Complex Clients

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? A. Secure the straps firmly around the boot B. Remove the device before showering C. Use crutches with rubber tips D. Adjust the screws to maintain alignment

C. Use crutches with rubber tips

The nurse is caring for the client. The nurse is caring for the client 1 hr following chest tube insertion. Click to highlight the findings in the nurses' note that indicate the client's condition is improving. To deselect a finding, click on the finding again.

- client reports pain as 3 on a scale of 0 to 10 - client reports shortness of breath has decreased - wound dressing is dry and intact - respiratory rate 24/min, - blood pressure 108/74 - oxygen saturation 95% on 2 L/min via nasal cannula

The nurse is caring for the client. Complete the following sentence by using the lists of options. The client is most likely experiencing a ________ as evidenced by the ________.

- hemothorax - respiratory findings A hemothorax is correct. The client has shortness of breath, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax. Respiratory findings is correct. The client has shortness of breath, hypoxia, diminished breath sounds, and a decreased hematocrit. Therefore, the client is likely experiencing a hemothorax.

The nurse is providing care for the client. The nurse is providing discharge teaching to the client. Which of the following statements made by the client indicates an understanding of the teaching? Select all that apply.

- " I should schedule several rest periods throughout the day" - " I should notify my provider if my temperature is higher than 101" "I can continue to drink coffee in the mornings" is incorrect. The client should be instructed to avoid gastrointestinal stimulants, such as caffeine. "I should schedule several rest periods throughout the day" is correct. The client should be reminded to take rest periods throughout the day to promote healing. "I should alternate taking acetaminophen with my prescribed pain medication" is incorrect. The nurse should instruct the client to avoid taking additional acetaminophen because the prescribed pain medication already contains acetaminophen. Additional doses of acetaminophen can result in hepatic toxicity. "I should notify my provider if my temperature is higher than 101° F" is correct. The nurse should instruct the client to report manifestations of an infection, such as pain, temperature greater than 38.3° C (101° F), swelling, redness, warmth, or bleeding at the incision site. "I can resume lifting objects after 2 weeks" is incorrect. The nurse should instruct the client that lifting objects following an exploratory laparotomy is contraindicated. The client should wait a minimum of 6 weeks, or as instructed by the provider, to allow the incision to heal.

A nurse is caring for a client who is scheduled for a right knee arthroplasty. The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

- "I will probably be going home with a walker" - "I will be sure to ask for pain medication before my knee starts to hurt too bad" - "I will need to do the breathing exercises every 1 to 2 hours after the surgery"

A nurse is caring for a client. Complete the following sentence by using the lists of options. After reviewing the findings in the client's medical record, the nurse should first address the client's _______ followed by the client's_______.

- Abd. distention - Acute pain Abdominal distention is correct. When using the greatest risk framework, the nurse should identify that abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. Acute pain is correct. When using the greatest risk framework, the nurse should identify that acute abdominal pain is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding next to reduce the risk of life-threatening complications, such as obstruction or infection.

The nurse is providing care for the client. The nurse is caring for the client who is preoperative for an exploratory laparotomy. Select the 4 actions that the nurse should take.

- Administer phenytoin with a sip of water prior to the surgery - Administer gentamicin 100 mg IV - Administer dextrose 5% in lactated Ringer's - Contact the wound, ostomy, and continence nurse Administer phenytoin with a sip of water prior to the surgery is correct. Medications for cardiac disease, respiratory disease, and seizure disorders should be administered before surgery. Administer gentamicin 100 mg IV is correct. The nurse should administer a broad-spectrum antibiotic for clients who have peritonitis. Administer dextrose 5% in lactated Ringer's is correct. Hypertonic IV fluid should be administered to clients who have peritonitis to restore fluid volume balance. Dextrose 5% in lactated Ringer's (D5LR) is a hypertonic IV solution. Contact the wound, ostomy, and continence nurse is correct. The nurse should collaborate with the certified wound, ostomy, and continence nurse to discuss wound management, if necessary. Provide the client with high-flow supplemental oxygen is incorrect. The nurse should identify that the client's oxygen saturation is in the expected reference range; therefore, they do not need supplemental oxygen at this time.

