ATI medsurg review
a nurse is providing dietary teaching to a client who has kidney disease, which of the following food choice should the nurse include in the teaching as containing the lowest amount of magnesium?
1 large hard-boiled egg-contains 5mg of magnesium, recommend this food as containing the lowest amount of magensium
a nurse is teaching a client who has DM what is expected if DKA
BG above 300- >600 is HHS
a nurse is caring for a client who has neutropenia, which of the following findings indicates a need for intervention?
a client's granddaughter is visiting and telling him about her first day of kindergarten-a nurse should limit visits to only health adults, a visit from a child who is attending school can place the client at risk for infection due to his immunocompromised status
a nurse is caring for a client who reports difficulty breathing and tingling in both hands, his RR is 36 and he appears very restless, which of the following values should the nurse anticipate to be outside the expected reference range fi the client is experiencing respiratory alkalosis?
PaCO2-decreased, due to hyperventilation
a nurse is teaching a client who is receiving chemotherapy. the client's lab results indicate bone marrow suppression, which of the following instruction should the nurse include in the teaching?
bathe with an antimicrobial soap twice per day-decrease her exposure to micro-organisms
a nurse is assessing a client who has diabetes mellitus and reports feeling anxious. which of the following findings should the nurse expect if the client if hypoglycemic
cool, clammy skin- in addition to anxiety, nervousness, tachycardia, and confusion
a nurse is assessing a client who has a new diagnosis of osteoarthritis, which of the following findings should the nurse expect?
crepitus with joint movement (loosened bone and cartilage move around in the fluid inside the joint) decreased range of motion of the affected joint (pain limits movement) joint pain that resolves with rest
a nurse is teaching a client how to prepare for a colonoscopy, which of the following instructions should the nurse include in the teaching
drink clear liquids for 24 hours prior to the procedure, and then take nothing by mouth for 6 hours before the procedure, maintain NPO status for 4-6 hours prior to the colonoscopy preserves the bowel's cleansed state
a nurse is assessing a client who is 2 days postoperative following a total prostatectomy, the nurse notes that the client's right calf is red, edematous, and warm to the touch, which of the following actions should the nurse take?
elevate the client's right extremity-suggest a deep-vein thrombosis
a nurse is reviewing the laboratory report of a client who has fluid volume excess, which of the following lab values should the nurse expect
hematocrit 34%-with fluid volume excess, hematocrit is below expected range (37-47% for females or 42-52% for males) fluid volume excess can cause hemodilution and a decreased hematocrit level
a nurse is reviewing the lab values of a client who has colorectal cancer, which of the following findings should the nurse expect
hemoglobin 9.1, below what is expected, due to occult intestinal bleeding
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?
i will decrease the amount of carbonated beverages i drink, that fatty foods, coffee, cola, tea, carbonated, chocolate all irritate the lining of the stomach
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?
i will eat beans to ensure i get enough fiber in my diet, client's who have celiac disease must maintain a gluten-free diet which eliminates fiber-rich whole wheat products, client's should eat beans nuts, fruits, and vegetables to ensure an adequate intake of fiber.
a nurse is providing discharge instructions for a client who is postoperative following abdominal surgery, which of the following client statements indicates an understanding of the teaching?
i will eat foods that are high in protein and vitamin C during my recovery-promote wound healing
a nurse is assessing a client who has Diabetes insipidus the nurse should expect?
increased hematocrit -dehdyration
a nurse is caring for a client who has viral pneumonia, which of the following findings should the nurse report to the provider?
left shift in WBC-indicates a bacterial origin, may be sepsis
a nurse is providing teaching to a group of clients regarding prevention of skin cancer, which of the following risk factors should the nurse include in the teaching?
light skin pigmentation
a nurse is teaching a client who has an autoimmune disease about the adverse effects of long-term corticosteroids therapy, nurse should include
osteoporosis (suppression of bone formation and the acceleration of bone resorption) moon-shaped face increased-risk for infection (suppression of immune system)
a nurse is reviewing the ABG results for four clients, which of the following findings should the nurse identify as metabolic acidosis?
pH 7.26, PaO2 84, PaCO2 38, HCO3 20- pH is below expected, HCO3 is lower then expected
a nurse is reviewing lab values for a client with DKA, expects...
pH 7.32, 36mmHg, 14mEq- acidosis
a nurse is caring for a client who has a thyroidectomy assess for as an indication of hypocalcemia?
