ATI Medical Surgical
A nurse is assessing a client who has appendicitis. Which of the following findings should the nurse expect? (SOA) A. Oral temperature 38.4 C (101.1F) B. WBC count 6,000/mm3 C. Bloody diarrhea D. Nausea and vomiting E. Right Lower quadrant pain
ADE
A nurse is reviewing the prescription for a client who has Campylobacter enteritis. Which of the following prescriptions should the nurse clarify with the provider? A. 0.45% sodium chloride IV B. Magnesium hydroxide C. Ciprofloxacin D. Potassium
B
A circulating nurse is monitoring the temperature in a surgical suite. The nurse should identify that cool temperature reduces a client's risk for which of the following potential complications of surgery? A. Malignant hyperthermia B. Blood clots C. Infection D. Hypoxia
C
A nurse is assessing a client who has history a deep-vein thrombosis and is receiving Warfarin. Which of the following findings should indicate to the nurse that the medication is effective? A. Hemoglobin 14 g/dL B. Minimal bruising of extremities C. Decreased bp D. INR 2
D
A nurse has administered propranolol by IV bolus to a client who is having a thyroid storm. Which of the following findings indicates that the client is having a therapeutic response? A. Reduction of the effects of thyroid hormone on the heart B. Blockage of the release of thyroid hormone from the thyroid gland C. Increase the heart sensitivity to thyroid hormone D. Increase the uptake of thyroid hormone by the thyroid gland
A
A nurse in an emergency department is assessing a client who has bradydysrhythmia. Which of the following findings should the nurse monitor for? A. Confusion B. Friction rub C. Hypertension D. Dry skin
A
A nurse in an emergency department is caring for a client who reports costovertebral angle tenderness, nausea, and vomiting. Which of the following laboratory values should the nurse report to the provider? A. WBC count 15,000/mm3 B. BUN 15 mg/dL C. Urine specific gravity 1.020 D. Urine pH 5.5
A
A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at a home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to administer? A. Tissue Plasminogen Activator B. Recombinant factor VIII C. Nitroglycerin D. Lidocaine
A
A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmHg, PaCO2 56 mmHg, and HCO3 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis
A
A nurse is an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer? A. Osmotic diuretics via IV bolus B. Mydriatic ophthalmic dops C. Corticosteroid ophthalmic drops D. Epinephrine via IV bolus
A
A nurse is assessing a client who had hyperkalemia. Which of the following findings should the nurse expect? A. Decreased muscle strength B. Decreased gastric motility C. Increased heart rate D. Increased BP
A
A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? A. Small, purple-colored skin lesions B. Fever and diarrhea lasting longer than 1 month C. Persistent, generalized lymphadenopathy D. CD4-t-cells decreased to 750 cells/mm3
A
A nurse is assessing a client who has Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which of the following findings should the nurse report to the provider? A. Sodium 110 mEq/L B. 2+ deep-tendon reflexes C. Potassium 3.7 mEq/L D. Urine specific gravity 1.025
A
A nurse is assessing a client who has a Crohn's disease. Which of the following findings should the nurse expect? A. Fatty diarrheal stools B. Hyperkalemia C. Weight gain D. Sharp epigastric pain
A
A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicate increasing ICP? A. Restlessness B. Dizziness C. Hypotension D. Fever
A
A nurse is assessing a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease. The nurse should report which of the following findings to the provider immediately? A. Watery diarrhea B. Vaginitis C. Furry tongue D. Nausea and vomiting
A
A nurse is assessing a client who has acute hepatitis B. Which of the following findings should the nurse expect? A. Joint pain B. Obstipation C. Abdominal distention D. Periumbilical discoloration
A
A nurse is assessing a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss
A
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? A. Hyperactive deep tendon reflexes B. Increased bowel sounds C. Drowsiness D. Decreased blood pressure
A
A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in the respiratory rate at rest D. SaO2 86% on room air
A
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. Confusion B. Peripheral edema C. Facial flushing and warmth D. Hyperreflexia
A
A nurse is assessing a client who is 2hour post operative following an appendectomy. Which of the following findings should the nurse report to the provider? A. Urine output of 20 mL/hr B. Temperature of 36.5C (97.7F) C. A 2 cm x 2 cm (0.79 in x 0.79 in) area of blood drainage on the dressing D. WBC count 9,000 mm3
A
A nurse is assessing a client who is postoperative following a gastrectomy. The nurse should identify which of the following findings as an indication of abdominal distention? A. Hiccups B. HTN C. Bradycardia D. Chest pain
A
A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? A. Sodium 128 mEq/L B. Potassium 4.8 mEq/L C. Calcium 9.1 mg/dL D. Magnesium 2.0 mEq/L
A
A nurse is caring for a client following the insertion of a permanent pacemaker. Which of the following client statement indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups" B. "I feel dizzy when I stand" C. "My incision site stings" D. "I have a headache"
A
A nurse is caring for a client who has a pheochromocytoma. Which of the following actions should the nurse take? A. Elevate the head of the client's bed B. Palpate the client's abdomen C. Monitor the client for hypotension D. Check the client's urine specific gravity
A
A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. Which of the following findings should the nurse plan to monitor for and report to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue
A
A nurse is caring for a client who has neutropenia. Which of the following findings indicates a need for intervention? A. The client's grandchild is visiting and telling the client about the first day of kindergarten B. The client has a grilled ham and cheese sandwich, a banana, and yogurt on their lunch tray C. The client's family brings in a silk flower arrangement D. The client's assistive personnel places paper cups and plastic utensils in the client's rooms
A
A nurse is caring for a client who reports a skin change. Which of the following findings should the nurse report to the provider? A. An asymmetrical papule that is pigmented B. A patch of silvery-white scales with a red epidermal bases C. A collection of irregular, dry papules that are black D. An elevated red lesion that arises from a scar
A
A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis? A. pH 7.51, PaO2 94 mmHg, PaCO2 36 mmHg, HCO3 31 mEq/L B. pH 7,48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3 26 mEq/L C. pH 7.31, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3 23 mEq/L D. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3 20 mEq/L
A
A nurse is developing a plan of care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan? A. Measure the client's abdominal girth daily B. Check mental status once daily C. Provide a daily intake of 4 g of sodium for the client D. Assess the client breath sounds every 12 hours
A
A nurse is developing a teaching plan for a client who had a thyroidectomy and takes a thyroid hormone replacement. Which of the following instructions should the nurse plan to include? A. "Take the medication on an empty stomach" B. "Take this medication with an antacid" C. "Change position slowly while taking this medication" D. "Limit your fluid intake while taking this medication"
A