The nurse is caring for the client. Drag words from the choices below to fill in each blank in the following sentence. The nurse should first address the client's ________ followed by the client's ________.

- Oxygenation - blood pressure Oxygenation and blood pressure are correct. Using the airway, breathing, circulation priority framework, the nurse should first address the client's oxygenation, followed by the client's blood pressure. The client's oxygenation is below the expected reference range and is the priority. The nurse should then address the client's circulation because the client's blood pressure is below the expected reference range.

A nurse in the emergency department is caring for a client. Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is experiencing manifestations of __________ as evidenced by the _____________.

- Pancreatitis - amylase / lipase Pancreatitis is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase. Amylase and lipase is correct. The client's laboratory results and physical assessment indicate the client is experiencing manifestations of pancreatitis. Clients who have pancreatitis experience an increase in pancreatic enzymes, amylase, and lipase.

The nurse is providing care for the client. The nurse is caring for the client who has manifestations of _________ therefore, the priority finding for the nurse to report is ____________.

- Peritonitis - Lab values Peritonitis is correct. The client has manifestations of peritonitis, including rigid abdomen and elevated WBC count and ESR. Peritonitis is an inflammation and infection of the abdominal cavity that can occur when bacteria enter the peritoneum through a perforation in the bowel as a complication of Crohn's disease. Laboratory values is correct. The nurse should identify that the client's laboratory values is the priority to report when using the urgent vs. nonurgent priority framework. An elevated WBC count and a high neutrophil count indicates an infection, which is a manifestation of peritonitis.

A nurse has received report on a client who is being admitted to the emergency department. Select the 3 findings that require follow-up by the nurse.

- Wound drainage - Oxygen saturation - Pain level Oxygen saturation is correct. The client has an oxygen saturation that is less than the expected reference level, indicating hypoxia. The nurse should plan to increase the client's supplemental oxygen. Pain level is correct. The nurse should follow up on the client's pain level. Wound drainage is correct. The nurse should apply a pressure dressing to control bleeding.

A nurse is caring for a client who is brought to the emergency department following an oil fire. Drag words from the choices below to fill in each blank in the following sentence. During the emergent phase of burn care, the client is at risk for developing _______ and _______.

- hypovolemia - respiratory failure Hypovolemia and respiratory failure are correct. Plasma volume is lost immediately during a burn injury, which can lead to a lack of perfusion to all body organs. Hypovolemia is indicated by the client's blood pressure declining and heart rate increasing. If fluid resuscitation is not initiated successfully, hypovolemic shock can occur. The initial priority following a burn injury is to assess and protect the airway. The client has burns to the face and chest, which will compromise respiratory function, placing them at risk for respiratory failure. The client's respiratory function is decompensating as edema to the airway increases. Continued decompensation might indicate the need for the client to be intubated. Hypokalemia, Curling's ulcer, and hyperthermia are incorrect. During the emergent phase, the client is at risk for hyperkalemia as a result of cellular destruction of the burn area. The nurse should identify that the client is at risk for Curling's ulcer, which usually develops 72 hr following the burn, not during the emergent phase. Following a burn injury, clients are at risk for hypothermia, as heat is lost through the damaged skin. The vital signs indicate that the client's temperature is decreasing.

A nurse is caring for a client who is 4 hr postoperative following a total vaginal hysterectomy. Click to highlight the findings the nurse should report to the provider immediately.

- perineal pad saturated with blood, large clots present - change of blood pressure, heart rate of 102/min Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider. Client sleeping, arouses to verbal stimuli, respiratory rate 14/min, oxygen saturation 95% on room air, breath sounds clear, and reports pain as 2 on scale of 0 to 10 are incorrect. These are expected findings. Therefore, the nurse does not need to report these findings to the provider.

The nurse is caring for the client. The nurse is caring for the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.

