Capstone Adult Med Sure Pre

A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of the following statements by the client should indicate to the nurse a need for further teaching? "the symptoms can get worse with penile penetration during intercourse" "a sensation of pressure in the pelvis can occur" "Low back pain can occur frequently" "Feces can be present in the vagina"

"Feces can be present in the vagina" The presence of feces in the vagina is a manifestation of a genital fistula. This statement indicates a need for further teaching.

a nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. which of the following client statements indicated an understanding of the teaching? "I can use either heat or ice to help relieve the discomfort" "ibuprofen is the first step in medication therapy for osteoarthritis" "I should limit physical activity to prevent further injury" "I will elevate my legs by placing two pillows under my knees when I go to bed"

"I can use either heat or ice to help relieve the discomfort" The nurse should reinforce that different treatment modalities, such as heat or cold therapy, can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbs nerve endings and decreases joint inflammation.

a nurse is teaching about disease management for a client who has type 1 diabetes mellitus. which statement made but the client indicates an understanding of the teaching? "i am to take my blood sugar reading after meals" "insulin allows me to eat ice cream at bedtime" "a weight reduction program will make me hypoglycemic" "I give the insulin injections in my abdominal area"

"I give the insulin injections in my abdominal area" The client should give insulin injections in one anatomic area for consistent day-to-day absorption. The abdomen is the area for fastest absorption

a nurse is providing teaching to a client who has nephrotic syndrome. the nurse should recognize that which of the following client statements indicates a need for further teaching? "I can expect to have swelling in my face" "I will lose protein in my urine" "I should expect my provider to prescribe a kidney biopsy" "I should increase my sodium intake"

"I should increase my sodium intake" A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and control hypertension.

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? "Without treatment, glaucoma can cause blindness" "Double vision is a common symptom of glaucoma" "Glaucoma is caused by inadequate production of fluid within the eye" "Use of eye drops will improve vision over time"

"Without treatment, glaucoma can cause blindness" The nurse should explain that without treatment glaucoma can result in blindness due to irreversible damage to the retina and optic nerve.

A client who is scheduled for a barium swallow study asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? "the laxative will prevent the absorption of magnesium" "the laxative helps eliminate the barium" "the laxative is the protocol at this facility" "the laxative makes the barium turn brown"

"the laxative helps eliminate the barium" The nurse's statement that the laxative will help eliminate the barium is appropriate and provides the client with the reason for the laxative.

A nurse is caring for a client who had total hop arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? Insert a nasogastric tube Administer an antiemetic Encourage use of the incentive spirometer Auscultate bowel sounds

Auscultate bowel sounds Using the nursing process, assessing for the presence or absence of bowel sounds and the passage of flatus is an appropriate action at this time. Determining the cause of the nausea and reducing contributing factors should precede any treatment.

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect. Fatigue Hypertension Bradycardia Diarrhea

Fatigue The nurse should identify that the client who has anemia due to blood loss following surgery will experience fatigue. This is due to the body's decreased ability carry oxygen to vital tissues and organs.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? Clamp the chest tube prior to transferring the client to a wheelchair Disconnect the chest tube from the drainage system during the transport Keep the drainage system below the level of the client's chest at all times Empty the collection chamber prior to transport

Keep the drainage system below the level of the client's chest at all times During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.

An acute care nurse receive shift report for a client who has increased intracranial pressure. the nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? Extension of the arms Pronation of the hands Plantar flexion of the legs External rotation of the lower extremities

Plantar flexion of the legs Plantar flexion of the legs is an indicator of decorticate posturing and is a result of lesions of the corticospinal tracts.

a clinic nurse is performing a physical assessment on a client who has systemic lupus erythematous (SLE). which of the following findings should the nurse expect? a grey colored, non-purpuric papular rash a dry, red rash across the bridge of the nose and on the cheeks pitting edema of the hands and fingers subcutaneous nodules on the ulnar side of the arm

a dry, red rash across the bridge of the nose and on the cheeks A "butterfly" rash that is dry, red, and raised is characteristic of SLE.

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. which of the following interventions should the nurse perform first? clean and dress the wound administer pain medication administer a tetanus booster administer IV fluids

administer IV fluids Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. the nurse should instruct the client to take which of the following actions? apply hydrating lotions apply moist heat sit in the sun for 10 min per day wash with plain soap and water

apply hydrating lotions The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.

a nurse is caring for a client who has a cardiopulmonary arrest. the nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia? epinephrine magnesium atropine sodium bicarbonate

atropine The team administers atropine during CPR if the client has symptomatic bradycardia, or is hemodynamically unstable.