A nurse is developing a teaching plan for a client who has Meniere's disease. Which of the following instructions should the nurse include? A. "Move your head slowly to decrease vertigo" B. "Apply warm packs to the affected ear during acute attacks" C. "Increase your intake of foods and fluids high in salt" D. "Take corticosteroids during acute attacks"
A
A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? A. Administer IV hydrocortisone sodium B. Give oral spironolactone C. Infuse 1 unit of platelets D. Restrict daily fluid intake
A
A nurse is monitoring a client who is 24 hours postoperative after a total thyroidectomy. Which of the following findings should the nurse report to the provider? A. Laryngeal stridor B. Productive cough C. Pain with hyperextension of the neck D. Hoarse, weak voice
A
A nurse is monitoring a client who received succinylcholine during a surgical procedure. Which of the following actions should the nurse take if the client develops manifestations of malignant hyperthermia? A. Administer dantrolene B. Institute seizure precautions C. Remove the endotracheal tube D. Administer IV Atropine
A
A nurse is monitoring the laboratory values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcomes of insulin therapy? A. Fasting blood glucose 96 mg/dL B. Postprandial blood glucose 195 mg/dL C. Random blood glucose 210 mg/dL D. Pre-prandial blood glucose 60 mg/dL
A
A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurse's priority? A. Maintain a PaCO2 of approximately 35 mmHg B. Provide small doses of fentanyl via IV bolus for pain management C. Measure body temperature every 1 to 2 hour D. Reposition the client every 2 hour
A
A nurse is planning care for a client who has acute glomerulonephritis. The nurse should plan to provide which of the following interventions? A. Weigh the client daily B. Encourage the client to drink 2 to 3 L of fluid per day C. Instruct the client to ambulate every 2 hour D. Check the client's blood glucose level
A
A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to monitor for signs of nephrotoxicity? A. A client who is receiving gentamicin for the treatment of a wound infection B. A client who is receiving digoxin for the treatment of HF C. A client who is receiving methylprednisolone for the treatment of severe asthma D. A client who is receiving propranolol for the treatment of HTN
A
A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? A. One large hard-boiled egg B. 1 cup bran cereal C. 1/2 cup almonds D. 1 cup cooked spinach
A
A nurse is providing discharge teaching for a client who has GERD. Which of the following statements by the client indicates an understanding of the teaching? A. "I will decrease the amount of carbonated beverage I drink" B. " I will avoid drinking liquid 30 minutes after taking a chewable antacid tablet" C. "I will eat a snack before going to bed" D. "I will lie down for at least 30 minutes after eating each meal"
A
A nurse is providing discharge teaching for a client who has peptic ulcer disease and a new prescription for famotidine. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take this medication at bedtime" B. "I should expect this medication to discolor my stools" C. "I will drink iced tea with my meals and snacks" D. "I will monitor my blood glucose level regularly while taking this medication
A
A nurse is providing discharge teaching to a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 0.9 kg (2 lb) in 24 hours) B. Increase of 10 mmHg in systolic blood pressure C. Dyspnea with exertion D. Dizziness when rising quickly
A
A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for Methotrexate. Which of the following client statements indicates an understanding of the teaching? A. "I will avoid being in large crowds while taking this medication" B. "I should expect symptoms to subside in 1 to 2 weeks after starting this medication" C. "I will increase my intake of vitamin D while taking this medication" D. "I should expect to experience constipation while taking this medication"
A
A nurse is providing teaching to a client who is 2 days postoperative following a heart transplant. Which of the following statements should the nurse include in the teaching? A. "You might no longer be able to feel chest pain" B. "Your level of activity intolerance will not change" C. "After 6 months, you will no longer need to restrict your sodium intake" D. You will be able to stop talking immunosuppressants after 12 months
A
A nurse is providing teaching to a client who takes an oral contraceptive and has a new prescription for Amoxicillin. Which of the following statements by the client indicates an understanding of the teaching? A. "I will use a backup method of birth control while I am taking this medication" B. "I should take this medication on an empty stomach" C. "I should expect to have constipation while taking this medication" D. "I will keep taking this medication until I feel better"
A
A nurse is providing teaching to a group of clients regarding skin cancer prevention. Which of the following risk factors should the nurse include in the teaching? A. Light skin pigmentation B. Psoriasis C. History of frostbite D. Immunodeficiency disorder
A
A nurse is reviewing laboratory values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? A. pH 7.32, PaCO2 36 mmHg, HCO3 14 mEq/L B. pH 7.38, PaCO2 55 mmHg, HCO3 22 mEq/L C. pH 7.44, PaCO2 40 mmHg, HCO3 24 mEq/L D. pH 7.5, PaCO2 42 mmHg, HCO3 30 mEq/L
A
A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions? A. "I should call my doctor if my vision gets worse" B. "I will take aspirin for eye discomfort" C. "I can blow my nose to clear out any drainage" D. "I can lift objects up to 20 pounds"
A
A nurse is reviewing the daily laboratory results for a female client who has acute leukemia. Which of the following values is an expected findings? A. WBC count 21,000/mm3 B. Hgb 14 g/dL C. Hct 40% D. Platelets 170,000/mmm3
A
A nurse is reviewing the medical history of a client who has ESKD. The nurse should identify that which of the following factors in the client's history is a contraindication for receiving hemodialysis? A. Hx of hemophilia B. Difficulty with ambulation C. Decreased WBC count D. Iodine allergy
A
A nurse is reviewing the medical record for a client who has a prescription for general anesthesia prior to surgery. Which of the following findings should the nurse report to the provider? A. Potassium 2.8 mEq/L B. Sodium 140 mEq/L C. INR 1.5 D. BUN 12 mg/dL
A
While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? A. Implement seizure precaution B. Administer phosphate C. Initiate diuretic therapy D. Prepare the client for hemodialysis
A
A nurse is planning a presentation for a group of clients who have HTN. Which of the following lifestyle modification should the nurse include? A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Tobacco cessation
ABE
A nurse is reviewing the laboratory report of a client who has acute kidney injury (AKI). Which of the following findings should the nurse expect? (select all that apply) A. BUN 30 mg/dL B. Urine output 40 mL in the past 3 hour C. Potassium 3.6 mEq/L D. Calcium 9.8 mg/dL E. Hematocrit 30%
ABE
A nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroid therapy. Which of the following adverse effects should the nurse include? (SOA) A. Osteoporosis B. Moon-shaped face C. Increased risk for infection D. Hearing loss E. Weight loss
ABC
A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect? (SOA) A. Crepitus with joint movement B. Decreased ROM of the affected joint C. Low-grade fever D. Spongy tissue over the joints E. Joint pain that resolves with rest
ABE
A nurse is caring for a client who has ulcerative colitis. The client has had several exacerbations over the past 3 years. Which of the following instructions should the nurse include in the plan of care to minimize the risk of further exacerbations? (SOA) A. Use progressive relaxation techniques B. Increase dietary fiber intake C. Drink 2 240mL (8 oz) glasses of milk per day) D. Arrange activities to allow for daily rest periods E. Restrict intake of carbonated beverages