- place the client in high fowler's position - place two rubber tipped hemostats in client's room - palpate the chest tube insertion site for subcutaneous emphysema - Ensure that all chest tube connections are securely attached Place the client in high-Fowler's position is correct. The nurse should place the client in high-Fowler's position to promote drainage of the hemothorax. Ensure there is continuous bubbling in the water seal chamber is incorrect. The nurse should monitor the water seal chamber for continuous bubbling because this is an indication of a leak in the chest tube system. Monitor drainage every 30 min for the first hour is incorrect. The nurse should monitor the drainage from the chest tube every 15 min for the first 2 hr to identify excessive drainage. Strip the drainage tubing to ensure it is patent is incorrect. The nurse should not strip the chest tube because this can cause increased intrathoracic pressure. Place two rubber-tipped hemostats in the client's room is correct. The nurse should place two rubber-tipped hemostats in the client's room to use in case of an emergency, such as chest tube dislodgment. Palpate the chest tube insertion site for subcutaneous emphysema is correct. The nurse should palpate the chest tube insertion site for subcutaneous emphysema because this is a manifestation of an air leak. Ensure that all chest tube connections are securely attached is correct. The nurse should ensure that all connections between the chest tube and drainage system are secure and intact to reduce the risk of a tension pneumothorax.

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer?

24

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? A. Check the client's neurologic status B. Document the client's statements C. Prepare the client for a CT scan D. Teach the client about using safety precautions for falls

A. Check the client's neurologic status The first action the nurse should take using the nursing process is to assess the client. Therefore, the nurse should first check the neurologic status of the client.

A nurse is preparing to present a program about prevention of atherosclerosis at a health far. Which of the following recommendations should the nurse plan to include? (Select all that apply.) A. Follow a smoking cessation program B. Maintain an appropriate weight C. Eat a low-fat diet D. Increase fluid intake E. Decrease intake of complex carbohydrates

A, B, C

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? A. "Discontinuing the treatments is your choice if it is your wish to do so." B. "Your daughter is named as your health care surrogate. I will ask her if you can stop them" C. "I will call your spiritual advisor to come in, so you can discuss this with them" D. "Next time you have an oncology appointment, you should as the oncologist"

A. "Discontinuing the treatments is your choice if it is your wish to do so."

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? A. Airborne B. Droplet C. Contact D. Protective environment

A. Airborne Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? A. Applying oxygen via face mask B. Placing the client in Fowler's position C. Administering epinephrine D. Initiating an IV infusion of 0.9% sodium chloride

A. Applying oxygen via face mask Evidence-based practice indicates that the priority intervention is for the nurse to apply oxygen. The nurse should use a high-flow nonrebreather mask to deliver oxygen at 90% to 100%.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? A. Document that depolarization has occurred B. Increase the pacemaker's voltage C. Decrease the pacemaker's sensitivity D. Check the placement of the ECG leads

A. Document that depolarization has occurred When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? A. Drink 240 mL (8 oz) of water after administration B. Expect results in 4 to 6 hr C. Take this medication before meals to increase appetite D. Reduce dietary fiber intake to improve medication absorption

A. Drink 240 mL (8 oz) of water after administration The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? A. Dyspnea B. Hemoptysis C. Mucus production D. Dysphagia

A. Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? A. Encourage the client to take deep breaths after the procedure B. Assist the client to hold their arms up during the procedure C. Instruct the client to remain NPO after midnight prior to the procedure D. Keep the client on bedrest for 8 hr following the procedure

A. Encourage the client to take deep breaths after the procedure After a thoracentesis, the client should deep breathe to re-expand the lung. The nurse should place the client in an upright position with their arms resting on an overhead table to widen the intercostal space and spread the ribs for tube insertion. The nurse should assist a client who cannot sit up into a side-lying position with the affected side up. The client should receive a local anesthetic for the procedure and will not require an NPO status after midnight prior to the procedure. The nurse should instruct the client that they can resume activity within 1 hr following the procedure.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? A. Extremity cool upon palpation B. Serosanguineous drainage on the dressing C. Capillary refill of 2 seconds D. Client report of discomfort when moving toes

A. Extremity cool upon palpation The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? A. Flex the foot every hour when awake B. Place a pillow under the knee when lying in bed C. Lower the leg when sitting in a chair D. Ensure the leg is abducted when resting in bed

A. Flex the foot every hour when awake The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return. The nurse should instruct the client to avoid placing pillows under the knee to prevent flexion contractures. The nurse should instruct the client to keep the operative leg in a neutral position when resting in bed to prevent dislocation of the knee.

