ATI exam

A nurse is teaching about herbal supplements with a group of newly licensed nurses. Which of the following herbal supplements should the nurse include in the teaching for treating hyperlipidemia?A: Feverfew B: Gingko C: Valerian D: Garlic

D - improves cholesterol levels and reduce the plaque build up of the arteries. "JJ's family"

A nurse is caring for a client who is receiving heparin therapy and has an aPTT of 92 seconds. Which of the following medications should the nurse anticipate the provider might prescribe for the client?A: LeucovorinB: Vitamin KC: DeferoxamineD: Protamine

D - its an antidote for heparin overdose

A nurse is providing discharge teaching for a client who had lithotripsy to break up calculi in the right kidney. Which of the following findings should the nurse instruct the client to report to the provider? A: Bruising over the right flank area B: Blood-tinged urine C: Urine pH 6.0 D: Painful urination

-d -flank or bladder pain, chills and fever, or difficulty urinating should be reported to MD.

a nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk for the development of pyelonephritis? A. diabetes b. radical prostatectomy 2 years ago c. cholethiasis

a -cholethiasis is gall bladder stones, dont effect kidneys

a nurse is assessing client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. which of the following manifestations should the nurse expect? a. orthostatic hypotension b. hoarse voice c. neck vein distention

a -other manifestations are decreased deep tendon reflexes, headache, confusion, and lethargy

a nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect? a. focuses on the source of anxiety b. exhibit an inability to speak c. experiences auditory hallucinations

a -should be expected, the client has a decreased attention span but is able to follow simple directions

a nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor. A. flushed dry skin B. seizures C. hyperreflexia

flushed dry skin - manifestations are warm, flushed, and dry skin due to vasodilation from an increased resp. rate and loss of CO2.

a nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. arrange the following steps. 1. withdraw the prescribed volume of NPH insulin into the syringe. 2. withdraw the prescribed volume of insulin aspart into the syringe 3. inject air into the vial equal to the amount of insulin aspart prescribed 4. inject air into the vial equal to the amount of NPH insulin prescribed

4,3,2,1

A nurse is providing dietary teaching for a client who has hyperlipidemia due to nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A: Less than 30% of daily calories should come from fat. B: Decrease caloric intake to less than 25 cal/kg/day. C: Increase sodium intake. D: Limit daily intake of foods high in carbohydrates

A

A nurse is providing discharge planning for a client who has gestational diabetes. Which of the following interventions should the nurse identify as a priority? A: Determine the client's knowledge regarding gestational diabetes. B: Explain the effects of gestational diabetes on the pregnancy and fetus with the client. C: Discuss dietary meal plans for gestational diabetes with the client. D: Tell the client about manifestations of hypoglycemia.

A

A nurse is assessing a client who reports a new onset of joint pain and stiffness. Which of the following findings should the nurse identify as an indication of osteoarthritis? A: Joint pain improves with rest. B: Joint pain is in both arms and shoulders bilaterally. C: Emotional upset exacerbates joint pain. D: Client is 35 years old.

A -joint pain improves with rest,

a nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend? A. one small orange B. one small apple C. one half cup of pineapples

A one small orange

A nurse has arrived at the site of an accident where a client has sustained a traumatic amputation of the big toe. Identify the sequence of steps the nurse should take to treat the musculoskeletal trauma. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A: Call 911 and examine the amputation site. B: Apply direct pressure with layers of dry cloth. C: Elevate the extremity above the client's heart. D: Find the toe and wrap it in sterile gauze in a clean cloth. E: Place the toe in a bag and place the bag in 1 part ice and 3 parts water.

A, B, C, D, E

a nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include? A. monitor the site daily for drainage b. leave the pressure dressing on for 48 hr. C. administer aspirin if the child reports pain

Audi ⁹9 -monitor for infection, drainage, redness, and swelling

A nurse is assessing a client who reports gastrointestinal distress. Which of the following findings should indicate to the nurse that the client has cholecystitis? A: Abdominal pain triggered by spicy food B: Abdominal pain that radiates to the right shoulder C: Abdominal pain in the right lower quadrant D: Abdominal pain that is continuous over several days

B

A nurse is caring for a client who has left hemiparesis following a stroke. Which of the following actions should the nurse take? A: Use a gait belt and stand on the client's right side to assist with ambulation. B: Encourage the client to use wide-grip utensils when eating with the right hand. C: Place personal items on the bedside table close to the bed on the client's left side. D: Remove rolled toilet paper from the holder for easier access for the client

B

a nurse is preparing to administer medication to a client who has a hx of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy? A. ginkgo biloba B. digoxin C. hydrochlorothiazide

C -a diuretic, and hypertension

a nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect a. calcium 9.5 mg/dl b. bicarbonate 23mEq/L c. potassium 3 mEq/L

C. -pt is expected to be hypokalemic, -

A nurse is reviewing the urinalysis results of a client who has completed a 14-day course of ciprofloxacin to treat pyelonephritis. WHich of the following values should indicate to the nurse that the client has a continuing infection? A: Negative nitrites B: RBCs < 2 C: Positive leukocyte esterase D: Amber-colored urine

C: Positive leukocyte esterase

a nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect a. fever b. dyspepsia c. pain radiating to the left should d. blood tinged stool e. eructation

a, b, e -pain radiates to right shoulder, fever, clay colored stool, eructation or belching

A nurse is assessing for manifestations of hyponatremia in a client who has been taking twice the prescribed dose of a diuretic. Which of the following findings should the nurse expect?A: Increased deep tendon reflexesB: Hypoactive bowel soundsC: Decreased level of consciousnessD: Bradycardia

c

a nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately? a. flank pain with radiation toward the scrotum b. 150 ml emesis c. oliguria with bladder distention

c. -bladder distention can be a sign of bladder obstruction

a nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. which of the following findings should the nurse identify as an adverse effect of this medication a. increased salivation b. bradycardia c. tinnitus d. distended bladder

d

a nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan. A. elevate the client's arm above the heart B. apply heat to the clients surgical site c. instruct client to avoid moving their fingers d. monitor the clients ability to complete wrist range of motion

elevate the client's arm above the heart - minimizes swelling of the surgical site and decreases discomfort

a nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer? A. lithium carbonate B. escitalopram C. methylphenidate

escitalopram

a nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as part of the second stage of the grieving process. A. persistent feelings of hopelessness B. loss of self-esteem c. feeling anger toward family members

feeling anger toward family members -stages of grief are denial, anger, bargaining, depression, acceptance

a nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include? A. wear open-toe shoes to allow air B. file your toenails straight across to prevent ingrown toenails C. apply a thin layer of lotion between toes twice daily

file your toenails straight across to prevent ingrown toenails

a nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching? A. decrease your calcium intake B. you should consume at least 2400 mg of salt per day C. limit the amount of spinach in your diet

limit the amount of spinach in your diet -food is high in oxalates, restrict spinach, tea, nuts, chocolate, strawberries, - pt shouldnt restrict calcium intake, but maintain it at 800-1200 mg per day

a nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. the client's ABG's results are pH 7.50, paCO2 29mmhg, HCO3 25 mEq/L. The nurse should interpret that these values are an indication of which of the following acid base imbalances? a. metabolic alkalosis b. metabolic acidosis c. respiratory alkalosis d. respiratory acidosis

respiratory alkalosis - caused by hyperventilation as an excess loss of co2. youll have elevated PH and decreased pa co2