ADE
A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (SOA) A. Administer IV fluids to the client evenly over 24 hours B. Provide the client with a salt substitute C. Assess the client for pitting edema D. Encourage the client to rise slowly when standing up E. Weigh the client every 8 hours
ADE
A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in place following thoracic surgery with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A. "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration" B. "I will notify the provider if there is continuous bubbling in the water seal chamber" C. "I will notify the provider if there is drainage of of 60 mL in the first hour after surgery" D. "I will notify the provider if there are several small, dark-red blood clots in the tubing"
B
A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A. Increased anterior-posterior chest diameter B. Productive cough with green sputum C. Clubbing of the fingers D. pursed-lip breathing with exertion
B
A nurse in an emergency department is assessing a newly admitted client. Which of the following actions places the client at increased risk for contracting hepatitis B? A. Residing in an institutional setting B. Engaging in unprotected sexual intercourse C. Working with hazardous chemical waste materials D. Travelling to a foreign country
B
A nurse is a women's health clinic is caring for a client who reports urinary urgency and dysuria. Which of the following additional findings should the nurse identify as an indication of a UTI? A. Vaginal discharge B. Pyuria C. Glucosuria D. Elevated creatinine Kinase-MB
B
A nurse is admitting a client who takes 40 mg Furosemide daily for HF and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? A. Sodium polystyrene sulfonate 30 g/day B. 0.9% Sodium Chloride with 10 mEq/L of Potassium Chloride at 100 mL/hr C. Bumetanide 8 mg/day D. 100 mL of dextrose 10% in water with 10 units of insulin
B
A nurse is assessing a client who had DM and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? A. Rapid, deep respirations B. Cool, clammy skin C. Abdominal cramping D. Orthostatic hypotension
B
A nurse is assessing a client who has L-sided HF. Which of the following manifestations should the nurse expect to find? A. Increased abdominal girth B. Weak peripheral pulses C. Jugular venous neck distention D. Dependent edema
B
A nurse is assessing a client who has RA. Which of the following findings should the nurse expect? A. Unilateral joint involvement B. Ulnar deviation C. Fractures of the spine D. Decreased sedimentation rate
B
A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? A. Deep-tendon reflexes B. Cardiac rhythm C. Peripheral sensation D. Bowel sounds
B
A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? A. Decreased heart rate B. Increased hematocrit C. High urine specific gravity D. Low BUN level
B
A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A. Rhonchi on inspiration B. Elevated temperature C. Barrel-shaped chest D. Diminished breath sounds
B
A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect? A. Bloody diarrhea B. Board-like abdomen C. Periumbilical cyanosis D. Increased bowel sounds
B
A nurse is assessing a client who has phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? A. Hepatic failure B. Abdominal pain C. Slow peripheral pulses D. Increase in cardiac output
B
A nurse is assessing a client who is 4 hour postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Bleeding at the surgical site B. Decreased oxygen saturation C. Urinary retention D. Increase pain level
B
A nurse is assessing a client who received a preoperative IV dose of Metoclopramide 1 hour ago. For which of the following findings should the nurse notify the provider? A. dry mouth B. Muscle rigidity C. Tinnitus D. Diarrhea
B
A nurse is caring for a client who had colorectal cancer and is receiving chemotherapy. The client asks the nurse why blood is being drawn for carcinoembryonic antigen (CEA) level. Which of the following responses should the nurse take? A. "The CEA determines the current stages of your colon cancer" B. "The CEA determines the efficacy of your chemotherapy" C. "The CEA determines if the neutrophils count is below the expected reference range" D. "The CEA determines if you are experiencing occult bleeding from the GI tract"
B
A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the actions should the nurse take to help stimulate micturition? A. Encourage the client to use the Valsalva maneuver B. Stroke the client's inner thigh C. Perform the Crede maneuver D. Administer a diuretic
B
A nurse is caring for a client who has a surgical wound with a Penrose drain in place. Which of the following intervention should the nurse plan to perform? A. Cut a slit in a 4-inch square gauze pad to place around the drain B. Use the sterile technique when performing dressing changes C. Establish a clamping schedule prior to removal D. Apply negative pressure when emptying the drain
B
A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measures should the nurse recommend to prevent injuries to the client's feet? A. Examine the skin of the feet weekly for alterations in skin integrity B. Monitor the temperature of bath water with a thermometer C. Shop for shoes early in the day D. Round the edges of toenails when trimming them
B
A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? A. Negative blood culture B. Left shift in WBC differntial C. Oxygen saturation 93% D. Crackles heard on auscultation
B
A nurse is caring for a client who is 2 days postoperative following a cholecystectomy. The client has been vomiting for the past 24 hours and reports a pain level of 8 on a 0 to 10 scale. The nurse notes a hard, distended abdomen and absent bowel sounds. After conferring with the provider, which of the following actions should the nurse take first? A. Draw the client's blood for electrolytes B. Insert an NG tube C. Administer pain medication D. Initiate Intake and Output
B
A nurse is caring for a client who is 8 hour postoperative following a coronary artery bypass graft (CABG). Which of the following findings should the nurse report? A. Mediastinal drainage 100 mL/hr B. Blood pressure 160/80 mmHg C. Temperature 37.1C (98.8F) D. Potassium 4.0 mEq/L
B
A nurse is caring for a client who is admitted for treatment of left-sided heart failure and is receiving intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain the client's current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the clients urine output
B
A nurse is caring for a client who is being treated for HF and has a prescription for Furosemide. The nurse should plan to monitor for which of the following adverse effects of the medication? A. SOB B. Lightheadedness C. Dry cough D. Metallic taste
B
A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? A. Assist with intubation B. Initiate high-flow oxygen therapy C. Administer a rapid-acting diuretic D. Provide cardiac monitoring
B
A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first? A. Reposition the patient B. Check the position of the weights and ropes C. Administer a muscle relaxant D. Provide distraction
B
A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? A. PaO2 B. PaCO2 C. Sodium D. Bicarbonate
B
A nurse is creating a plan of care for a client who is preoperative for a total hip arthroplasty. The client informs the nurse that they practice Judaism and adhere to a kosher diet. Which of the following interventions is the nurse's priority? A. Listen and allow the client to express feelings about the surgery B. Determine if the client's faith conflicts with the treatment plan C. Ensure the client's meal plan serves only Kosher food following surgery D. Teach the client how to perform various relaxation exercise
B