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's inital vital signs were HR 80, BP 130/70, R 16, and temp 96.8. Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? A. Heart rate 110 B. BP 160/70 C. R 14 D. Temp 101.1

A. Heart rate 110

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period B. Assist the client to start arm exercises 48 hr after surgery C. Maintain the right arm in an extended position at the client's side when in bed D. Place the client in a supine position for the first 24 hr after surgery

A. Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24 hr period The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? A. Keep a lead-lined container in the client's room B. Limit each visitor to 1 hr per day C. Place a dosimeter badge on the client D. Remove soiled linens from the client's room each day

A. Keep a lead-lined container in the client's room The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Low urine specific gravity B. Hypertension C. Bounding peripheral pulses D. Hyperglycemia

A. Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? A. PaCO2 56 mm Hg B. pH 7.38 C. HCO3 24 mEq/L D. PaO2 90 mm Hg

A. PaCO2 56 mm Hg A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range. A client who has COPD will have a pH less than 7.35 due to poor gas exchange resulting from having elevated PaCO2 and HCO3- levels, along with low oxygen levels, for an extended period of time. A client who has COPD will have high HCO3- levels as a result of the kidneys' inability to excrete metabolic acids, leading to a retention of HCO3- in the blood and an increase in pH. A client who has COPD will have high HCO3- levels as a result of the kidneys' inability to excrete metabolic acids, leading to a retention of HCO3- in the blood and an increase in pH.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? A. Report of sore throat B. Report of memory loss C. Alopecia D. Mucositis

A. Report of sore throat When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

A nurse is providing follow-up care for a client who is sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? A. Sedimentation rate B. Hematocrit C. Calcium D. Acid phosphatase

A. Sedimentation rate

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures B. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy C. Family members should follow airborne precautions at home D. A follow-up tuberculosis skin test is necessary in 2 months

A. Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures After three negative sputum cultures, the client is no longer considered infectious.

A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? A. Stridor B. Oral secretions C. Hoarseness D. Sore throat

A. Stridor Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should report the finding immediately and implement an intervention.

A nurse is caring for a client who is postoperative. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Actions To Take: - Insert a large gauge IV - Initiate a fluid challenge Potential Condition: - Hypovolemia Parameters to Monitor: - Urine output - blood pressure The nurse should insert a large-gauge IV and initiate a fluid challenge because the client is most likely experiencing hypovolemia as evidenced by the client's restlessness, tachycardia, hypotension, decreased pulses, cool extremities, and decreased urine output. The nurse should monitor the client's urine output and blood pressure to evaluate the effectiveness of treatment.

The nurse is caring for the client. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Anticipated - Transfuse packed RBCs - Prepare the client for chest tube insertion - Initiate NPO status Contraindicated - Place the client in Trendelenburg position - Cover the client with a cooling blanket Transfuse packed RBCs is anticipated. The client's increased heart rate and decreased blood pressure indicate decreased circulating blood volume due to trauma. Therefore, the nurse should anticipate transfusing packed RBCs. Place the client in Trendelenburg position is contraindicated. Due to clinical manifestations of hypovolemia, the nurse should position the client flat or place their head of bed no more than 30° to promote venous return to the heart. Prepare the client for chest tube insertion is anticipated. The client has manifestations of a hemothorax. Therefore, a chest tube is indicated. Cover the client with a cooling blanket is contraindicated. The client's temperature is below the expected reference range, which is a manifestation of hypothermia. Therefore, covering the client with a cooling blanket is contraindicated. Initiate NPO status is anticipated. The client might require a surgical procedure. Therefore, the nurse should anticipate initiating NPO status.

The nurse is providing care for the client. The nurse is planning care for the client who has peritonitis and Crohn's disease. For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.