A nurse is planning an educational program about basal cell carcinoma. which of the following information should the nurse plan to include? basal cell carcinoma has a low incidence of metastasis basal cell carcinomas has a high mortality rate basal cell carcinoma is aggressing and rapid growing basal cell carcinoma develops from a nevi or mole

basal cell carcinoma has a low incidence of metastasis Basal cell carcinoma is a localized lesion that seldom metastasizes.

A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of buck's extension traction. the nurse should include which of the following information in the teaching? buck's extinction traction will reduce the fracture buck's extension traction will relieve muscle spasms buck's extension will maintain alignment of the pins buck's extension traction will allow supported movement of the extremity

buck's extension traction will relieve muscle spasms Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.

the nurse is caring for a client who has heart failure and a history of asthma. the nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? carvedilol fluticasone captopril isosorbide denitrate

carvedilol Medications that block beta-2 receptors, such as carvedilol, are contraindicated in clients with asthma.

A nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? pale yellow greenish-brown red dark and foamy

dark and foamy The nurse should expect the client to have dark and foamy urine, which indicates the kidneys are filtering excess bilirubin from the blood.

a nurse is caring for a client following an esophagogastroduodenoscopy (EGD) procedure. which of the following assessments is the nurses priority? pain nausea gag reflex level of consciousness

gag reflex The greatest risk to the client's safety following an EGD is aspiration. Until the client's gag reflex returns, the nurse must keep the client NPO and prepare to intervene to keep the airway open and unobstructed.

a nurse in a provider's office is assessing a client who reports dyspnea and fatigue. physical assessment reveals tachycardia and weak peripheral pulses. the nurse should recognize these findings as manifestations of which of the following conditions? asthma aortic valve regurgitaion heart failure aortic stenosis

heart failure Fatigue and tachycardia are early manifestations of heart failure. Other manifestations include dyspnea and weak peripheral pulses.

a nurse is selecting a qualified staff member to double check a blood label with a client ID bracelet prior to infusing a unit of blood. the nurse should identify that which of the following persons is qualified oncology nurse assistive personnel senior nursing student phlebotomist

oncology nurse The nurse should ask another nurse or a provider to double check the blood label and client ID prior to an infusion.

a nurse is caring for a client 4 hr following evacuation of a subdural hematoma. which of the following assessments is the nurse's priority? intracranial pressure serum electrolytes temperature respiratory status

respiratory status When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respirations, noting the rate and pattern, and evaluating arterial blood gases. Following intracranial surgery, even slight hypoxia can worsen cerebral ischemia.

a nurse is giving a presentation at a community center about chronic bronchitis. which of the following information should the nurse include as effective for preventing this disorder? maintenance of ideal weight annual influenza immunization smoking cessation regular moderate exercise

smoking cessation Smoking is a major cause of chronic bronchitis; therefore, smoking cessation is an effective preventive strategy.

a nurse is reviewing risk factors for osteoporosis with a group of nursing students. the nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis? thyroid hormones anticoagulants nsaids cardiac glycosides

thyroid hormones Long-term use of a synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss.

a nurse is caring for a client who came to the emergency department reporting chest pain. the provider suspects a myocardial infarction. while waiting for the troponin levels report, the client asks what this blood test will show. which of the following explanations should the nurse provide the client? troponin is an enzyme that indicates damage to the brain, heart, and skeletal muscle tissues troponin is a lipid whose levels reflect the risk for coronary artery disease troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart troponin is a protein that helps transport oxygen throughout the body

troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart Troponin is a myocardial muscle protein that releases into the bloodstream when there is injury to the myocardial muscle. Troponin levels are specific point-of-care testing for clients who are having a myocardial infarction.

a nurse is caring for a group of clients in an infectious disease unit. the nurse should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases? pertussis mycoplasma pneumonia tuberculosis respiratory syncytial virus

tuberculosis Tuberculosis is transmitted by small droplets. Therefore, nurses providing care to clients who have tuberculosis should wear individually fitted N95 respirator masks.

a nurse is caring for a client who has acute pancreatitis. after treating the client's pain, which of the following should the nurse address as the priority intervention? auscultate the clients lungs assist the client to a side-lying position provide oral hygiene withhold oral fluids and food

withhold oral fluids and food To rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.