A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? A. BUN 26 mg/dL B. Sodium 142 mEq/L C. Hct 56% D. Urine Specific gravity 1.035
B
A nurse is monitoring a client's ECG monitor and notes the client's rhythm has changed from normal sinus rhythm to SVT. The nurse should prepare to assist with which of the following interventions? A. Initiate chest compression B. Vagal stimulation C. Administration of atropine IV D. Defibrillation
B
A nurse is obtaining a urine specimen for culture and sensitivity from a client who has manifestation of a UTI. Which of the following actions should the nurse take? A. Collect the client's urine in a clean specimen container B. Instruct the client to start urinating then pass the container into the stream C. Obtain the client's first morning urine on the following day D. Place the client's urine specimen in a container with a preservative
B
A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report to the provider? A. Slight asymmetrical breast size. B. Breast tissue with an orange-peel appearance C. Nipple inversion of one breast since puberty D. Elevated Montgomery's glands
B
A nurse is planning care for a client who has a potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? A. Hyperactive deep-tendon reflexes B. Orthostatic Hypotension C. Rapid, deep respiration D. Strong, bounding pulses
B
A nurse is planning teaching for a client who has type 1 diabetes mellitus? Which of the following instruction should the nurse plan to include? A. Consume no more than 3 servings of alcohol per day B. Ingest food with alcohol to reduce alcohol-induced hypoglycemia C. Increased insulin dosage before planned exercise D. Rest for 3 dats between periods of vigorous exercise
B
A nurse is providing dietary teaching for a client who is postoperative following a gastrectomy. Which of the following foods should the nurse encourage the client to include in their diet to reduce the risk for dumping syndrome? A. Ice cream B. Egg C. Grape juice D. Honey
B
A nurse is providing dietary teaching to a client who has HF and is receiving Furosemide. Which of the following foods should the nurse recommend as containing the greatest amount Potassium? A. 1/2 chopped celery B. 1 cup plain yogurt C. One slice whole grain bread D. 1/2 cup cooked tofu
B
A nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease? The nurse should inform the client that which of the following medications inhibits gastric acid secretion? A. Calcium carbonate B. Famotidine C. Aluminum hydroxide D. Sucralfate
B
A nurse is providing discharge teaching for a client who has chronic hepatitis C. Which of the following statements by the client indicates an understanding of the teaching? A. "I will avoid alcohol until I'm no longer contagious" B. "I will avoid medications that contain acetaminophen" C. "I will decrease my intake of calories" D. "I can donate blood once when I am in remission"
B
A nurse is providing discharge teaching to a client who has HIV. Which of the following statements by the clients indicates an understanding of the teaching? A. "I will clean the bathroom surfaces with full-strength bleach" B. "I should discard open beverages that have been unrefrigerated for 1 hour" C. "I should wash laundry that is soiled with a body fluid in cool water" D. "I will work in the garden for exercise"
B
A nurse is providing discharge teaching to a client who has a prescription for transdermal nitroglycerin patches. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch B. Place the patch on an area of skin away from skin folds and joints C. Keep the patch on 24 hours per day D. Replace the patch at the onset of angina
B
A nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? A. "Depress the pump once before using the nasal spray for the first time" B. "Blow your nose gently prior to using the nasal spray" C. "Administer the nasal spray while in a side-lying position" D. "Notify the provider if you develop numbness or tingling around the mouth"
B
A nurse is providing health teaching to a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism B. A client who has diabetes mellitus C. A client whose daily caloric intake consists of 25% fat D. A client who consumes two 12-oz (0.35 L) bottles of beer a day
B
A nurse is providing preoperative teaching for a client who is scheduled to have a below-the-knee amputation. Which of the following instructions should the nurse include? A. "You should avoid lying on your abdomen after surgery" B. "Your surgeon might prescribe an antibiotic before surgery" C. "It is important for you to sit in a chair at the bedside for several hours everyday to reduce the risk of pneumonia" D. "To promote wound healing, it is important to reduce your intake of carbohydrates once you return home"
B
A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching? A. Notify the provider if bloating occurs B. Expect to have two to three soft stools per day C. Restrict carbohydrates in the diet D. Limit oral fluid intake to 1,000 mL per day of clear liquids
B
A nurse is providing teaching to a client who is scheduled for a Papanicolaou (Pap) test. The nurse should inform the client that the Pap test is used to screen for which of the following? A. Uterine cancer B. Cervical cancer C. Ovarian cysts D. Fibroids
B
A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect? A. Overgrowth of B-lymphocyte plasma cells B. Reed-Sternberg cells C. Epstein-Barr virus D. Overproduction of blast phase cells
B
A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? A. Hgb 20 g/dL B. Hct 34% C. BUN 25 mg/dL D. Urine specific gravity 1.050
B
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Blood glucose 110 mg/dL B. Increased amylase C. WBC count 9,000/mm3 D. Decreased bilirubin
B
A nurse is reviewing the laboratory results of a client who has acute pancreatitis. Which of the following findings should the nurse expect? A. Blood glucose 110 mg/dL B. Increased amylase C. WBC count 9,000/mm3 D. Decreased billirubin
B
A nurse is reviewing the medical records of four clients. The nurse should identify which of the following disorders as a risk factor for chronic pyelonephritis? A. Parkinson's disease B. Diabetes mellitus C. Peptic Ulcer disease D. Gallbladder disease
B
A nurse is teaching a client about glucosylated hemoglobin (HbA1c) testing. Which of the following client statements indicates an understanding of the teaching? A. "I need to fast after midnight the night before the test." B. "This test's result is a good indicator of my average blood glucose level" C. "A level of 8 to 10 percent suggests adequate blood glucose control" D. "I will use my hemoglobin A1C level to adjust my daily insulin doses"
B
A nurse is teaching a client who has a new prescription for an ACE inhibitor to treat HTN. The nurse should instruct the client to notify their provider if they experience which of the following adverse effect of this medication? A. Tendon pain B. Persistent cough C. Frequent urination D. Constipation
B
A nurse is teaching a client who has multiple sclerosis and has a new prescription for Glatiramer acetate. Which of the following statements indicates that the client understands the teaching? A. "I will ask my partner to give the injection in the same spot each time" B." I will avoid going to the store when it is crowded" C. "I will see relief of my symptoms in about 1 week" D. "I will exercise rigorously while taking this medication"
B
A nurse is teaching a client who has osteoporosis and has a new prescription for Alendronate. Which of the following information should the nurse include in the teaching? A. "Take this medication with 8 oz of milk" B. "Remain upright for 30 minutes after taking this medication" C. "Wait 1 hour after taking other medications to take Alendronate" D. "Take Vitamin C to promote absorption of this medication"
B