tingling and numbness of hands and feet
a nurse is caring for a client who has DM2 and has HHS, what do you expect?
serum pH of 7.45- enough insulin to prevent ketosis, but not enough to prevent hyperglycemia, glucose will be >600
a nurse is reviewing the medical record of a client who has diabetes mellitus 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?
serum potassium 3.0-below what is expected reference range, hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition
a nurse in an emergency department is caring for a client who suddenly lost consciousness and fell in her home, the provider determines that the client has an embolic stroke, which of the following medications should the nurse administer?
tissue plasminogen activator- is a thrombolytic agent that should dissolve the clot that caused the stroke
a nurse is assessing a client recovery from spinal anesthesia, which of the following sensations should the nurse expect to return to the client first?
touch
a nurse is admitted a client who has hyperthyroidism, what do you expect
tremors- diaphoresis and insomnia
a nurse is assessing a client who has R.A , which of the following assessment findings should the nurse expect?
ulnar deviation-lateral deviation of the fingers can occur from opening jars and other similar motions
a nurse is providing discharge teaching for a client who is postoperative following a rhinoplasty using general anesthesia, which of the following instructions should the nurse include?
use cool compress on your eyes, nose, and face-reduce swelling and ecchymosis
a nurse is assessing a client who has acute hepatitis B which of the following findings should the nurse expect
joint pain
a nurse is caring for a client who has a sodium level of 155mEq/L, which of the following IV fluids should the nurse anticipate the provider to prescribe?
0.45% sodium chloride-indicated that there is hypernatremia, nurse should anticipate a prescription for hypotonic solution, the 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys
a nurse is admitting a client who takes 40mg furosemide daily for heart and has experienced 3 days of vomiting, the nurse suspects hypokalemia which of the following medications should the nurse prepare to administer
0.9% sodium chloride with 10mEq/L of potassium chloride at 100mL/hr- offset the losses from vomiting, typical amount of potassium chloride to administer IV is 5-10mEq/hr and not to exceed 20mEq/hr, dilution should be 1mEq to 10mL of NS
a nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide, which of the following foods should the nurse recommend as containing the greatest amount of potassium?
1 cup plain yogurt-contains 380g of potassium
a nurse is providing teaching for a client who has chronic pancreatitis, which of the following food selections by the client indicates an understanding of the teaching?
1 cup sliced banana, foods high in fat can cause diarrhea for clients who have pancreatitis, bananas are low fat option with adequate carbs and calories
a nurse is assessing a client who has dehydration, which of the following assessments is the priority?
mental status-greatest risk is a fall due to declined mental status
a nurse is caring for a client who is preoperative and is asking multiple questions about the risks of the procedure, which of the following actions should the nurse take?
ask the surgeon to speak to the client for clarification
the nurse is reviewing the daily laboratory results for a female client who has acute leukemia? which of following values is an expected findings?
WBC count 21,000- the nurse should expect a client who has acute leukemia to have an elevated WBC count
a nurse is receiving evening shift report on four clients who returned from the PACU that morning, the nurse should assess which of the following client's first
a client who is postoperative following a thoracotomy and has a chest tube with 150mL of bright-red blood in the collection chamber from the past hour, indicates hemorrhage
a nurse is teaching a client about (HbA1c) testing, which of the following statement should the nurse identify as an indication that the client understands the information about this test?
a good test for average blood glucose- over 120 days (lifespan of RBC)
a nurse is assessing a client who is 2 hour postoperative following an appendectomy, which of the following findings should the nurse report to the provider?
a urine output of 20ml/hr-decreased output can indicate hypovolemia and decrease perfusion of the kidneys
a nurse if teaching a client about the ACTH hormone, stimulation test. the nurse should explain that the purpose of the test is to assess for which of the following disorders?
addisons disease - test measures the response is absent or very decreased in clients who have primary adrenal insufficiency
an 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?
administer IV fluids evenly over 24 hours (administering rapidly over a short period of time places the client at risk for fluid overload) encourage the client to rise slowly when standing up (prevent injury from falls) weight the client every 8 hours (provides information regarding fluid balance)
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?
administer a dose of gabapentin to the client-nonopioid medication to help minimize phantom limb pain, that is effective for treating sharp, burning, phantom limb pain
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?
administer dantrolene
a nurse is caring for a client who is postoperative following abdominal surgery, which of the following nursing interventions should the nurse perform to prevent respiratory complications?