Anticipated: - Obtain blood cultures - Obtain VS every hour - Insert a nasogastric tube Contraindicated: - Administer a hypotonic IV solution Obtain blood cultures is indicated. Blood culture studies might be performed to determine the causative organism and the recommended antibiotic therapy that should be prescribed. Obtain vital signs every hour is indicated. Vital signs should be obtained hourly to monitor the client for changes. Administer a hypotonic IV solution is contraindicated. The nurse should anticipate a prescription for hypertonic IV fluids. Hypotonic fluids will further disrupt the client's fluid and electrolyte imbalance. Insert a nasogastric tube is indicated. A nasogastric tube might be inserted to decompress the stomach.

A nurse is caring for a client. The nurse is performing an assessment on the client. For each assessment finding, click to specify if the finding is consistent with appendicitis, diverticular disease, or Crohn's disease. Each finding may support more than one disease process.

Appendicitis - pain in RLQ - Nausea Diverticular Disease - blood in stool - Nausea Crohn's Disease - blood in stool - Pain in RLQ - Diarrhea - Nausea

A nurse is planning for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? A. Set the wall suction to 80 to 100 mm Hg B. Compress the drain reservoir after emptying C. Allow the drainage to collect on a sterile gauze dressing D. Position the drain below the bed to promote drainage

B. Compress the drain reservoir after emptying Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) A. Night sweats B. Calf pain C. Vaginal dryness D. Numbness in the arms E. Intense headache

B, D, E Night sweats is incorrect. Night sweats are a manifestation of menopause and do not require notification of the provider. Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the provider immediately. Vaginal dryness is incorrect. Vaginal dryness is an expected finding of menopause. Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately. Intense headache is correct. An intense headache can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately.

A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupunture because it provides greater relief than pain medication. Which of the following statements should the nurse make? A. "Acupuncture is not an approved treatment for cancer pain" B. "I can speak to the provider about incorporating acupuncture into your treatment plan" C. "I will ask the provider to prescribe a stronger medication to help ease your pain" D. "I can contact a family member or spiritual advisor for you to speak with"

B. "I can speak to the provider about incorporating acupuncture into your treatment plan"

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control" B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients" C. "Meperidine is the medication of choice for older adult clients experiencing severe pain" D. "Older adult clients taking oxycodone are at risk for diarrhea"

B. "Ibuprofen can cause gastrointestinal bleeding in older adult clients" A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? A. Increase intake of foods containing calcium B. Alternate application of heat and cold to the affected joints C. Keep the affected extremities elevated D. Limit movement of the affected joints

B. Alternate application of heat and cold to the affected joints The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? A. Obtain a sputum specimen to determine if there is colonization B. Bathe the client using chlorhexidine solution C. Place the client in droplet isolation D. Restrict visits from the client's friends and family

B. Bathe the client using chlorhexidine solution The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is caring for a client who is receiving total paretneral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? A. Check the client's blood glucose according to facility mealtimes B. Contact the provider to clarify the prescription C. Request for meals to be provided for the client D. Hold the prescription until the client is no longer NPO

B. Contact the provider to clarify the prescription

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? A. Decreased heart rate B. Crackles heard on auscultation C. Increased urinary output D. Decreased deep tendon reflexes

B. Crackles heard on auscultation

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? A. Warm, moist skin B. Distended neck veins C. Dark amber, odiferous urine D. Orthostatic hypotension

B. Distended neck veins

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? A. Painless ulcerations on the ankles B. Hair loss on the lower legs C. No extremity pain when resting D. Rubor with elevation of the extremity

B. Hair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? A. INR 1 B. INR 2.5 C. aPTT 45 seconds D. aPTT 90 seconds

B. INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? A. Explain procedures as they occur to the client B. Place personal items, such as pictures, at the client's bedside C. Orient the client to their location once a shift D. Encourage the family members to remain home until the client has adjusted

B. Place personal items, such as pictures, at the client's bedside The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? A. Document the client's intake and output B. Scan the bladder with a portable ultrasound C. Pour warm water over the client's perineum D. Perform a straight catheterization