A nurse caring for a client who has viral meningitis. Which of the following actions should the nurse take? A. Assess the client's neurologic status every 8 hour B. Initiate droplet precautions C. Check capillary refill at least every 4 hours D. Place the client in a well-lit environment
C
A nurse is assessing a client who has a systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? (SOA) A. Subcutaneous nodule B. Decreased urine output C. Renal calculi D. Butterfly rash E. Joint inflammation
BDE
A nurse in a PACU is assessing a client who is postoperative. Which of the following findings should the nurse report to the provider? A. Blood pressure 10% lower than baseline B. Pain level of 4 on a 0 to 10 scale C. Presence of inspiratory stridor D. Small amount of sanguineous drainage on dressing
C
A nurse in a emergency department is caring for a client who has a bp of 254/139 mmHg. The nurse recognize that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions B. Tell the client to report vision changes C. Elevate the head of the client bed D. Start a peripheral IV
C
A nurse is admitting a client who has acute pancreatitis. Which of the following actions should the nurse take first? A. Insert a nasogastric tube for the client B. Administer Ceftazidime to the client C. Identify the client's current level of pain D. Instruct the client to remain NPO
C
A nurse is admitting a client who has hyperthyroidism. When assessing the client. the nurse should expect which of the following findings? A. Cold intolerance B. Lethargy C. Tremors D. Sunken eyes
C
A nurse is admitting who has a leg ulcer and history of DM. Which of the following focused assessments should the nurse use to help differentiate between an arterial ulcer and a venous Stasis ulcer? A. Explore the client's family history of PAD B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection
C
A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficit should the nurse expect? A. Aphasia B. Right-sided neglect C. Impulsive behavior D. Inability to read
C
A nurse is assessing a client who has a new diagnosis of Cushing disease. Which of the following findings should the nurse expect? A. Decreased BP B. Weight loss C. Hirsutism D. Increased skin thickness
C
A nurse is assessing a client who has adrenal insufficiency. Which of following findings should the nurse expect? A. Moon-shaped face B. Weight gain C. Calcium 12.8 mg/dL D. Sodium 150 mEq/L
C
A nurse is assessing a client who has chronic kidney disease and has completed the third peritoneal dialysis (PD) treatment. Which of the following findings should the nurse report to the provider? A. Greater outflow of dialyste than the inflow B. Weight loss C. Cloudy dialysate effluent D. Report of pain during inflow
C
A nurse is assessing a client who has cirrhosis. Which of the following findings is the priority for the nurse to report to the provider? A. Spider angiomas B. Peripheral edema C. Bloody stools D. Jaundice
C
A nurse is assessing a client who has upper gastrointestinal bleeding. Which of the following findings should the nurse expect? A. Bradycardia B. Bounding peripheral pulses C. Hypotension D. Increased hematocrit levels
C
A nurse is assessing a client who is taking propylthiouracil. The nurse should identify which of the following findings is an indication that the medication has been effective? A. increased ability to sweat B. Increased bowel movement C. Increased body weight D. Increased libido
C
A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mmHg, PaCO2 28 mmHg, and HCO3 24 mEq/L. Which of the following actions should the nurse take? A. Instruct the client to cough forcefully B. Assist the client with ambulation C. Provide calming interventions D. Discontinue the PCA
C
A nurse is caring for a client following a thyroidectomy. The nurse should assess for which of the following findings as an indication of hypocalcemia? A. Strong, bounding pulses B. Decreased bowel sounds C. Tingling and numbness of the hands and feet D. Diminished deep-tendon reflexes
C
A nurse is caring for a client who had an onset of chest pain 24 hours ago. The nurse should identify that an increase in which of the following values is diagnosis of myocardial infarction (MI)? A. Myoglobin B. C-reactive protein C. Creatine kinase-MB D. Homocysteine
C
A nurse is caring for a client who has HIV. Which of the following laboratory findings should suggest to the nurse that medication therapy is effective? A. WBC count 3,500/mm3 B. Lymphocyte 1,400/mm3 C. Decreased viral load D. Low CD4/CD8
C
A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect? A. Photophobia B. Complete vision loss C. Flashes of bright light D. Cloudiness of the lens
C
A nurse is caring for a client who has acute kidney injury (AKI). Which of the following serum laboratory findings should the nurse report to the provider? A. Potassium 5 mEq/L B. Calcium 9 mg/dL C. Creatinine 4 mg/dL D. Amylase 84 units/L
C
A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority? A. Provide frequent rest periods throughout the day B. Administer pain medication on a regular schedule C. Monitor pulse oximetry findings D. Administer baclofen for spasticity
C
A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic test? A. Palpation of testes B. Human chorionic gonadotropin levels C. Digital rectal examination D. Pelvic ultrasound
C
A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? A. Increase urine specific gravity B. Hypoactive bowel sounds C. Bounding peripheral pulses D. Decreased respiratory rate
C
A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? A. Hypoactive deep-tendon reflexes B. Ascending paralysis C. Intention tremors D. Increased lacrimation
C
A nurse is caring for a client who is 1 hour postoperative following an aortic aneursym repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguinous drainage on dressing B. Severe pain with coughing C. Urine output of 20 mL/hr D. Increase in temperature from 36.8C (98.2F) to 37.5 (99.5F)
C
A nurse is caring for a client who is 72 hour postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take? A. Remind the client that the surgery removed the limb B. Change the dressing on the client's residual limb C. Request a prescription for Gabapentin for the client D. Elevate the client's residual limb above heart level
C
A nurse is caring for a client who is admitted with enlarged lymph nodes and a fever. To confirm a diagnosis of bacterial pharyngitis, the nurse should anticipate which of the following diagnostic test? A. Indirect laryngoscopy B. Chest x-ray C. Throat culture D. Monospot test
C
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Upon detecting an output obstruction, which of the following actions should the nurse take first? A. Irrigate the catheter with 0.9% sodium chloride irrigation B. Notify the provider C. Check the irrigation tubing for kinks D. Provide PRN pain medication
C
A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? A. Monitor the client's bowel sounds B. Review the client's daily laboratory results C. Auscultate the client's lungs D. Palpate the client's peripheral pulses
C
A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? A. Excess secretions B. Kinks in the tubing C. Artificial airway cuff leak D. Biting on the endotracheal tube
C
A nurse is caring for a client who is scheduled for a coronary artery bypass graft (CABG) in 2 hour. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me b/c I haven't taken my aspirin in a week" B. "My bp presssure shouldn't be high because I took my BP meds this morning" C. "I took my warfarin last night according to my usual schedule" D. "I will check my blood sugar b/c i took a reduced dose of insulin this morning"
C
A nurse is caring for a postoperative client following arteriovenous (AV) fistula creation in the left arm. Which of the following actions should the nurse take? A. Measure blood pressure in the client's left arm every 4 hours B. Keep the client's left arm in a dependent position C. Ausucultate for bruits in the client's fistula every 4 hours D. Instruct the client to sleep on the affected side