advise the client to splint the surgical incision when coughing and deep breathing
a nurse is reviewing the laboratory results of a client who has hepatic cirrhosis, which of the following lab findings should the nurse report to the provider?
ammonia 180, is above expected reference range of 10-80 the nurse should report an increased ammonia level because it can indicate portal-systemic encephalopathy
a nurse is caring for a client who reports a skin change. which of the following findings should the nurse report to the provider?
an asymmetrical papule that is pigmented-indicated melanoma
a nurse is providing care for four clients. which of the following clients is at the greatest risk for pneumonia?
an older client who has dysphagia-due to the increased risk for aspiration when eating
a nurse if providing teaching to a client who has rheumatoid arthritis and reports pain. which of the following responses should the nurse make?
ask a friend or a family member to help with household chores- reduce joint injury and to give the client the opportunity to rest
a nurse in an emergency department is assessing a client who has myasthenia gravis, the client reports recent increasing muscle weakness and the nurse suspects the client is having a myasthenic crisis, which of the following actions is the nurse's priority?
assist with a tensilon test-will determine whether the client is having a myasthenic crisis or a cholinergic crisis
a nurse is caring for a client who has GERD and a new prescription for metoclopramide the nurse should plan to monitor for which of the following adverse effects?
ataxia- extrapyramidal symptom
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?
auscultate the client's lungs-an adverse effect of many diuretics is hypokalemia, the nurse should first auscultate the clients lungs to assess for respiratory changes due to weakness of the respiratory muscles
a nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. which of the following should the nurse include in the teaching?
avoid crowds-can cause leukopenia due to bone marrow suppression, which can increase the clients risk for infection
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?
avoid direct sun exposure to the skin-client's skin is sensitive to sunburn due to the external radiation
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
bloody stools-greatest risk is hemorrhagic shock due to bleeding in the esophageal varices
a nurse if providing discharge teaching for a client who has diabetes insipidus and has a new prescription for desmopressin nasal spray. which should the nurse teach?
blow nose gently before using spray-prevent dilution of the med with nasal secretions
a nurse is assessing a client who has peritonitis, which of the following findings should the nurse expect?
board-like abdomen, distended abdomen, accompanied by extreme pain and tenderness is an expected findings in a client who has peritonitis
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 signs of fluid overload?
bounding peripheral pulses-increased vascular volume results in full, bounding peripheral pulses
a nurse is performing a breast examination on a female client who is pregnant, which of the following findings should the nurse report?
breast tissue with an orange peel appearance- indicates a blockage of lymph channels, which is a manifestation of advanced breast cancer
a nurse is assessing a client who has adrenal insufficiency, which of the following findings should the nurse expect
calcium 12.8-above expected
a nurse is assessing a client who has a serum calcium level of 8.1 mg/dL which of the following findings is the priority for the nurse to assess?
cardiac rhythm-because total serum calcium level is below the expected reference range, hypocalcemia can cause ECG changes, bradycardia, or tachycardia
a nurse is assessing a client who has upper gastrointestinal bleeding, which of the following findings should the nurse expect?
hypotension, risk for hemorrhagic shock
a nurse is providing to a client who has an allergy to peanuts, which fo the following instructions is the priority to include in the teaching?
carry an emergency anaphylaxis kit- the greatest risk to the client is injury or death from an anaphylactic reaction. therefore. the instruction for the client is to be prepared for emergency treatment by carrying an emergency anaphylaxis kit
a nurse is providing teaching to a client who is scheduled for a papanicolaou (PAP) test. the nurse should inform the client that she is being tested for which of the following?
cervical cancer- pap test is used to screen for cervical cancer
a nurse is caring for a client who has viral meningitis, which of the following actions should the nurse take?
check capillary refill at least every 4 hours, to monitor for vascular compromise
a nurse is caring for a client who has a full arm cast and reports a pain severity of 8 on a scale from 0 to 10 that pain medication does not relieve, which of the following actions should the nurse plant to take first?
check the circulation of the affected extremity-neuromuscular injury resulting from compartment syndrome, the first action the nurse should take is to check for circulation impairment in the affected extremity
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?
check the position of the weights and ropes-the weights might be too heavy, or the nurse might need to realign the client
a nurse is planning care for a client who is postoperative and has a closed-wound drainage system in place, which of the following interventions should the nurse plan to include?