B. Scan the bladder with a portable ultrasound

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? A. Administer an antihistamine B. Slow the infusion rate C. Give the client a corticosteriod D. Elevate the client's lower extremities

B. Slow the infusion rate Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? A. The client starts to cough B. The client's heart rate increases C. The client is diaphoretic D The client's blood pressure decreases

B. The client's heart rate increases Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia. A client's blood pressure can increase initially with hypoxia. If this occurs, the nurse should stop suctioning and manually oxygenate the client. Long-term hypoxia can lead to a decrease in blood pressure and shock. Diaphoresis is not associated with suction-induced hypoxia. However, long-term hypoxia can lead to diaphoresis.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? A. RBC count 5.2 million/mm^3 B. WBC count 2,000/mm^3 C. Platelets 380,000/mm^3 D. Potassium 4 mEq/L

B. WBC count 2,000/mm^3 A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. which of the following statements should the nurse make? A. "Ginkgo biloba relieves nausea for people who have vertigo" B. "Taking ginkgo biloba will help relieve your joint pain" C. "Ginkgo biloba can cause an increased risk for bleeding" D. "Taking ginkgo biloba decreases the risk of migraine headache"

C. "Ginkgo biloba can cause an increased risk for bleeding"

A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? A. "I will eat a salad at least once each day to increase my intake of vitamin K" B. "I can work in my flower garden as long as I wear gardening gloves to cover my skin" C. "I will no longer floss my teeth after brushing my teeth" D. "I can sip on a glass of juice for at least 2 hours before I should discard it"

C. "I will no longer floss my teeth after brushing my teeth" The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection.

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? A. "You should accept your body image change before discharge" B. "It is important for you to look at the incisional site when the dressings are removed" C. "I will refer you to community resources that can provide support" D. "The scar will remain red and raised for many years after surgery"

C. "I will refer you to community resources that can provide support" The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? A. "Take this medication on an empty stomach" B. "Eczema is an immediate expected adverse effect of this medication" C. "Increase fiber intake to avoid constipation" D. "Monitor your blood pressure monthly"

C. "Increase fiber intake to avoid constipation" The nurse should instruct the client that constipation is an adverse effect of verapamil. The client should increase fiber intake to promote regular bowel function.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? A. "I will need to take antibiotics for 1 year" B. "My partner will need to take an antiviral medication" C. "My joints ache because I have Lyme disease" D. "I will bruise easily because I have Lyme disease"

C. "My joints ache because I have Lyme disease" Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? A. "Wear an eye patch over one eye" B. "Make sure to have a staff member walk on your stronger side" C. "Scan the environment by turning your head from side to side" D. "Make sure to look at your feet while walking"

C. "Scan the environment by turning your head from side to side"

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? A. A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L and reports constipation B. A client who has Alzeimer's Disease (AD), has a room near the nurse's station, and is agitated C. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed D. A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen removal

C. A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? A. Electrically generated feelings of heat B. Cryotherapy for painful areas C. A tingling sensation replacing the pain D. Realignment of energy flow through meridians

C. A tingling sensation replacing the pain

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? A. Shellfish B. Peanuts C. Avocados D. Eggs

C. Avocados Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? A. Potassium 4.8 mEq/L B. Magnesium 1.7 mEq/L C. BUN 34 mg/dL D. Hematocrit 45%

C. BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? A. The chest tube is draining serosanguineous fluid at 65 mL/hr B. The client tolerates gentle milking of the tubing C. Bubbling in the water seal chamber has ceased D. There is tidaling in the water seal chamber

C. Bubbling in the water seal chamber has ceased Bubbling in the water seal chamber ceases when the lung re-expands.

A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? A. Clean the wound daily with an antiseptic B. Use a donut-shaped pillow when sitting in a chair C. Change positions every hour D. Massage the area two times daily

C. Change positions every hour

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? A. Obtain the client's vital signs B. Describe the blood transfusion procedure to the client C. Check for the type and number of units of blood to administer D. Initiate a peripheral IV line