A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. chest x ray results show increased lung space B. sputum culture show gram positive bacteria C. SPO2 level is 88%

sputum culture show gram positive bacteria

a nurse is admitting a client who has peptic ulcer disease and upper gastrointestinal bleed. Which of the following manifestations should the nurse expect? select all that apply. a. dark, tarry stool b. bright red emesis c. increased heart rate d. increased bp e. bounding peripheral pulses

a,b,c

a nurse is assessing a client who has developed C. diff. as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe to treat the C. diff? a. vancomycin b. magnesium hydroxide c. rifampin

a

a nurse is assessing a client whose parent recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving? a. the client lost his house in a house fire 1 month ago b. client retired 30 years ago c. the client's parent was an older adult

a

a nurse is assessing a school age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority? a. inaudible lung sounds b. yellow zone peak flow meter reading c. prolonged expiration phase

a

a nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching? a. bacterial infection with e. coli b. Long-term use of NSAIDS c. Frequent use of proton pump inhibitor

b

a nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching? a. i should avoid taking this medication with milk b. i will return to have my cholesterol levels checked in 2 weeks c. i understand that muscle tenderness is an expected result of this medication

b

a nurse is caring for a school age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first? a. encourage the child to take frequent sips of cool fluids b. apply humidified oxygen with a simple mask c. start a peripheral access iv

b - opens airway -a is incorrect/correct because its not the first step

a nurse is assessing a client for manifestations of right-sided heart failure. which of the following findings should the nurse expect? A. jugular vein distention B. fatigue C. angina D. hacking cough

jugular vein distention -fatigue, angina, hacking cough are all manifestations of left side hrt failure

a nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect? a. hypertension b. somnolence c. oliguria

olguria -heat stroke leads to low fluids, dehydration and oliguria, anxiety, bizarre behavior, agitation

a nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse instruct the parent to report to the provider? A. swollen cervical lymph nodes B. exudate on tonsils C. onset of abdominal pain

onset of abdominal pain -report this because this indicates splenomegaly

a nurse is assessing a client who musculoskeletal trauma following motor-vehicle crash 2 days ago. which of the following findings should the nurse report to the provider? *pt. has a cast. a. blood pressure b. pain report (8 out of 10 from pain medications c. ecg results (tachycardia)

pain report - indicates compartment syndrome with cast

A nurse is caring for a client who has Cushing's disease. The nurse should identify that the client is at risk for which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

B - Cushing syndrome, adrenocorticotropic hormone levels are low due to hyper secretion of the adrenal cortex. leading to an increase in renal excretion of potassium "HYPOKALEMIA"

a nurse is reviewing the medical record of a client who has age related macular degeneration. which of the following findings should the nurse identify as a risk factor for this visual impairment? A. male sex B. hypertension C. osteoporosis

B

A nurse in an emergency department is caring for an adolescent who died following a motor vehicle crash. Which of the following reactions should the nurse expect the client's 10-year-old sibling to exhibit? a. the sibling believes the client will wake up in few hours b. the sibling is curious about what happen to the client's body.

B - 10 year old child to be inquisitive about what happens to the body and what will occur during funeral or memorial services - a preschooler to believe is that death is temporary, or a type a sleep, not a 10 year old

A nurse is caring for a preschooler who has a terminal illness. Which of the following reactions to death should the nurse expect the preschooler to exhibit? (Select all that apply.) A: Fears transmitting their disease to others B: Personifies death as being a type of monster C: Exhibits interest in what happens to the body following death D: Believes death is a temporary type of sleep E: Believes that their own thoughts can cause death

( D, E ) -preschooler view death as a temporary condition like sleep, believe their thoughts can cause death, which can lead to feelings of guilt and shame - school age kids view death as a type of monster, fear of transmitting disease, and exhibit interest in what happens to the body following death.

a nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? A. inhale the second puff of cromolyn 2min after the first B. use the cromolyn following exercise if shortness of breath occurs C. Use the albuterol prior to planned exercise

C. Use the albuterol prior to planned exercise. -pt who have asthma, albuterol should be used 5 to 20 min prior to exercise.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. brown discoloration of the lower extremities B. superficial ulcer on the medial aspect of the ankle C. dependent rubor D. telangiectasias

C. dependent rubor -nurse should expect redness to the lower extremities, or dependent rubor, when the clients legs are dangling or in a dependent position incorrect A because brown discoloration of lower extremities is VENOUS INSUFFICIENCY.

A nurse is teaching a client who has scabies about a new prescription for lindane lotion. Which of the following client statements indicates an understanding of the treatment for this parasitic infection?? A: "I will apply the lotion once a day for 1 week." B: "I will rub in the lotion thoroughly from my face to my toes." C: "I will wash the lotion off 12 hours after I apply it." D: "I should avoid bathing for 6 hours prior to applying the lotion."

c -leave lotion for 8-12hrs and then remove it by washing it off

a hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make? A. youre sad now, but grief will pass eventually B. you should attend a grief support group to see how others cope with loss C. what are some of the best times with your partner that you remember

what are some of the best times with your partner that you remember? - encouraging reminisce allows client to acknowledge the loss and to progress through the grief process

a nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. which of the following findings should the nurse identify as an indication that the client's nutritional status is improving? a. intake of fluid is less than output over the past 2 days B. 1 kg weight gain over the past 2 days C. blood glucose 206 mg/dl

1 kg weight gain over the past 2 days -indicates client is responding to the parenteral nutrition.

A nurse in an emergency department is caring for a client whose ABG results are pH 7.31, PaCO2 50 mm Hg, and HCO3 25 mEq/L after experiencing an airway obstruction. Which of the following interventions is the nurse's priority for the client? A: Apply oxygen therapy to the client. B: Administer an anti-inflammatory medication. C: Check the client's nail beds. D: Initiate IV fluid therapy.

A

A nurse is assessing a 1-hour-old newborn who has hypothermia, with a temperature of 36.1° C (97° F). Which of the following manifestations should the nurse expect? A: Hypoglycemia B: Flushed skin C: Tachycardia D: Hypertonicity

A

A nurse is assessing a client who has pernicious anemia. Which of the following findings should the nurse expect? A: Numbness of hands B: Gingival hyperplasia C: Clay-colored stools D: Carotid bruits

A

A nurse is teaching a male client who has hypertension about dietary guidelines to help manage his disorder. Which of the following instructions should the nurse include? A: Reduce sodium intake to 1,500 mg/day or less. B: Maintain a BMI of 30. C: Add high-protein sources, such as beef and pork, to the diet. D: Limit alcohol consumption to no more than three drinks per day.