cleanse the drain plug with alcohol after emptying- use one hand to compress the top and bottom of the device together and the other to cleanse the plug before replacing it
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?
clear drainage from nose-indicates that cerebrospinal fluid is leaking from the skull fracture, this places the client at risk for meningeal infection because micro-organisms have access to the cranium though the nose and the tear in the dura, the nurse should report this findings to the provider
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
client's report of pain on a pain scale
a nurse is reviewing the medication administration record for a client who is scheduled for surgery the next day, the nurse should identify that which of the following medications places the client at risk for complications during surgery and should be reported to the provider
clopidogrel-oral antiplatelet medication used to prevent coronary artery stenosis and other vascular incidents, therefore the medication should be discontinued 5 days prior to surgery because it acts similarly to aspirin and can cause the client to experience increased bleeding
a nurse is assessing a client who has respiratory acidosis, which of the following findings should the nurse expect?
confusion-from a lack of cerebral perfusion, if acidosis is not reversed the client's level of consciousness will decrease and coma may occur
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?
dark purple stoma-indicates bowel ischemia
a nurse is assessing a client who has hyperkalemia, which of the following findings should the nurse expect?
decreased muscle strength-muscle weakness, fatigue, paresthesia, and nausea
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?
decreased shortness of breath, increased abdominal fluid can limit the expansion of the diaphragm and prevent the client from taking a deep breath, once excess peritoneal fluid is removed the diaphragm will expand more freely,
a nurse is assessing a client who has systemic lupus erythematosis (SLE) which of the following findings should the nurse expect?
decreased urine output (due to kidney damage) butterfly rash (a scaly rash on the face) joint inflammation
a nurse is caring for a client who has HIV, which of the following lab findings should suggest to the nurse that medication therapy is effective?
decreased viral load-indicates a positive response
a nurse is creating a plan of care for a client who is postoperative for a total hip arthroplasty, practices judaism, and adheres to a kosher diet, which of the following interventions is the nurse's priority?
determine if the client's faith conflicts with the treatment plan, nurse can then take the necessary steps to inform the provider and prevent an issue during or after the surgical procedure
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 tests?
digital rectal examination-used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostate hypertrophy and prostate cancer
a nurse is providing discharge teaching for a client who is HIV positive, which the following instructions should the nurse include in teaching?
discard beverages that have been unrefrigerated for 1 hour
a nurse is providing teaching for a client who is in the immediate postoperative period and has a PCA pump, which of the following statements should the nurse include in the teaching?
do not allow your family to push the button if you are sleeping
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?
draw up insulin into separate syringes - insaline glargine is not compatible with other insulins
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 her diet to prevent dumping syndrome?
eggs- increase dietary intake of protein-containing foods, such as eggs, to decrease the risk for manifestations of dumping syndrome, client should eat some form of protein at each meal
a nurse is caring for a client who has a pheochromocytoma which of the following actions should the nurse take?
elevate the head of the bed-to reduce BP and abdominal pressure
a nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5, the client reports a throbbing headache and nausea, the nurse notes facial flushing and a blood pressure of 220/100, which of the following actions should the nurse take first?
elevate the head of the client's bed-client is experiencing autonomic dysreflexia and is at greatest risk for possible rupture of a cerebral vessel or increased intracranial pressure, the first action the nurse should take is to move the client from a supine to an upright position, which will result in rapid postural hypotension
a nurse in the emergency department is assessing a newly admitted client. which of the following findings place the client at increased risk for contracting hepB?
engaging in unprotected sexual intercourse
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?
epinephrine- a vasopressor, to increase the client's heart rate and prevent cardiac arrest
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?
erythema of the IV site-greatest risk is to tissue due to extravasation
a nurse is caring for a client who has a history of status epilecpticus and requires seizure precautions, which of the following actions should the nurse take
establish IV access, with a large bore catheter and administer 0.9% sodium chloride if seizures are imminent, if the client is stable, the nurse should initiate a saline lock
a nurse is education program for a group of males of testicular cancer, what should she include?
examine the testes immediately after showering- on a monthly basis
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?
expect to have two to three soft stools per day, lactulose is to promote the excretion of ammonia in the stool, the nurse should instruct the client to take the medication every day and inform the client that two or three bowel movements every day is the treatment goal
a nurse is assessing a client who had a right hemispheric stroke, which of the following neurologic deficits should the nurse expect?