C
A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information about hyperacute rejection should the nurse include in the teaching? A. Hyperactive rejection can occur during the first few weeks after the transplant B. If hyperacute rejection occurs, the kidney can become enlarged C. The organ will need to be removed if hyperacute rejection occurs D. Immunosuppressive therapy is given to reverse hyperacute rejection
C
A nurse is monitoring a client following hemodialysis. The nurse should recognize that which of the following factors places the client at risk for seizures? A. Hypokalemia B. A rapid increase of catecholamines C. A rapid decrease in fluid D. Hypercalcemia
C
A nurse is performing an admission assessment of a client who has acute glomerulonephritis. The nurse should expect which of the following findings? A. Low blood pressure B. Polyuria C. Dark-colored urine D. Weight loss
C
A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include? A. Testicular cancer is more common in males who are older than 65 B. With early treatment, the survival rate is 50% C. Examine the testicles immediately after showering D. Schedule an annual ultrasound to screen for testicular cancer
C
A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take? A. Apply the pressure dressing to the site for 8 hours B. Restrict the client's fluid intake for 24 hours C. Ensure the client lies flat for up to 12 hour D. Inform the client that neck stiffness is an expected outcome of the procedure
C
A nurse is planning discharge teaching for a client who is receiving chemotherapy and has bone marrow suppression. Which of the following instructions should the nurse plan to include in the teaching? A. "take aspirin for minor aches and pains" B. "Clean your toothbrush with warm water weekly" C. "Bathe with an antimicrobial soap twice per day" D. "Wear clothing that will minimize sun exposure"
C
A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? A. Administer a hypertonic solution B. Repeat the potassium level C. Withhold the medication D. Monitor for paresthesia
C
A nurse is providing dietary teaching for a client who has a new diagnosis of celiac disease. Which of the following statements by the client indicates an understanding of the teaching? A. "I can return to regular diet when I am free of symptoms" B. "I will need to avoid taking vitamin supplements while on this diet" C. "I will eat beans to ensure I get enough fiber in my diet" D. "I need to avoid drinking liquids with my meals while on this diet"
C
A nurse is providing discharge teaching for a client following an ileostomy. The nurse should instruct the client to report which of the following findings to the provider? A. Intolerance to high-fiber foods B. Liquid ileostomy output C. Dark purple stoma D. Sensation of burning during bowel elimination
C
A nurse is providing discharge teaching for a client who has a new colostomy and is concerned about flatus and odor. Which of the following foods should the nurse recommend to the client? A. Eggs B. Fish C. Yogurt D. Broccoli
C
A nurse is providing discharge teaching for a client who has mild diverticulitis. Which of the following statements by the client indicates an understanding of the teaching? A. "I may experience right lower quadrant pain" B. "I will remain active by working in my garden every day" C. "I should eat foods that are low in fiber" D. " I will use a mild laxative every day"
C
A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? A. Inform other healthcare professionals of the allergy B. Wear a medical identification tag C. Carry an emergency anaphylaxis kit D. Keep a food diary
C
A nurse is providing teaching to a client who has chronic kidney disease (CKD). Which of the following statements by the client indicates an understanding of the teaching? A. "I will check my blood pressure once per week" B. "I will take a magnesium antacid if I get constipated" C. "I will weight myself every morning" D. "I will use a salt substitute in my diet"
C
A nurse is providing teaching to a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client indicates an understanding of the teaching? A. "I should use a sunscreen with an SPF of at least 15" B. "Long-term immunosuppressive therapy could cure this disease" C. "I should wear gloves when it is cold outside" D. "SLE should not affect my lungs or breathing"
C
A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? A. "If my stockings feel tight, I'll just roll them down for a while" B. "I'll put on my elastic stocking at the first sign of swelling" C. "When I sit down to watch television, I'll be sure to put my feet up" D. "It's okay to cross my legs as long as it's for less than an hour"
C
A nurse is reviewing the laboratory results of several male clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which of the following laboratory value? A. Cholesterol 180 mg/dL, HDL 70 mg/dL, LDL 90 mg/dL B. Cholesterol 185 mg/dL, HDL 50 mg/dL, LDL 120 mg/dL C. Cholesterol 190 mg/dL, HDL 25 mg/dL, LDL 160 mg/dL D. Cholesterol 195 mg/dL, HDL 55 mg/dL, LDL 125 mg/dL
C
A nurse is reviewing the medical record of a client who has DM and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? A. Urine output 30 mL/hr B. Blood glucose 180 mg/dL C. Serum potassium 3.0 mEq/L D. BUN 18 mg/dL
C
A nurse is teaching a client how to prepare for a colonoscopy. Which of the following instructions should the nurse include in the testing? A. "Refrain from eating or drinking for 2 hours prior to the procedure" B. "Stop taking aspirin the day before the procedure" C. "Drink clear liquids for 24 hours prior to the procedure, and then take nothing by mouth for 6 hour before the procedure" D. "Drink the oral liquid preparation for bowel cleansing slowly the night before the procedure"
C
A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa levodopa. Which of the following client statements indicates an understanding of the teaching? A. "I should expect an increase in my blood pressure while taking this medication" B. "I should take this medication 2 hours after meals to increase adsorption" C. "I should expect that this medication can cause me to be drowsy" D. "I should expect this medication to be effective within 48 hours
C
A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? A. Inject the insulin intramuscularly B. Shake the insulin vigorously prior to administration C. Draw up the insulin into separate syringes D. Expect the insulins to appear cloudy
C
A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements by the client indicates an understanding of the teaching? A. "I should stop taking my insulin if I feel nauseous" B. "I will test my urine for protein when I start to feel ill" C. "I will call my doctor if my blood sugar is more than 250" D. "I should check my blood sugar level every 8 hours"
C
A home health nurse is assessing a client who requires lifelong hormone replacement therapy for the treatment of hypothyroidism. The client has not been taking the medication regularly. Which of the following findings should the nurse expect? A. Increased urine output B. Persistent diarrhea C. Tachycardia D. Hypotension
D
A nurse in an emergency department is caring for a client who had an anterior myocardial infarction. The client's hx reveal they are 1 wk postoperative following an open cholecystectomy. The nurse should identify that which of the following interventions is contraindicated? A. Administering IV morphine Sulfate B. Administering O2 at 2L/min via nasal cannula C. Helping the client to the beside commode D. Assisting with thrombolytic therapy
D