A

A hospice nurse is caring for a preschooler who has a terminal illness. One of the child's parents tells the nurse that it is too difficult to cope any longer and has decided to move out of the house. Which of the following responses should the nurse make? A: "Let's talk about a few ways you have dealt with stress in the past." B: "I believe that you will regret that decision. Your family needs your support." C: "I agree that you have to do what is best for your well-being at this time." D: "I think you should try to put your feelings aside and focus solely on your child."

A

A nurse in an emergency department is caring for a client who has heat stroke. Which of the following actions should the nurse take to treat this form of hyperthermia? A: Apply ice packs to the client's axillae, neck, groin, and chest. B: Administer aspirin to the client C: Initially offer the client cool, oral fluids. D: Continue cooling measures until the client's rectal temperature is 37.2º C (99º F).

A

A nurse in an emergency department is caring for a client who reports abdominal pain, vomiting, and appears dehydrated. The client's ABG results are pH 7.28, PaCO2 36 mm Hg, and HCO3 14 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

A

a nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices by the client indicates an understanding of the teaching? A. a black bean burger on a whole grain bun B. oatmeal with whole milk C. a baked potato with butter

A

A nurse is caring for a client who has had prolonged vomiting, has an NG tube for gastric decompression, and is receiving total parenteral nutrition. The client's ABG results are pH7.48, PaCO2 50 mm Hg, and HCO3 30 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic alkalosis B: Metabolic acidosis C: Respiratory acidosis D: Respiratory alkalosis

A -

A nurse is teaching a client ways to prevent osteoporotic fractures due to osteoporosis. Which of the following information should the nurse include in the teaching? A: "Maintain bone health by eating fruits, vegetables, and protein. "B: "Tamsulosin can slow the progression of bone deterioration." C: "Walk 20 minutes two times a week to manage osteoporosis." D: "Start to increase vitamin C and magnesium in your diet."

A -

A nurse is providing discharge teaching for a client who has a hearing impairment. Which of the following actions should the nurse take? A: Encourage the client to repeat what the nurse has said. B: Stand to the side of the client and speak directly into the client's ear. C: Talk to the client by speaking in a loud tone of voice. D: Avoid the use of hand gestures and motions when speaking with the client.

A - don't stand to the side and speak in clients ear, stand in front

A nurse is assessing a school-age child who has appendicitis with possible perforation. Which of the following findings should the nurse identify as a manifestation of peritonitis? A: Abdominal distention B: Bradycardia C: Hyperactive bowel sounds

A - you would expect abdominal distention, hypoactive not hyperactive, rapid shallow breathing, and tachycardia

A nurse is teaching a client who has a new prescription for finasteride to treat benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching?A: "You might need to take the medication for several months before seeing any relief." B: "This medication will cause an increase in your libido." C: "You might experience prolonged erections while taking this medication." D: "This medication will elevate your blood pressure."

A -6-12 months for finasteride to kick in - a decrease in libido (sexual desire)

A nurse is assessing a client who reports vision impairment and is diagnosed with primary open-angle glaucoma (POAG). Which of the following findings should the nurse expect? A: Progressive loss of peripheral vision B: Opacity of the lens of the client's eye C: Impaired central vision D: Report of seeing floating dark spots

A -a report of progressive loss of peripheral vision, not central vision (macular degeneration)

A nurse is providing postoperative education for a client following a laparoscopic cholecystectomy for cholelithiasis. Which of the following client statements indicates an understanding of the teaching? A: "The adhesive bandages on my incision will fall off as the incision heals." B: "I will be able to take a shower in 1 week." C: "I will need to follow a liquid diet for the first 3 days after surgery." D: "I can begin to resume my normal activity level in 2 weeks."

A -adhesive bandages lose their adhesiveness in 7 to 10 days. client can remove the bandages or allow the bandages to fall off over time - should shower or bathe the day following surgery - can resume regular diet following surgery and slowly introduce foods containing fat to determine tolerance - rest for the first 24hrs following surgery and then begin resuming normal activities. usually can resume usual activities within 1 week.

A nurse is teaching the parent of a school-age child who has pediculosis capitis about treating this parasitic infestation. Which of the following instructions should the nurse include? A: Wash bedding, clothes, and towels in hot water in a washing machine. B: Rinse the child's hair with vinegar three times a day. C: Seal items that are not machine washable in plastic bags for 1 week.

A -c is incorrect because items that are not washable should be sealed for 14 days

A nurse is assessing a client who has a calcium level of 6.3 mg/dL. Which of the following findings should the nurse expect? A: Circumoral tingling B: Hypoactive reflexes C: Fatigue D: Anorexia

A -hypocalcemia causes paresthesias (tingling), hyperactive reflexes, Chvostek's sign (facial muscles tightening), -hypercalcemia causes anorexia, fatigue, nausea, vomiting, constipation, hypoactive reflexes

A nurse is assessing a client whose ABG results are pH 7.51, PaCO2 29 mm Hg, and HCO3 24 mEq/L. Which of the following findings should the nurse expect A: Paresthesias B: Bradycardia C: Muscle flaccidity D: Respiratory depressio

A -symptoms of respiratory alkalosis is numbness and tingling or paresthesia due to decrease in calcium ionization. other include light headedness, tachycardia, and cardiac dysrhythmias

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? (Select all the apply.) A: Nocturia B: Dependent edema C: Dyspnea D: Hacking cough E: Anorexi

A, C, D

A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take? A. observe the client perform the incentive spirometry B. administer the influenza vaccine C. provide teaching about antibiotic therapy.

A. observe the client perform the incentive spirometry -best priority

A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by mRSA. which of the following client statements indicates an understanding of the teaching? A. i will soak in a bathtub one-forth full of water with one-half cup of bleach B. i will wash clothes in cold water and detergent C. i will throw away my razor after using it three times

A. i will soak in a bathtub one-forth full of water with one-half cup of bleach -twice a week at least soaked for 5min

A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect? A. increased urination B. sweating c. dizziness

A. increased urination -nurse should also expect client to exhibit hyperglycemia, thirst, nausea, vomitting, increased urination, flushed dry skin, weak rapid pulse, acetone breath odor

A nurse is caring for a client who is experiencing an asthma attack. which of the following procedures should the nurse use to assess the client's respiratory status? A. peak expiratory flow meter testing B. spirometer C. pulmonary function testing

A. peak expiratory flow meter testing -provides information on how well asthma is being controlled as a part of daily monitoring and can be used for pt. having an asthma attack.

A nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make? A. Arranging small stuffed animals in the crib is recommended to provide a feeling of security for your baby B. dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet.

B

A nurse is providing teaching to a client who has chronic obstructive pulmonary disease (COPD). Which of the following statements should indicate to the nurse that the client understands the teaching? A: "I should drink 1.5 liters of water daily to keep hydrated." B: "I should make my abdomen rise with each inhalation." C: "I should inhale through my mouth and exhale through my nose." D: "I should limit walks to 10 minutes daily in order to conserve my energy."