impulsive behavior-poor judgement, and lack of awareness of neurologic deficits
a nurse is providing discharge teaching for a client who has a new prescription for medications to treat peptic ulcer disease, the nurse should identify that which of the following medications inhibits gastric acid secretion?
famotidine- is an h2 recpetor antagonist that is prescribed for the treatment of peptic ulcer disease to inhibit the secretion of gastric acid
a nurse is monitoring the lab values of a client who has DM and is taking insulin, which result indicates a therapeutic outcome of insulin?
fasting BG of 96
a nurse is assessing a client who has crohn's disease, which of the following findings should the nurse expect
fatty diarrheal stools
a nurse is caring for a client who has retinal detachment, which of the following client reports about the affected eye should the nurse expect?
flashes of bright light- or floating dark spots in the affected eye as the retinal layers separate
a nurse is caring for a client who is receiving moderate (conscious) sedation with midazolam, the client's RR decreases from 16 to 6 and the O2sat decreases from 92 to 85, which of the following medications should the nurse administer
flumazenil- a benzodiazepine agonist to reverse the sedative effects of the medication
a nurse is caring for a client who is 12 hour postoperative from a gastrectomy and has an NG tube set to continuous low suction, which of the following findings requires intervention by the nurse?
gastric distention-indicate the NG is not patent, check tube for kinks, blockages, and loose connections, reposition client to facilitate drainage, avoid removing or irrigating the tube unless directed to do so
a nurse if caring for a client undergoing screening for primary cushings disease. the nurse should expect an elevation in which of the following laboratory findings?
glucose - elevated in a client with cushings
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?
hiccups- can be caused by phrenic nerve irritation due to abdominal distention
a nurse if assessing a client who has a new diagnosis of cushing's disease, which of the following findings should the nurse expect?
hirsutism- increased hair growth, due to increased androgen production
a nurse is managing the care of a client who is post-op and has acute adrenal insufficiency. which of the following action should the nurse take
hydrocortisone sodium is necessary to replace the cortisol deficiency tha occurs with adrenal insufficiency
a nurse is assessing a client who has hypomagnesemia, which of the following findings should the nurse expect?
hyperactive deep-tendon reflexes- for a client who has hypomagnesemia includes muscle cramps, numbness, and tingling
a home health nurse is assessing a client who requires lifelong hormone replacement therapy for treatment of hypothyroidism. the client has not been taking his medication regularly, what should you expect?
hypotension- along with bradypnea, dysrhthmias, cold intolerance, and cool dry skin
a nurse is providing teaching for a client who is scheduled to undergo moderate sedation for a bronchoscopy, the nurse should verify that the client understands the procedure when the client state which of the following?
i can expect to feel sleepy for several hours after the procedure
a nurse is reviewing postoperative instructions with a client following cataract surgery, which of the following statements should the nurse identify as an indication that the client understands the instructions
i should call my doctor if my vision gets worse-there should be an improvement in vision after the surgery
a nurse is providing discharge teaching for an older adult client who has mild diverticulitis, which of the following statements by the client indicates an understanding of the teaching?
i should eat foods that are low in fiber, when the inflammation subsides the client should consume foods that are high in fiber
a nurse is teaching a client who has parkinson's disease about taking carbidopa-levodopa which of the following statements should the nurse identify as an indication that the client understands the teaching?
i should expect my urine to be a darker color- saliva, urine, and sweat can darken in color during the therapy
a nurse is providing discharged teaching for a client who has a peptic ulcer disease and a new prescription for famotidine, which of the following statements by the client indicates an understanding of the teaching
i should take this medication at bedtime, to inhibit the action of histamine at the H2-receptor site in the stomach
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?
i should wear gloves when it is cold outside- raynaud's phenomenon commonly accompanies SLE and can cause painful vasoconstriction client fingers when exposed to cold temperatures
a nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk, which of the following statements by the client indicates an understanding of the teaching?
i will add broccoli and kale to my diet-which are good source of calcium, as alternatives to daily products
a nurse in an outpatient clinic is teaching a client who has DM foot ulcer about foot care. which indicates the client understands?
i will apply lotion to dry areas of the feet, but NOT between the toes (prone to bacterial growth)
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?
i will avoid medications that contain acetaminophen-which can cause additional liver damage
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?