A nurse in an outpatient clinic is teaching a client who has diabetic foot ulcer about foot care. Which of the following statements by the client indicates an understanding of the teaching? A. "I will let my feet air dry after washing" B. "I will wear sandals to allow air to circulate around my feet" C. "I will buy OTC medicine to treat the calluses on my feet D. I will apply lotion to the dry areas of my feet but not between my toes"
D
A nurse is assessing a client immediately following a paracentesis for the treatment of ascites. Which of the following findings indicates the procedure was effective? A. Presence of a fluid wave B. Increased heart rate C. Equal pre-and post-procedure weight D. Decreased SOB
D
A nurse is assessing a client who had dehydration. Which of the following assessment is the priority? A. Skin turgor B. Urine output C. Weight D. Mental Status
D
A nurse is assessing a client who has a duodenal ulcer. Which of the following findings should the nurse expect? A. The client states that the pain is in the upper epigastrium B. the client is malnourished C. The client states that the ingesting food intensifies the pain D. The client reports the pain occurs during the night
D
A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level level C5. The client reports a throbbing headache and nausea. the nurse notes facial flushing and a BP of 220/110 mmHg. Which of the following actions should the nurse take first? A. Administer hydralazine via IV bolus B. Loosen the client's clothing C. Empty the client's bladder D. Elevate the head of the client's bed
D
A nurse is caring for a client following extracorporeal shock wave lithotripsy (ESWL) for the treatment of calcium phosphate kidney stones. Which of the following actions should the nurse take? A. Monitor the client's urine for ketones B. Provide the client with an increase animal protein diet C. Limit the client's fluid intake to 1.5 L per day D. Strain all of the client's urine
D
A nurse is caring for a client immediately following a kidney transplant. The nurse should identify which of the following findings as a possible indication of a delay in functioning of the transplanted kidney? A. Blood pressure 110/58 mmHg B. Incisional tenderness C. Pink and bloody urine D. Urine output 30 mL/2 hr
D
A nurse is caring for a client who had an open transverse colectomy 5 days ago. The nurse enters the client's room and recognizes that the wound has eviscerated. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take? A. Go to the nurses' station to seek assistance B. Reinsert the organ into the abdominal cavity C. Place the client in a reverse Trendelenburg position D. Obtain VS to assess for shock
D
A nurse is caring for a client who has GRD and a new prescription for metoclopramide. The nurse should plan to monitor for which of the following adverse effect? A. Thrombocytopenia B. Hearing loss C. Hypersalivation D. Ataxia
D
A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? A. Glasgow Coma Scale score of 15 B. Intracranial pressure reading of 15 mmHg C. Ecchymosis at base of skull D. Clear drainage from nose
D
A nurse is caring for a client who has a history of angina and is scheduled for exercise electrocardiography at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 0700" B. "I didn't tale my heart pills this morning because the doctor told me not to" C. "I have had chest pain a couple of time since I saw my doctor in the office last week" D. "I smoked a cigarette this morning to calm my nerves about having this procedure"
D
A nurse is caring for a client who has a hx of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take? A. Assess hourly for a spike in BP B. Keep the client on bed rest C. Keep a padded tongue blade at the bedside D. Establish IV access
D
A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? A. Dextrose 5% in 0.9% sodium chloride B. Dextrose 5% in LR C. 3% Sodium Chloride D. 0.45% Sodium Chloride
D
A nurse is caring for a client who has bradycardia following a surgical procedure using spinal anesthesia. The nurse should plan to administer which of the following medications to the client? A. Amiodarone B. Propranolol C. Methyldopa D. Epinephrine
D
A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillian-Barre syndrome C. Myelodysplastic syndrome D. Valvular disease
D
A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? A. Loss of body hair B. Report of anorexia C. Mucositis of the oral cavity D. Erythema at the IV insertion site
D
A nurse is caring for a client who has type 2 diabetes mellitus and is experiencing a hyperglycemic hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? A. Serum pH 7.32 B. Blood glucose 250 mg/dL C. Blood glucose 425 mg/dL D. Serum pH 7.45
D
A nurse is caring for a client who is postoperative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A. pH 7.5, PO2 95 mmHg, PaCO2 25 mmHg, HCO3 22 mEq/L B. pH .5, PO2 87 mmHg, PaCO2 35 mmHg, HCO3 30 mEq/L C. pH 7.3, PO2 90 mmHg, PaCO2 35 mmHg, HCO3 20 mEq/L D. pH 7.3, PO2 80 mmHg, PaCO2 55 mmHg, HCO3 22 mEq/L
D
A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which of the following actions should the nurse take if the client's aPTT is 96 seconds. A. increase the heparin infusion flow rate by 2 mL/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time (PT) D. Stop the heparin infusion
D
A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions? A. Check the client's cheek on the affected side after meals to be sure no food remains there B. Encourage the client to sit upright with their head tilted slightly forward during meals C. Provide the client with eating utensils that have large handles D. Remind the client to look consciously at both sides of their meal tray
D
A nurse is caring for a client who is scheduled for an IV urography. Which of the following interventions is the nurse priority? A. Tell the client to increase fluid intake following the procedure B. Place the informed consent document in the client's medical record C. Inform the client that a warm sensation can occur when the contrast dye is injected D. Determine if the client has an allergy to iodine or shellfish
D
A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widening QRS complex. Which of the following laboratory values supports this findings? A. Sodium 152 mEq/L B. Chloride 102 mEq/L C. Magnesium 1.8 mEq/L D. Potassium 6.1 mEq/L
D
A nurse is caring for four clients. Which of the following clients is at greatest risk for pneumonia? A. A school-age child who has a history of asthma B. A young adult client who is living in a college dormitory C. A middle adult who is using an incentive spirometer following surgery D. An older adult client who has dysphagia
D
A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain? A. Client's VS change B. Client's report of the type of pain C. Client's nonverbal communication D. Client's report of pain on a pain scale
D
A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease? A. "If bitten by a tick, you should be tested immediately" B. "If you have a tick embedded in your skin, apply a lit match to remove it" C. "You should wear dark-colored clothing to deter ticks from biting" D. "If you develop pain and stiffness in your joints, you should see your doctor"
D
A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A. Cromolyn sodium B. Prednisone C. Fluticasone/Salmeterol D. Albuterol
D
A nurse is planning care for a client who has leukemia and a platelet count of 48,000/mm3. Which of the following interventions should the nurse include in the plan? A. Provide the client with a diet that is low in Vitamin K B. Place the client on contact precaution C. Administer subcutaneous epoetin alfa D. Test the client's urine and stool for occult blood
D
A nurse is planning care for a client who is postoperative following a nephrectomy. Which of the following assessments is the nurse's priority? A. Bowel sounds B. WBC count C. Pain level D. Blood pressure
D