B

a nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching? A. avoid lifting objects greater than 50lbs B. consume a clear liquid diet until symptoms resolve

B

A nurse is teaching disease management techniques to a client who has COPD. Which of the following instructions should the nurse include in the teaching? A: Avoid activities that increase the respiratory rate. B: Use pursed-lip breathing when feeling short of breath. C: Consume a diet high in carbohydrates for increased energy. D: Limit fluid intake to 1.5 L daily

B

A nurse on a mental health unit is developing a plan of care for a client who is experiencing a panic level of anxiety. Which of the following actions should the nurse identify as a priority? A: Reduce environmental stimulation. B: Protect the client from harm. C: Administer an anxiolytic. D: Encourage physical exercise.

B

A nurse is caring for a client who has a fear of open spaces. WHich of the following clinical names for this fear should the nurse document in the client's medical record? A: Pyrophobia B; Agoraphobia C: Monophobia D: Astraphobia

B - agoraphobia is the fear of being outside and can be debilitating and limits a clients ability to function.

A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse report to the provider immediately? A: WBC 16,000/mm³ B: Board-like abdomen C: Nausea and vomiting D: Temperature of 38° C (100.4°

B - board-like abdomen indicates peritonitis, this is urgent - wbc of 16000 is non urgent and is expected, the same with N/V, and temperature of 100.4f

A nurse is assessing a client who has as an ulcer due to peripheral vascular disease. Which of the following findings should the nurse identify as an indication that the client has a venous ulcer rather than an arterial ulcer? A: Diminished peripheral pulsations in the right lower leg B: Discoloration and edema of the right ankle C: Atrophy of the skin and hair loss on the right leg D: Dependent rubor in the right leg

B - discoloration and edema of ankle -all other are symptoms of PAD

A nurse is teaching a client who has asthma about using a metered-dose inhaler. Which of the following client statements indicates an understanding of the teaching? A: "I'll roll the canister between my palms a few times before using it." B: "I'll take a deep breath and blow it out before I inhale the medication." C: "I'll hold the mouthpiece 3 inches in front of my mouth before depressing the canister." D: "I'll hold my breath for up to 5 seconds after inhaling the medication."

B - like a free throw

A nurse is assessing a school-age child who has diabetes mellitus and a blood glucose level of 250 mg/dL. Which of the following findings should the nurse expect?A: Hyperreflexia B: Fruity breath odor C: Sweating D: Shallow respirations

B - likelyhood to have a fruity or acetone breath odor, lethargy, thirst, confusion

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings is a priority to report to the provider? A: Melena stools B: Hemoglobin 7.6 mg/dL C: Weight gain of 1.4 kg (3 lb) in 2 weeks D: Dyspepsia during the day

B - normal hemoglobin is 11.7-16.1, 12.6-17.4, low hgb means low bleeding -melena stools are from peptic ulcers that bleed but are not urgent.

A nurse is reviewing the medical record of a client who has a family history of gallstones. Which of the following findings should the nurse identify as a risk factor for developing cholecystitis?A: Client is an adult male. B: Client is taking atorvastatin. C: Client is of Asian descent. D: Client has a history of asthma

B -atorvastatin increases risk of developing cholecystitis. - females, especially between ages of 20-60 are at increase risk for cholecystitis, American Indians, Mexican Americans, or caucasian descents are at greater risk, -crohns disease or DM can increase risk

A nurse is planning care to prevent hospital-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection for a client who is immunocompromised. Which of the following interventions should the nurse include to prevent this antibiotic-resistant infection? A: Initiate contact precautions for this client. B: Bathe the client with chlorhexidine wipes. C: Administer ceftaroline to the client as a prophylactic measure. D: Avoid using alcohol-based hand sanitizers after caring for the client

B -clean pt. with chlorhexidine wipes to decrease risk of hospital-acquired MRSA, put pt in protected environment.

A nurse is providing teaching to a client who is experiencing malabsorption related to lactose intolerance. Which of the following foods should the nurse recommend to the client as the best nondairy source of calcium? A: Ground beef B: Collard greens C: Cauliflower D: Walnuts

B -contains 268mg of calcium, beef contains 20mg of calcium

A nurse is planning care for a client who has chemotherapy-induced anemia and is starting epoetin. Which of the following interventions should the nurse include in the plan? A: Shake the medication vial prior to drawing up the medication. B: Withhold epoetin if hemoglobin is less than 9 g/dL. C: Initiate contact isolation. D: Monitor for hypertension.

B -epoetin causes hypertension, M.I and strokes - anemia doesn't need contact precaution

a nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is at risk for malnutrition? A. wbc count B. albumin level c. CD4 T cell count

B -low albumin level indicates risk for malnutrition

A nurse is planning care for a client who has generalized anxiety disorder. Which of the following interventions should the nurse include in the client's plan of care? A: Give the client detailed instructions. B: Reframe situations in a positive manner for the client. C: Speak in a brisk manner to the client. D: Avoid involving the client in problem solving

B -they tend to worry excessively, reframing them positively offers the client a fresh perspective and helps adjust his thought distortions -not a because someone with G.A.D. might have difficulty concentrating and following directions

A nurse in an emergency department is assessing a client who has hyperthermia. Which of the following findings should the nurse identify as an indication that the client has heat exhaustion? A: Hallucinations B: Vomiting C: Bradycardia D: Seizures

B -you would have excess sweating leading to dehydration, nausea, vomiting, headache, dizziness, fainting, and tempt. 101 and 102 f

A nurse is teaching a client who is at moderate risk for osteoporosis about ways to help prevent this chronic disease. Which of the following instructions should the nurse include? (Select all that apply.) A: Avoid sun exposure. B: Increase dairy product intake. C: Engage in weight-bearing exercises regularly. D: Increase phosphate intake. E: Reduce excessive caffeine intake

B, C, E -phosphate reduces calcium need for bone remodeling

a nurse is assessing a client in the triage room of an emergency department. "reports weight loss, lethargy, and night sweats over the last 3 weeks." A. perform rapid influenza testing B. place a surgical mask on the client C. request a prescription for a single dose short-acting insulin.

B. - the symptoms are signs of tb

A nurse is providing teaching to a client who has a hearing impairment and has a new prescription for a hearing aid. Which of the following client statements indicates an understanding of the teaching? A: "I should wipe off the hearing aid each day with an alcohol wipe." B: "I will change the battery in the hearing aid when it makes a whistling sound." C: "I will make sure the hearing aid is off before inserting it in my ear." D: "I should start wearing the hearing aid for at least 1 hour at a time."

C

a nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make? A. place child in cool bath for 20min twice a day B. avoid giving aspirin C. give 8 doses of acetaminophen in 24hrs.

B. aspirin increases rye fever

A nurse is assessing an 18-month toddler who has gastroenteritis with dehydration. The toddler is able to consume 3ml of oral rehydration solution every 5min but still has emesis and diarrhea. Which of the following medications should the nurse anticipate administering to the toddler? A. bumetanide B. ondansetron C. Loperamide

B. odansetron med for gastroenteritis and dehydration

A nurse is caring for a client who has severe hyperthermia. Which of the following actions should the nurse take. A. heat the clients body by using external rewarming devices. B. contact a specialized team to place the client on cardiopulmonary bypass.