i will be able to shower after the doctor removes the drain
a nurse is teaching a client who has type 1 DM about how to prevent complications during illness. which the following statements should the nurse identify as an indication that the client understands the teaching?
i will call my doctor sugar is more than 250mg per dL
a nurse is providing teaching to a client who has a new prescription for amoxicillin to treat a respiratory infection. which of the following statement by a client indicates an understanding of the teaching?
i will use a backup method of birth control while i am taking this medication-antibiotics accelerate the elimination of oral contraceptives
a nurse is providing teaching for 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?
i will use the incentive spirometer every hour-respiratory depression and limited chest expansion are both causes of respiratory acidosis, using an incentive spirometer will promote chest expansion
a nurse is admitting a client who has acute pancreatitis, which of the following actions should the nurse take first?
identify the client's current level of pain
a nurse is planning an education program for a group of high school teachers who will be taking students on a hike. what should the nurse include regarding lyme disease?
if you develop pain and stiffness in your joints, you should see a doctor-manifestations of stage 1 lyme disease include influenza like symptoms, a bull's-eye rash, muscle pain
while reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 which of the following actions should the nurse take?
implement seizure precautions- due to low excitation threshold as a result of a decreased calcium level, the nurse should initiate seizure precautions to prevent injury
a nurse is reviewing the lab results of a client who has acute pancreatitis, which of the following findings should the nurse expect?
increased serum amylase, due to pancreatic cell injury
a circulating nurse is monitoring the temperature in a surgical suite, the nurse should identify that cool temperatures reduce the client's risk for which of the following potential complications of surgery
infection-humidity 30-60% reduces risk for infection
a nurse is planning teaching for a client who has type 1 DM. which of the following instructions should the nurse include
ingest alcohol with food to reduce alcohol-induced hypoglycemia
a nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. which of the following action should the nurse take first?
initiate high-flow oxygen therapy-by mask at 5-6L/min to keep the clients oxygen sat over 90%
a nurse is caring for a client who is 2 days postoperative following a cholecystomy the client has been vomiting for the past 24 hours and reports a pain level of 8 on a scale from 0 to 10, 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
insert an NG tube-to begin decompressing
a nurse is caring for a client who has multiple sclerosis, which of the following findings should the nurse expect?
intention tremors- clients with multiple sclerosis are at risk for motor dysfunction, with intention tremors, poor coordination, and loss of balance
a nurse is monitoring a client's status 24 hour after total thyroidectomy. which of the following findings should the nurse report to the provider?
laryngeal stridor- harsh high-pitched sound with inspiration, indicates obstruction, take immediate action to preserve the airway
a nurse is assessing a client who is preoperative, the nurse should identify that which of the following factors reported by the client increases the risk for a postoperative wound infection?
long term use of corticosteroids- inhibits leukocyte response which increases the clients risk for infection
a nurse is reviewing the prescriptions for a client who has campylobacter enteritis, which of the following prescriptions should the nurse clarify with the provider?
magnesium hydroxide-nausea vomiting, diarrhea are manifestations of enteritis, nurse should clarify prescription of milk of magnesium this med increases gastric motility, which can increase the client's risk for an electrolyte imbalance and contribute to dehydration
a nurse is planning care for a client who has a closed head injury from a fall and is receiving mechanical ventilation, which of the following interventions is the nurse's priority?
maintain a PaCO2 of approximately 35mmHg, to prevent hypercarbia and subsequent vasodilation that can lead to an increase in intracranial pressure
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?
measure the client's abdominal girth daily, to monitor the amount of fluid accumulation in the abdomen and the effectiveness of treatment measures
a nurse is caring for a client who has advancing amyotrophic lateral sclerosis, which of the following interventions is the nurse's priority
monitor pulse oximetry findings-respiratory compromise due to progressive paralysis of respiratory muscles, therefore the priority intervention is to monitor the client's oxygen saturation to identify respiratory compromise as soon as possible
a nurse is caring for a client who has DM and has developed peripheral neuropathy. which of the following measures should the nurse recommend to prevent injuries to the clients feet?
monitor the temp of bath water with a thermometer
a nurse is developing a teaching plan for a client who has meniere disease, which of the following instructions should the nurse include
move your head slowly to decrease vertigo-keep from worsening the vertigo
a client had 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?
obtain vital signs to assess for shock
a nurse is assessing a client who has appendicitis, which of the following findings should the nurse expect?
