a right-leg long-leg cast and no weight bearing on the right leg, the nurse determines that the patient is prepared to ambulate independently with the crutches on observing that the patient a.uses the bedside chair to assist in balance as needed when ambulating in the room. b.keeps the padded area of the crutch firmly in the axillary area when ambulating. c.advances the right leg and both crutches together and then advances the left leg. d.moves the left crutch with the left leg and then the right crutch with the right leg.

c ( Corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HRT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.)

When the nurse is assessing a new patient in the clinic, which information about the patient's medications will be of most concern? a. The patient takes hormone replacement therapy (HRT) to prevent "hot flashes. "b. The patient takes a daily multivitamin and calcium supplement .c. The patient has severe asthma and requires frequent therapy with steroids. d. The patient has migraine headaches which are treated with NSAIDs.

d ( Repetitive strain injuries caused by prolonged times working at a keyboard can be prevented by the use of a pad that will keep the wrists in a straight position. Stretching exercises during the day may be helpful, but these would not be needed before starting. Use of a compression bandage is not needed, although a splint may be used for carpal tunnel syndrome. NSAIDs are appropriate to use to decrease swelling.)

When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to a. do stretching and warm-up exercises before starting work. b.wrap the wrists with a compression bandage every morning. c.use acetaminophen (Tylenol) instead of NSAIDs for wrist pain. d.obtain a keyboard pad to support the wrist while word processing.

4 ( DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC)

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35 year old pregnant client with placenta previa 2. A 42 year old client with a pulmonary embolus 3. A 60 year old client receiving hemodialyasis 3 days a week 4. A 78 year old client with septicemia

a ( The patient's height and weight indicate obesity, which places stress on weight-bearing joints. The use of whole milk, avoiding fruits and vegetables, and use of a daily multivitamin are not risk factors for musculoskeletal problems.)

Which information obtained during the nurse's assessment of the patient's nutritional-metabolic pattern may indicate the risk for musculoskeletal problems? a. The patient is 5 ft 2 in and weighs 180 lb. b. The patient prefers whole milk to nonfat milk. c. The patient dislikes fruits and vegetables. d. The patient takes a multivitamin daily.

2 ( Fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.)

Which lab result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT) 2. A low fibrinogen level 3. An increased platelet count 4. An increased white blood cell count

C. (An esophageal manometry assesses the function of the esophagus' ability to squeeze the food down and how the lower esophageal sphincter closes.)

Your patient, who is presenting with signs and symptoms of GERD, is scheduled to have a test that assesses the function of the esophagus' ability to squeeze food down into the stomach and the closer of the lower esophageal sphincter. The patient asks you, "What is the name of the test I'm having later today?" You tell the patient the name of the test is: A. Lower Esophageal Gastrointestinal Series B. Transesophageal echocardiogram C. Esophageal manometry D. Esophageal pH monitoring

FYI

a client has been diagnosed with ulcerative colitis and the nurse is preparing client education what should the nurse include in the clients plan regarding their diet? FYI no smoking, alcohol or caffeine or Nsaids and AVOID DAIRY Eat high protein, LOWER fiber intake, have small frequent meals, low residue diet ( pretty much low fiber- anything that can stimulate a bowel movement)

D ( clients should sit upright for 30 mns after taking meds. to prevent esophageal irritation and ulceration. The nurse should instruct the client to take alendronate in the morning. "The nurse should instruct the client that high-calcium foods can reduce the absorption of alendronate. Alendronate can cause hypocalcemia; therefore, the client might require a calcium supplement taken at a different time of day. The nurse should instruct the client to take alendronate at least 30 min before food.)

a nurse is teaching a client who has a new prescription for alendronate for a tx of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? a. I will take meds in the evening. b. I will drink a full glass of milk with the meds c. I will take meds at mealtime d i will sit upright after taking the meds

D (Following the procedure, the client remains NPO (nothing by mouth) until the gag reflex returns, which is usually in 1 to 2 hours. The remaining options are not specific assessments related to this procedure)

client is scheduled for an upper gastrointestinal (GI) endoscopy. Which assessment is essential to include in the plan of care following the procedure? A. Assessing pulses B. Monitoring urine output C. Monitoring for rectal bleeding D. Assessing for the presence of the gag reflex

1 ( Signs and symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues)

he client is admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site 2. Sudden onset of chest pain and frothy sputum 3. Foul smelling, concentrated urine 4. A reddened, inflamed central line catheter site

d (Rationale: Patients with permanent pacemakers cannot have MRI. An open MRI will not cause claustrophobia. The patient will need to be instructed to remove the hearing aid before the MRI, but this does not require consultation with the health care provider. Contrast medium will not be used, so shellfish allergy is not a contraindication to MRI.)

patient has a new order for open magnetic resonance imaging (MRI) to evaluate for right femur osteomyelitis. Which information obtained by the nurse indicates that the nurse should consult with the health care provider before scheduling an MRI? a. The patient is claustrophobic. b. The patient wears a hearing aid. c. The patient is allergic to shellfish. d. The patient has a pacemaker.

a

patient who has severe peripheral arterial disease and ischemic foot ulcers is upset with the health care provider's recommendation to have an above-the-knee amputation. The patient tells the nurse, "If they want to cut off my leg, they should just shoot me instead." The most appropriate response to the patient's statement is, a."Let's talk about how you feel this surgery will affect you." b."If you do not want the surgery, you do not have to have it. "c."I understand why you are upset, but there really is no choice because your leg is so badly diseased. "d."Many people are able to function normally with a prosthesis after amputation, and you can too."