B. severe hypothermia required a specialized team.

A nurse is teaching a client who has hypothyroidism about taking levothyroxine. Which of the following statements should the nurse make? A: "You'll need to take this medication once a day at bedtime." B: "This medication causes adverse effects if the dosage is too high or too low." C: "Continuing this medication therapy long-term will eventually cure your hypothyroidism." D: "Potassium supplements can reduce the effectiveness of this medication."

B: "This medication causes adverse effects if the dosage is too high or too low."

A nurse is assessing a client for manifestations of grief after having a colostomy for removal of colon cancer. Which of the following findings indicates to the nurse that the client has accepted the loss? A: Becomes angry when it is time to perform colostomy care B: Touches the colostomy stoma when the bag is changed C: Looks away as the nurse empties the colostomy bag D: Tells others that it will be nice to have a normal bowel movement again

B: Touches the colostomy stoma when the bag is change

A nurse is caring for a client who has generalized anxiety disorder and is experiencing a mild level of anxiety. Which of the following manifestations should the nurse expect? A: Chest pain B: Hallucinations C: Feels unreal D: Follows directions

D

A nurse is assessing a client who has Graves' disease. Which of the following findings should the nurse expect? A: Somnolence B: Cold intolerance C: Exophthalmos D: Dry, scaly skin

C

A nurse is assessing a client who has a potassium level of 2.6 mg/dL and is receiving potassium chloride by continuous IV infusion. Which of the following findings should the nurse identify as an indication that the potassium infusion has brought the client's potassium level back to the expected reference range? A: The client's ECG shows inverted T waves. B: The client's bowel sounds become hyperactive. C: The client's hand grasp becomes stronger. D: The client's standing systolic BP is within 30 mm Hg of her sitting systolic BP.

C

A nurse is assessing a client who is 1 hour postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. For which of the following assessment findings should the nurse notify the provider? A: Urine color is light pink. B: The suprapubic area is soft to palpation. C: The catheter tubing has multiple red clots.

C

A nurse is caring for a toddler who sustained a left lower leg fracture in a motor vehicle crash. The toddler, who has light-pigmented skin, received a cast 24 hours ago. Which of the following assessment findings from the casted leg should the nurse report to the provider? A: The toddler's toes are pink in color. B: The toddler's foot swells when dependent. C: The toddler's toe movement is limited. D: The toddler's capillary refill time is less than 2 seconds.

C

A nurse is planning care for a client who has renal calculi. WHich of the following interventions should the nurse include to promote elimination of the calculi? A: Maintain bedrest until calculi are expelled. B: Withhold thiazide diuretics. C: Encourage intake of at least 3 L of fluid each day. D: Collect all urine for 24 hr in a collection containe

C

A nurse is teaching a client who has atherosclerosis about self-care. Which of the following instructions should the nurse include in the teaching? A: Consume five to seven servings of red meat per week. B: Limit daily calorie intake from saturated fat to 18%. C: Increase fiber intake to at least 30 g per day. D: Exercise 2 days a week for at least 60 min

C

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following manifestations should the nurse expect? A: Otitis media B: Parotitis C: Facial eruption D: Lymphadenopathy

C

A nurse is providing teaching an adolescent client who mRSA. which of the following instructions should the nurse provide to prevent the spread of this infection? a. bath in a tub of warm water using mild soap twice daily b. place soiled dressing bandages in a red biohazard bag for disposal C. do not return to football practice until the infection has healed

C - pt should not bath in mild soap, instead use antibacterial soap, and the soiled bandages should be placed in a sealed bag then disposed in regular trash bin, no need for biohazard bag

A nurse in an emergency department is assessing a client who is experiencing mild hypothermia. Which of the following manifestations should the nurse expect? A: Stupor B: Decreased pulse C: Slurred speech D: Dysrhythmias

C - shivering, slurred speech, decreased coordination, and diuresis is expected finding of mild hypothermia

A nurse is providing home care instructions to a client who had a short-arm plaster cast applied for a wrist fracture. Which of the following instructions should the nurse include? A: Apply heat for the first 48 hr. B: Wear a sling when resting in bed. C: Elevate the wrist above heart level. D: Use a soft-bristle toothbrush to relieve itching under the cast.

C -always elevate the wrist above heart level to reduce swelling and minimize pain, apply ice for 24-36 hrs, wear sling out of bed, never insert any foreign objects down into the cast, for itching blow cool air from hair dryer to itchy spot.

A nurse is assessing a client who has been taking antacids frequently for gastrointestinal distress. The assessment findings include drowsiness, muscle weakness, bradycardia, and hypotension. Which of the following electrolyte imbalances should the nurse suspect? A: Hypophosphatemia B: Hypochloremia C: Hypermagnesemia D: Hypernatremia

C -antacids and laxatives (think of mom supplements) contain magnesium that can cause hyper magnesium. symptoms include hypotension, bradycardia, absent deep tendon reflexes, weak skeletal muscle contraction, ecg changes, muscle contraction, drowsiness that can progress into traumatizes.

A nurse is assessing a client who is 1 day postoperative following open ileostomy placement to treat an inflammatory bowel disorder. Which of the following findings is the priority for the nurse to report to the provider? A: The stool is a dark green liquid with a small amount of blood. B: The ileostomy output is 1,000 mL for the past 24 hr. C: The stoma is purple in color. D: The output from the NG tube has decreased over the past 24 hr

C -stoma should be pink to bright red in color and shinny. a stoma that is purple, pale bluish, dark red-purplish, or black in color is not receiving adequate blood supply. a decrease in ng fluid is nonurgent because it's an expected finding for a client postoperative.

A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for extended-release metformin. Which of the following client statements indicates an understanding of the teaching? A: "I will avoid drinking grapefruit juice." B: "I will chew the medication if I can't swallow it whole." C: "I will call the doctor if I have muscle pain in my back." D: "I will take this medication on an empty stomach."

C, muscle aches, sleepiness, malaise, and hyperventilation manifest for lactic acidosis

A nurse is caring for a client who has cellulitis of the lower extremity. Which of the following actions should the nurse take? (Select all that apply.) A: Apply cold packs to the affected area. B: Treat the affected area with propranolol. C: Elevate the affected area 15.24 cm (6 in) above the heart. D: Place a dry heating pad over the affected area. E: Administer cefazolin intermittent IV bolus

C, E

A nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease? A. bmi of 26 or above B. frequent weight bearing exercises C. hip fracture 6 months ago

C. hip

A nurse is teaching a client who has asthma how to use a peak flow meter. Which of the following statements should the nurse identify as an indication the client understands the teaching? A: "I will blow out as hard as I can before I use the peak flow meter." B: "I will not take my controller medication if my peak flow meter scores in the yellow zone." C: "I will base my peak flow meter score on the best of three attempts." D: "I will go to the emergency room if my peak flow meter is in the green zone.

C: "I will base my peak flow meter score on the best of three attempts."

A nurse is planning care for a client who had surgery for osteomyelitis from a past musculoskeletal trauma to the lower leg. Which of the following interventions should the nurse include in the plan of care? A: Position the affected leg flat when sitting up in bed. B: Instruct the client to perform weight-bearing activities on the affected leg. C: Check for paresthesia of the affected leg. D: Apply heat to the surgical incision area of the affected leg.