A nurse is planning care for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL) to treat urolithiasis. Which of the following actions should the nurse plan to take? A. Place the client in semi-fowler position B. Prepare to intubate the client C. Monitor urine flow through a nephrostomy tube D. Apply electrode for cardiac monitoring
D
A nurse is planning to teach a client who has epilepsy and a new prescription for Phenytoin. Which of the following instructions should the nurse plan to include? A. Rinse with antiseptic mouthwash instead of using dental floss B. Use an OTC antihistamine if a rash develops C. Slowly taper the medication after 6 consecutive months without seizure activity D. Take medications at a consistent time each day to maintain therapeutic blood levels
D
A nurse is preparing a client for coronary angiography. Which of the following findings should the nurse report to the provider prior to the procedure? A. Hemoglobin 14.4 g/dL B. History of peripheral arterial disease C. Urine output 200 mL/4 hour D. Previous allergic reaction to shell fish
D
A nurse is preparing a teaching plan for a client who has DM and requires intranasal desmopressin. Which of the following information should the nurse include? A. "Drink at least 3 L of fluid per day" B. "Weigh yourself weekly while wearing similar clothing at the same time of day" C. "Notify the provider of a weight loss of 1 point or more per week" D. "Report nocturia b/c it requires a dosage adjustment
D
A nurse is providing dietary teaching for a client who has chronic pancreatitis. Which of the following food selection by the client indicates an understanding of the teaching? A. 8 oz (0.24 L) whole milk B. One slice of beef bologna C. 1 oz (28.3 g) cheddar D. 1 cup (0.24 L) sliced banana
D
A nurse is providing instructions for reducing the dietary intake of potassium to a client who has chronic kidney disease. Which of the following client food selections indicates an understanding of the teaching? A. 1 cup cubed cantaloupe B. 1 cup boiled spinach C. One medium baked potato D. One large raw apple
D
A nurse is providing preoperative teaching to a client who is scheduled for gastrectomy in 1 week. The client expresses anxiety about the upcoming surgery. Which of the following actions should the nurse take? A. Sympathize with the client's feelings B. Reassure the client that the surgery will go fine C. Change the topic of discussion D. Provide concise, factual information
D
A nurse is providing preoperative teaching to a client who is scheduled to have a mastectomy with reconstructive surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I should wait to take my pain medication until after I have completed my ROM exercise" B. "I should wait until a week after surgery to start my hand-strengthening exercise" C. "I will be able to lift an object that weighs 10 pounds 2 weeks after my surgery D. "I will be able to shower after the doctor removes the drain"
D
A nurse is providing teaching a male client who has a continent internal ileal reservoir following surgery to treat bladder cancer. Which of the following client statements indicates an understanding of the teaching? A. "This should not affect my ability to function sexually" B. "I should expect to gain some weight during the next few weeks" C. "I will need to avoid foods that produce intestinal gas" D. "I must insert a catheter through my stoma to drain the urine"
D
A nurse is providing teaching to a client who has Hodgkin's lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? A. Use an antibacterial soap to cleanse the skin B. Wash the ink marking off when showering C. Rub the skin with a towel when drying D. Avoid direct sun exposure to the skin
D
A nurse is providing teaching to a client who has RA and reports persistent pain. Which of the following responses should the nurse make? A. "take a cool bath in the evening" B. "Exercise every other day" C. "Use pillow to support your joint while in bed" D. "Ask a friend or family member to help with household chores"
D
A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? A. "I should conserve energy by limiting my physical activity B. "I will wait until my pain is at least 6 out of 10 before I use the PCA" C. "I will limit my daily fluid intake to 2 or 3 glasses" D. "I will use the incentive spirometer every hour"
D
A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? A. pH 7.51, PaO2 94 mmHg, PaCO2 38 mmHg, HCO3 29 mEq/L B. pH 7.48, PaO2 89 mmHg, PaCO2 30 mmHg, HCO3 24 mEq/L C. pH 7.36, PaO2 77 mmHg, PaCO2 52 mmHg, HCO3 26 mEq/L D. pH 7.26, PaO2 84 mmHg, PaCO2 38 mmHg, HCO3 20 mEq/L
D
A nurse is reviewing the laboratory results of a client undergoing screening for primary Cushing's disease. The nurse should expect an elevation in which of the following laboratory findings? A. Lymphocyte count B. Potassium C. Calcium D. Glucose
D
A nurse is reviewing the laboratory results of a client who has hepatic cirrhosis. Which of the following laboratory findings should the nurse report to the provider? A. Albumin 4.0 g/dL B. INR 1.0 C. Direct bilirubin 0.5 mg/dL D. Ammonia 180 mcg/dL
D
A nurse is reviewing the laboratory values of a client who has colorectal cancer. Which of the following findings should the nurse expect? A. Negative fecal occult blood test B. Decreased serum carcinoembryonic antigen (CEA) test C. Hematocrit 43% D. Hemoglobin 9.1 g/dL
D
A nurse is teaching a client about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should explain that the purpose of the test is to assess for which of the following disorders? A. Diabetes Inspidus B. Hyperthyroidism C. Pheochromocytoma D. Addison's disease
D
A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching? A. "There is a test for Alzheimer's disease that can establish a reliable diagnosis" B. "The goal of medication therapy is to reverse the degenerative changes that can occur in brain tissue" C. "Early manifestations of Alzheimer's disease include mild tremors and muscular rigidity" D. "The medications that treat Alzheimer's disease can help delay cognitive changes"
D
A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected findings of DKA? A. Decreased urine output B. Weight gain of 0.45 kg (1 lb) in 24 hours C. Rapid, shallow respiration D. Blood glucose levels above 300 mg/dL
D
A nurse is teaching a client who is scheduled for a vanillylmandelic acid test for pheochromocytoma. Which of the following statements should the nurse include in the teaching? A. "Start fasting at midnight prior to the day of the test" B. "Begin the 24-hour urine collection with the first morning urination" C. "Take low-dose aspirin for pain during the testing period" D. "Restrict coffee intake 2 to 3 days prior to the test"
D
A nurse is teaching assistive personnel (AP) about providing care to a client following total hip arthroplasty. Which of the following instructions should the nurse include? A. Avoid applying anti-embolism stocking to the affecting leg B. Have the client lean forward when moving from a sitting to a standing position C. Discourage the client from sitting in a wheelchair with the back reclined D. Place an abductor pillow between the client's legs when turning the client
D
A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statement by the client indicates an understanding of the teaching? A. "I will eat more cheese because I can't drink milk" B. "I need to avoid food with vitamin D because I am allergic to milk" C. "I will stop taking my calcium supplements if they irritate my stomach" D. "I will add broccoli and kale to my diet"
D
A nurse is teaching the parent of a child about administration guidelines for the human papilloma virus (HPV) vaccine. Which of the following information should the nurse include? A. One dose is administered at birth and another is administered at age 5 B. The vaccine does not protect males C. The vaccine protects against chlamydia D. Three doses are administered to adolescents who start the series after age 15
D