oral temperature of 101.1 F nausea vomiting are expected findings in a client who has appendicitis right lower quadrant pain
a nurse is planning care for a client who has a serum potassium level of 3.0 the nurse should plan to monitor the client for which of the following?
orthostatic hypotension-manifestations of hypokalemia
a nurse in 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 administer
osmotic diuretics via IV bolus- such as mannitol to reduce intraocular pressure and prevent damage to the eye
a nurse is caring for a client who requires nasogastric suctioning. which of the following sets of lab results indicates that the client has metabolic alkalosis?
pH 7.51, PaO2 94, PaCO2 36, HCO3 31-elevated pH and HCO2 with a paCO2 elevated or in normal range (alkalosis)
a nurse is teaching an assistive personnel (AP) about care of a client following a total hip arthroplasty, which of the following instructions should the nurse include
place an abductor pillow between the client's legs when turning the client,
a nurse is caring for a client who requires continuous cardiac monitoring, the nurse identifies a prolonged PR interval and widened QRS complex, which of the following lab values supports this finding?
potassium 6.1-hyperkalemia defined as a potassium level above 5.0 can cause a prolonged PR interval, a wide QRS complex, a flat or absent P waves and tall T waves
a nurse in the PACU is assessing a client who is postoperative, which of the following findings should the nurse report to the provider
presence of inspiratory stridor-manifestation of tracheal edema and requires intervention
a nurse is assessing a client who is using PCA following a thoracotomy- the client is short of breath, appears restless, and has a RR of 28, the client's ABG results are pH 7.52, paO2 89, PaCO2 28, and HCO3 24, which of the following actions should the nurse take?
provide calming interventions - should decrease RR, will cause an increase in CO2, and lowers the pH, instruct the client to breath slowly
a nurse is providing preoperative teaching to a client who is scheduled for a gastrectomy in 1 week, the client is anxious about the upcoming surgery, which of the following actions should the nurse take?
provide concise, factual information-allows for open communication and gives the nurse the opportunity to dispel the client's fears
a nurse is administering propranolol by IV bolus to a client who is having a thyroid storm. what indicates a therapeutic response?
reduction of effect of thyroid hormone of the heart-
a nurse is reviewing the lab report for a client who has hodgkin's lymphoma, what should the nurse expect?
reed-sternberg cells-cancer cells specific to hodgkin's
a nurse is teaching a client who has osteoporosis and a new prescription for alendronate, which of the following information should the nurse include in the teaching?
remain upright for 30 minutes after taking this medication-prevent esophagitis or esophageal ulcers that can results from alendronate therapy, the client should sit up for 30 minute after taking this medication
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?
remind the client to look consciously at both sides of his meal tray-will have lost the right visual field of both eyes and might only eat the food he is able to see on the left half of the meal tray, therefore the nurse should remind the client to look at both sides of his meal tray to help him compensate for the visual loss
a nurse if preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin which of the following information should the nurse include in the teaching plan?
report nocturia because it requires a dosage adjustement -the client should receive the initial dose of desmopressin in the evening, the provider will increase the dosage until the client no longer has nocturia
a nurse is admitting a client who has status asthmaticus, the clients ABG results are pH 7.32, paCO2 56, HCO3 26, the nurse should interpret these lab values as which of the following imbalances?
respiratory acidosis-low pH, elevated PaCO2, and a regular HCO3
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 indicates increasing intracranial pressure
restlessness-behavioral changes (early manifestations)
to screen a client for pheochromocytoma, a nurse schedules a vanillylmandelic acid test. which teaching the client about this test, which of the following instructions should the nurse include?
restrict coffee intake 2-3 days prior- avoid teas, bananas, chocolate, and vanilla for 2-3 days to prior
a nurse is reviewing the medical record of a client who is to undergo general anesthesia for surgery, the nurse should report which of the following findings to the provider?
serum potassium at 2.8-risk for cardiac dysrhythmias
a nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration, which of the following lab findings indicates that the fluids therapy has been effective?
serum sodium 138-isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt, a serum sodium level of 138mEq is within the expected reference range and indicates that the fluid therapy has been effective
a nurse is assessing a client who has phosphorous level of 2.4mg which of the following findings should the nurse expect?
slow peripheral pulses-phosphorous is low, nurse should expect the client to have slow peripheral pulses, the nurse might also find that the clients pulses are difficult to find and easy to block
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?