C: Check for paresthesia of the affected leg.

A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death? A: Adolescents cope with death better than children of other ages. B: Adolescents view funeral services as an opportunity for closure. C: Adolescents are more concerned with the past than the present or future. D: Adolescents often alienate themselves from their peers when grieving.

D

A nurse in an emergency department is assessing a preschooler who has severe dehydration as a result of gastroenteritis and is receiving isotonic IV fluids. Which of the following findings should the nurse identify as an indication that the treatment is effective? A: Urine output 0.5 mL/kg/hr B: Capillary refill 3 seconds C: Heart rate 148/min D: Brisk skin turgor

D

A nurse is admitting a client who has an acute bacterial wound infection and a temperature of 39.8° C (103.6° F). Which of the following actions should the nurse take? A: Obtain a wound culture 30 min after initiating IV antibiotics. B: Place a fan on the lowest setting in the client's room. C: Apply a cooling blanket directly on the client's skin. D: Set the temperature of the client's room to 22.2° C (72° F)

D

A nurse is assessing an older adult client who is experiencing malnutrition. Which of the following findings should the nurse expect? B: Diaphoretic skin C: Clubbing of fingers D: Brittle hair

D

A nurse is reviewing the laboratory report of a client who is taking exenatide to treat type 2 diabetes mellitus. The nurse should recognize that which of the following laboratory results is an indication of an adverse reaction to the medication? A: HbA1c 6.8% B: Hct 45% C: Creatinine 0.9 mg/dL D: Lipase 185 units/L

D - lipase levels are 0-160 units/L

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux about home care. Which of the following statements by the parent indicates an understanding of the teaching A: "I should feed my infant a larger amount of formula less frequently." B: "I should feed my infant a bottle of formula within 1 hour of bedtime." C: "I should place my infant on his side to sleep." D: "I should add 1 teaspoon of rice cereal to my infant's formula."

D - rice cereal thickens the formula and decreases the incidence of GER, pt should place bb on his back to sleep

A nurse is teaching a client who has type 1 diabetes mellitus about actions to take when having manifestations of hypoglycemia with a glucometer reading between 40 and 60 mg/dL. Which of the following instructions should the nurse include? A: Self-administer 1 mg of glucagon subcutaneously. B: Self-administer 20 units of regular insulin. C: Drink 120 mL (4 oz) of skim milk. D: Drink 120 mL (4 oz) of fruit juice.

D - skim milk should be given at 8oz not 4oz

A nurse is providing discharge teaching to an older adult client who had surgery to treat visual impairment due to cataracts. Which of the following client statements indicates an understanding of the teaching? A: "I will keep an eye patch in place for the first 3 days after surgery." B: "It is okay for me to lift my 2-year-old granddaughter." C: "I will be able run the vacuum cleaner in a day or two." D: "It might take 4 to 6 weeks for my vision to fully improve."

D -4-6 weeks for optimal recovery. wear eye patch at night while sleeping to prevent rubbing of the affected eye, not continuously

A nurse in an emergency department is assessing a client who reports severe constipation. The nurse should identify which of the following findings as an indication that the client might have a small-bowel obstruction?A: Peripheral edema B: Minimal vomiting C: Intermittent cramping in the lower abdomen D: Visible peristaltic waves in the upper abdomen

D -c is is large bowel obstruction

A nurse is developing an in-service for a group of coworkers about adolescents' reactions to death. Which of the following information should the nurse include when discussion an adolescent's response to death? A: Adolescents cope with death better than children of other ages. B: Adolescents view funeral services as an opportunity for closure. C: Adolescents are more concerned with the past than the present or future. D: Adolescents often alienate themselves from their peers when grieving.

D -difficulty communicating their feelings and alienate themselves from peers and family. - they're focused on the present, view funeral service as unnecessary, have difficulty coping with death and dying.

A nurse in a provider's office is assessing a preschooler who has developed contact dermatitis following exposure to poison ivy. Which of the following statements should the nurse make to the child's parent regarding disease management? A: "Wash your child's exposed clothing in cold water using powder detergent." B: "Keep your child away from other children for 10 days after lesions appear." C: "Scrub your child's affected areas with an antibacterial soap every other day." D: "Place your child in an oatmeal bath using tepid water for 15 minutes."

D -tepid baths containing oatmeal or mineral oil can decrease itching and evenly disperse the antipruritic solution. never hot bath

A nurse is teaching a client who has gastroesophageal reflux disease about ways to prevent reflux. Which of the following information should the nurse include in the teaching? A: Drink tomato juice with the breakfast meal. B: Suck on peppermint when having indigestion. C: Elevate the head of the bed 10 cm (4 in) using wooden blocks. D: Plan to finish eating at least 3 hr before bedtime

D: Plan to finish eating at least 3 hr before bedtime.

a nurse is planning discharge teaching for the parent of a newborn. which of the following information should the nurse include? A. cover your newborn with a light blanket while she is sleeping B. Do not bathe your newborn immediately after she eats C. place your newborn in a crib with bumper pads

Do not bathe your newborn immediately after she eats - decrease risk of regurgitation, bathe the newborn every 2 or 3 days.

A nurse is providing teaching home care with the parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching? A. i should apply the cream only to the areas where there is a rash B. i should wash my child's bed linens and clothing in hot water and detergent. C. i should expect my child rash to go away within 72hrs after starting treatment.

I should wash my child's bed linens and clothing in hot water and detergent. -very contagious from mites, rash takes 2 to 3 weeks to heal, leave cream on child 8 to 14 hrs then bathe

a nurse is caring for a client who is experiencing a panic attack. which of the following actions should the nurse take? A. distract the client by having him complete a puzzle B. encourage the client to take a deep breath every 2 seconds C. Stay with client until manifestations subside

Stay with client until manifestations subside - ensures safety and conveys concern to the client

A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching? a. keep mouth open when sneezing b. block one nostril when blowing your nose c. use an ear wick candle to remove excess cerumen from the canal

a

a nurse is planning discharge for a postpartum client. The client tells the nurse she is having a subdermal implant placed for contraception at her 6 week follow-up examination and asks about the adverse effects of the implant. Which of the following manifestations should the nurse include? a. irregular bleeding b. fatigue c. shoulder pain

a

a nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse a. gonorrhea b. herpes genitalis c. hpv d. bacterial vaginosis

a - an infectious disease, should be reported to the cdc -other does not require reporting by the nurse

a nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider a. black tarry b. ringing in the ears c. urinary retention d. recent hallucinations

a - black tarry stool is a sign of bleeding in the gi and should be reported immediately

a nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurse assess? a. right upper quadrant b. right lower quadrant c. left lower quadrant

a - cholelithiasis is gallstones

a nurse is assessing a client who has DVT in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect? a. swelling b. coolness c. distended, tortuous veins

a - you'd expect swelling, redness, warmth, and aching of the extremity

a nurse is providing dietary teaching for a client who has GERD. the nurse should instruct the client to avoid which of the following items? a. caffeinated coffee b. shell fish c. apple juice

a -this decreases the tone of the lower esophageal sphincter and increases the exposure of acid to the esophagus. pt. should also avoid citrus, tomatoes, chocolate, peppermint, spearmint, alcohol, smoking, and tobacco.

a nurse is reviewing a client's home medication list during admission to a long term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis? (select all that apply) A. lidocaine 5% patches B. celecoxib C. vancomycin D. cyclobenzaprine E. glucosamine

a,b,d,e

a home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first? a. place the client in high-fowler's position b. encourage the client to perform diaphragmatic breathing c. instruct the client to perform a huff-coughing technique

a. -according to evidenced based practice, high fowler position facilitate ease of breathing

a nurse is providing dietary teaching to a client who is at 13 weeks of gestation and has hyperemesis gravidarum. which of the following statements should the nurse make? a. drink fluids between, rather than with, meals b. eat foods that are served warm c. do not go more than 6hr between meals

a. -avoid drinking fluids with meals which causes nausea

a nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect? -abdominal distention - flank pain - hypervolemia - vomiting - hyperactive bowel sounds

abdominal distention, vomiting, hyperactive bowel sounds

A nurse is teaching a client who has asthma about medications to treat an acute asthma attack. Which of the following medications should the nurse include in the teaching? A: Fluticasone B: Salmeterol C: Albuterol D: Montelukast

albuterol

A nurse is assessing the eyes and ears of a 2-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A: Presence of a transparent cornea B: Presence of strabismus C: Pinna moderately extends outward from the skull D: Walls of peripheral aspect of auditory canal are pink

b

a nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication? a. the client's skin is warm and moist b. the client reports sleeping longer during the night c. the client is experiencing increased bowel movements

b

a nurse is assessing a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate a. holding on to the left arm while ambulating b. stand on the right side and hold on the gait belt c. stand in front of the client walker

b

a nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take? a. palpate the left lower quadrant of the abdomen to check for rebound pain b. start IV fluid replacement c. treat the client's pain with oral opioids with food

b

a nurse is providing discharge teaching for a client who has a new diagnosis of COPD. which of Following client statements indicates and understanding of the teaching? A. i will quickly complete household errands in the morning before taking a break B. i will breath out slowly through pursed lips if i feel short of breath C. eat 3 large meals every day

b

a nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching? a. i should wash my feet with soap before i try to treat my calluses b. i should limit wearing the same shoes 2 days in a row c. i should use home remedies to treat any blisters or sores on my feet

b

a nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine. A. total bilirubin 0.8 mg/dl b. wbc count 4000/mm3 c. platelet 190,000/mm3

b

a nurse is reviewing the laboratory results of an adult male client who has hyperlipidimia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has achieved a therapeutic response? a. LDL 168 mg/dl b. HDL 50mg/dl c. total cholesterol 268 mg/dl

b

a nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. which of the following statements should the nurse include in the teaching? a. you can safely continue taking this medication if you become pregnant. b. this medication could cause you to have thoughts of self-harm c. you should take this medication 1 hour before eating

b - suicidal thoughts

a nurse is reviewing the lab report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect? A. ldl 100mg/dl B. AST 45 unit/L

b -hepatotoxicity

a nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take? a. apply warm dry packs initially then apply cool moist packs to the lower extremity. b. elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level. c. gently massage the affected extremity for 10-15 min every shift.

b -promote venous return and decrease edema

a nurse is caring for a client who has respiratory acidosis due to opioid oversedation. which of the following actions should the nurse take first. a. apply oxygen using a rebreather oxygen mask B. ensure a pt airway using chin-lift maneuver c. administer a reversal agent to the client

b -the first action, open the client's airway by performing a chin-lift maneuver

a nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take? a. administer an antiviral medication to the infant b. initiate droplet precautions for the infants c. limit the infant's oral intake of fluids to 60 ml/hr.

b -why A is wrong? its a bacteria not virus

a nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescriptions should the nurse expect the provider to prescribe? a. vitamin k b. protamine sulfate c. flumazenil

b protamine sulfate -it reverses the anticoagulant effects of heparin - vitamin k is prescribed for pts. receiving warfarin

A nurse is planning care for a client who is postoperative and has developed left lower leg deep-vein thrombosis. Which of the following interventions should the nurse include in the plan of care? A: Initiate complete bed rest. B: Massage the left lower leg three times a day. C: Make sure the client's legs are elevated while in bed. D: Apply cold compresses to the left lower leg every 2 hr.

c

A nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider? a. prothrombin time 12 seconds b. history of sinusitis several times yearly each year c. report of urinating small amounts twice daily

c

A nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider? a. wbc count 10000/mm3 b. magnesium 2 meq/l c. creatinine 2.5 mg/dl

c

A nurse on a pediatric unit is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? A: Place the child in a room equipped with a positive-pressure airflow system. B: Place the child in a room equipped with a negative-pressure airflow system. C: Initiate droplet precautions for the child. D: Initiate contact precautions for the child.

c

a nurse is assessing a 6-moth old infant who has bacterial pnuemonia. which of the following manifestations should the nurse expect? a. protruding tongue b. facial flushing c. nasal flaring

c

a nurse is assessing a client who has external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome? a. flushing of the skin on the right arm b. bounding pulse palpated in the radial artery c. numbness to the fingers on the right arm

c

a nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record? a. agorphobia b. xenophobia c. acrophobia

c

a nurse is providing teaching to a client who has mrsa skin infection. which of the following client statements indicates an understanding of the management of antibiotic resistant infections? A. i will keep the infected area open to air to help it heal b. i can sleep in the same bed as my partner after i have been taking antibiotics for 24 hrs c. i will wash all uninfected skin areas with a fresh washcloth.

c

a nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include? a. congenital hypothyroidism b. meconium staining at birth c. congenital heart disease

c

a nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect? a. epigastric distention b. large amount of emesis of fecal material c. ribbon-like stools

c -

A nurse is teaching a female adult client who is obese about disease management. Which of the following information should the nurse include in the teaching? A: Average body fat for women is 15%. B: Obesity can cause osteoporosis. C: Morbid obesity is measured as a BMI over 40. D: Coronary artery disease increases with a waist size of 81.28 cm (32 in).

c - CAD increases with a waist of 35, not 32

a nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect? a. hyperactive deep tendon reflexes b. abdominal distention c. bradycardia d. positive trousseau's sign

c - a manifestation of hypermagnesmia, as well as peripheral vasodilation and hypotension due to reduced membrane excitabillity -a,b,d are all signs of hypomagnesmia

a nurse is teaching a client who recently lost his partner to a terminal illness. The client asks how his 4 year old son is expected to react to the death of his partner. which of the following information should the nurse include in the teaching? a. a preschooler has no concept of death b. a preschooler is often interested in what happens to the body after death c. a preschooler often believes that death is reversible

c - child has no understanding of death,

a nurse is assessing a 6-month old infant who has gastroenteritis with mild dehydration. Which of the following findings should the nurse expect? a. absence of tear when crying b. loss of 6% body weight c. capillary refill greater than 2 seconds

c - infants who have mild dehydration have high cap refill

A nurse is caring for a client who has respiratory depression following opioid administration to control cancer-related pain. The client's ABG results are ph 7.28, PaCO2 49 mm Hg, and HCO3 24 mEq/L. Based on these findings, the nurse should identify that the client has which of the following acid-base imbalances? A: Metabolic acidosis B: Metabolic alkalosis C: Respiratory acidosis D: Respiratory alkalosis

c - respiratory acidosis indicates low ph, and high PaCO2, and normal HCO3

a nurse is providing teaching to a client who has osteoporosis. which of the following information should the nurse include in the teaching? a. increase daily intake of foods containing vitamin a b. limit alcohol consumption to 10 oz daily c. perform exercises to strengthen the abdominal core d. start a jogging regimen

c - strengthen the abs and back muscles to maintain stability of the spinal column and prevent vertebral fractures