small purple-colored skin lesions, kaposi sarcoma
a nurse is assessing a client who has a syndrome of inappropriate antidiuretic hormone (SIADH) reports?
sodium 110-retain fluids which causes dilutional hyponatremia
a nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic which of the following lab values should the nurse report to the provider?
sodium 128-low, likely cause of altered mental status, report for weakened respiratory effort
a nurse is caring for a client who has a spastic bladder following a spinal cord injury, which of the following actions should the nurse take to help stimulate micturition?
stroke the client's inner thigh-techniques includes pinching the skin above the groin and providing digital anal stimulation
a nurse is developing a teaching plan for a client who has a thyroidectomy and takes a thyroid hormone replacement, what should the nurse plan include?
take med on an empty stomach-to promote proper absorption and do not eat or drink for 60 minutes after
a nurse is planning to teach a client who has epilepsy and is to start therapy with phenytoin, which of the following instructions should the nurse include in the client's medication teaching plan?
take medication at a consistent time each day to maintain therapeutic blood levels
a nurse is caring for a client who has leukemia and platelet count of 48,000, which of the following actions should the nurse take?
test the client's urine and stool for occult blood- thrombocytopenic is at risk for bleeding
a nurse is caring for a client who has colorectal cancer and is receiving chemotherapy, the client asks the nurse why his blood is being drawn for a carcinoembryonic antigen (CEA) level, which of the following responses should the nurse make?
the CEA determines the efficacy of your chemotherapy, it will decrease if chemotherapy is effective
a nurse is assessing a client who has a duodenal ulcer, which of the following findings should the nurse expect
the client reports that pain occurs during the night - pain with empty stomach, 1.5-3 hours after meals
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?
the organ will need to be removed if hyperacute rejection occurs- removing the organ is the only treatment for rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant
a surgical nurse enters a surgical suite to ensure surgical asepsis is maintained, which of the following findings requires intervention by the nurse?
the scrub technologist is wearing a watch under his scrubs-remove all jewelry first
a nurse is teaching a client and his 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?
this medications that treat alzehmier's disease can help delay cognitive changes-enhances the availability of acetylcholine, which can slow cognitive decline in some clients
a nurse is teaching the parent of a child about the HIV vaccine what is true?
three doses are administered to adolescents who start the series after age 15-
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 tests?
throat culture- identified by specific micro-organism present in the pharynx
a nurse is caring for a client who has ulcerative colitis, the client has had several exacerbation 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
use progressive relaxation techniques (minimizes stress), arrange activities to allow for daily rest periods (decreases stress and reduces intestinal motility), restrict intake of carbonated beverages (GI stimulant, nuts, peppers, and smoking)
a nurse is caring for a client who has a surgical wound with a penrose drain in place, which of the following interventions should the nurse plan to perform?
use sterile technique when performing dressing changes-
a client is transferred from the surgical suite to the PACU following oral surgery, while monitoring the client's vital signs, the nurse finds that the client't tongue has become swollen and is obstructing the airway, which of the following actions should the nurse take first?
use the head-tilt, chin-lift method to open the airway
a nurse is reviewing the medical record of a client who is scheduled for an elective surgery, which of the following medications should the nurse expect the provider to discontinue prior to surgery to minimize the risk of complications?
warfarin-an anticoagulant, increased risk of bleeding
a nurse is caring for a client who has a new prescription for clindamycin to treat acute pelvic inflammatory disease, the nurse should monitor for and report what findings?
watery diarrhea-greatest risk is pseudomembranous colitis (manifested by watery diarrhea)
a nurse is caring for a client who is taking proplythiouracil. the nurse should identify that the client has met the treatment goals when she reports an increase in which of the following manifestations?
weight-propylthiouracil suppresses the production of thyroid hormones, and therefore allows for weight gain.
a nurse is providing teaching for a client who has venous insufficiency of the lower extremities which of the following statements by the client indicates an understanding of the teaching?
when i sit down to watch television, I'll be sure to put my feet up-elevating her feet will increased the return, the client should elevate her feet for at least 20 minutes several times per day
a nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 which of the following actions should the nurse take first
withhold the medication-
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
yogurt, crackers, toast, prevent flatus
a nurse is providing preoperative teaching for a client who is about to have a below-the-knee amputation, which of the following instructions should the nurse include?
your surgeon might prescribe an antibiotic before surgery-to reduce the risk of infection