A nurse is assessing a client who has social phobia and reports feeling fear and panic when at social gatherings. Which of the following medications should the nurse expect the provider to prescribe? A: Carbamazepine B: Risperidone C: Paroxetine D: Quetiapine

c -Its a ssri to treat anxiety

a nurse is caring for group of clients. which of the following clients should the nurse identify as being at risk for developing respiratory acidosis? a. a client who is anxious b. a client who has fever c. a client who has abdominal ascites

c -abdominal ascites can cause restriction of chest expansion, which impairs gas exchange

a nurse is providing teaching about exercises to a client who has osteoarthritis. Which of the following information should the nurse include? A. apply heat to the joints following exercise B. avoid aerobic exercises such as biking c. perform exercises even on days when the joints are painful

c -because consistency will help the management of the disease. The client can reduce the amount of exercise if joints are especially painful.

a nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take? A. restrict oral intake of clear liquids B. place a heating pad on the client's abdomen C. place the client in semi-fowler position

c -contains abdominal drainage in the lower abdomen and prevent it from seeping into peritoneum.

a nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complications of diabetes mellitus. Which of the following findings should the nurse expect? a. fruity-scented breath b. serum glucose 350 mg/dl c. hypotension

c -has glucose level at 600, decreased ph,

a nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which of the following actions should the nurse include? A. limit the amount of time the client spends with the newborn after birth. B. discourage the client from having other family members see the newborn C. bathe, diaper, and dress the child before bringing the newborn to the client.

c -tho baby isn't alive, it shows that the newborn has been cared for in a meaningful way -b is incorrect because clients want other family members to have the opportunity to see and hold newborn

a nurse is assessing a client for manifestations of GERD. which of the following findings indicates to the nurse that the client might have GERD? a. decreased salivation b. diarrhea c. globus

c. -the feeling of something being in the back of the throat, other manifestations are abdominal pain, flatulence, hypersalivation,

a nurse is providing teaching to a client who is postoperative following a transurethral resection of the prostate (TURP) for treatment of benign prostatic hyperplasia. Which of the following instructions should the nurse include in the teaching? a) notify your provider if you notice small pieces of tissue in your urine B) expect to see an increase in the amount of semen produced C) perform kegal exercises several times throughout the day

c. kegal exercises helps regain urinary control and eliminate dribbling or the leakage of urine.

A nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include. a. rinse the childs hair each day with cup of vinegar b. soak combs and brushes in hot water for 5 min c. Comb the child's hair daily with an extra fine-tooth comb

c. comb the child's hair

a nurse is providing teaching to the parent of a school age child who has severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include? A. administer the medication into your abdomen B. expect your child to sleep for several hours after recieving the medication C. give a second injection if the first fails to reverse your child's symptoms.

c. give a second injection if the first fails to reverse your child's symptoms.

a nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect? A. cold intolerance B. diaphoresis C. weight loss

cold intolerance - weight gain, poor wound heeling, bradycardia, hypotension, depression, constipation, decreased body temperature as a manifestations

a nurse is assessing a client who is receiving intravenous medications. which of the following findings should the nurse identify as a manifestation of respiratory acidosis? A. confusion B. flushed, moist skin C. bounding pulses

confusion

a nurse is assessing a client for manifestations of left-sided heart failure. which of the following findings should the nurse expect? A. weight gain B. enlarged liver C. distended abdomen D. cool extremities

cool extremities - due to decrease CO leading to impaired tissue perfusion

a nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended doses of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen? A. elevated aspartate aminotransferase (AST) levels B. decreased skin turgor C. elevated WBC count D. decreased audio acuity

elevated aspartate aminotransferase levels - indicated liver injury

a nurse is assessing an infant whose guardian reports, "my baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of following manifestations should the nurse expect for an infant who might have otitis media? A. enlarged postauricular lymph nodes B. Increased flatulence with constipation C. indicates a desire to suck more frequently

enlarged postauricular lymph nodes -

a nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following findings should the nurse identify as a risk factor for this condition? a. heredity b. gender c. anemia

heredity -risk factors are heredity, age, hypertension, dm, retinal detachment, severe myopia

a nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression? A. i teach my kids about children eating because my anxiety makes me want to overeat B. i started taking kickboxing classes to release the stress i feel from work C. i avoid thinking about the problem that worry me until i have time to focus on a solution

i avoid thinking about the problem that worry me until i have time to focus on a solution - this indicates an adaptive use of suppression -not B because its an adaptive use of displacement

A nurse is providing teaching for client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching? A. i will have best vision 3 weeks after my surgery b. i should report a creamy white discharge from my eye to my doctor C. i will avoid getting water in my eyes until the second day after surgery D. i should avoid using the vacuum cleaner for several weeks.

i should avoid using the vacuum cleaner for several weeks. -

a nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching? A. i will drink one and a half liters of fluids every day B. I will get the pneumonia vaccine yearly C. i will wash hands whenever i come home from the grocery store

i will wash hands whenever i come home from the grocery store -b is incorrect because pt. should get vaccine every 5 years

a nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching. A. i'll wash my feet every day with soap and lukewarm water B. its okay for me to go barefoot in the house, but not outside c. ill soak my feet every evening before bed

i'll wash my feet every day with soap and lukewarm water

a nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive? A. megastrol B. Ondansetron C. famotidine

megastrol

A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite? A. slowly institute rewarming of the affected areas B. place the affected areas of frostbite in a warm water bath C. massage the affected areas

place the affected areas of frostbite in a warm water bath

a nurse is reviewing the lab results of a client who is scheduled for surgery and notes a potassium level of 6 meq/L. which of the following ECG findings should the nurse expect? A. heart rate 64/min B. tall t waves C. shortened pr interval

tall t waves - a manifestation of hyperkalemia, effects myocardium and impacts the client's surgical risk

a nurse is planning care for a client following collection of admission date. Which of the following findings should the nurse identify as the priority client need? A. the client requests to see a priest for spiritual guidance B. the client reports coughing and a change of voice whenever he eats C. the client reports pain immediately following physical therapy

the client reports coughing and a change of voice whenever he eats -m

a nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect? A. pain with palpation to the substernal notch B. urinary burning C. ecchymosis over the flank

urinary burning - pt with acute pyelonephritis can experience burning, frequency, and urgency with urination.