C. Check for the type and number of units of blood to administer According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client's medication administration record.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? A. Potassium 3.5 mEq/L B. pH 7.28 C. Glucose 272 mg/dL D. HCO3 14 mEq/L

C. Glucose 272 mg/dL A glucose reading less than 300 mg/dL indicates improvement in the client's status.

A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? A. Breathing in rapidly while administering the medication B. Washing the plastic case and cap of the inhaler in the dishwasher C. Holding breath for 10 seconds after inhaling D. Waiting 15 seconds between puffs, if two puffs are required

C. Holding breath for 10 seconds after inhaling The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? A. Bounding pedal pulse B. Capillary refill less than 2 seconds C. Pain that increases with passive movement D. Areas of warmth on the cast

C. Pain that increases with passive movement The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? A. Use pillows to support the client's head and neck B. Offer opioid medication C. Place a tracheostomy tray at the bedside D. Place the client in semi-Fowler's position

C. Place a tracheostomy tray at the bedside The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? A. Conjugated estrogens B. Enalapril C. Prednisone D. Colchicine

C. Prednisone The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? A. Elevated blood pressure B. Dehydration C. Stress ulcers D. Hypernatremia

C. Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? A. Moderate serosanguinous drainage on the dressing B. Calcium 9.5 mg/dL C. Temperature 38.9 C (102 F) D. Decreased bowel sounds

C. Temperature 38.9 C (102 F) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take my iron with a glass of milk" B. "I will take an antacid with my iron" C. "I will limit my intake of red meat" D. "I will eat more high-fiber foods"

D. "I will eat more high-fiber foods" The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? A. "I can expect to have blood in my urine during the first week of injections" B. "I will floss my teeth after each meal" C. "I will gently massage the site after I inject my medication" D. "I will use an electric razor to shave"

D. "I will use an electric razor to shave" Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin.

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? A. "You will have an implant placed twice each month for the duration of the treatment" B. "You should remain at least 6 feet away from others between treatments" C. "You should expect to have blood in your urine for a few days after treatment" D. "You will need to stay still in the bed during each treatment session"

D. "You will need to stay still in the bed during each treatment session" The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged.

A nurse is teaching a family about the care of a patient who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? A. Position tabletop clocks with multi-colored backgrounds throughout the home B. Explain how to complete a task while having the client do the task C. Place a calendar on the wall with days and weeks included D. Create complete outfits and allow the client to select one each day

D. Create complete outfits and allow the client to select one each day The family should place completed outfits on hangers and allow the client to select which one to wear each day.

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? A. After 1 week of medication, TB is no longer communicable B. Dispose of contaminated tissues in a paper bag C. Airborne precautions are necessary in the home D. Family members in the household should undergo TB testing

D. Family members in the household should undergo TB testing Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB. The nurse should inform the client that they are no longer contagious after 2 to 3 weeks of continuous medication therapy or following three consecutive negative sputum cultures, which are typically obtained every 2 to 4 weeks. TB is a highly communicable disease that is spread through aerosolization when the client sneezes, coughs, or laughs. The nurse should instruct the client to cover their mouth when sneezing or coughing and to place contaminated tissues in a plastic bag for disposal.

A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? A. Multiple sclerosis B. Skin cancer C. Urolithiasis D. Hypertension

D. Hypertension

A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? A. Check on the client every 2 hr B. Provide a quiet environment with no distractions C. Turn on the television in the client's room D. Keep the client occupied with a manual activity

D. Keep the client occupied with a manual activity The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? A. Anorexia and jaundice B. Bronchospasm and urticaria C. Hypertension and bounding pulse D. Low back pain and apprehension

D. Low back pain and apprehension Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? A. Flush the line before administering antibiotics B. Position the client in Trendelenburg to obtain measurements C. Have the client bear down when readings are obtained D. Place a pressure bag around the flush solution

D. Place a pressure bag around the flush solution The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line. Accurate readings from an arterial line cannot be obtained by having the client bear down since this action temporarily increases arterial pressure. The most appropriate positioning of a client while recording values obtained from an arterial line is supine with the head of the bed elevated up to 60°. An arterial line is not appropriate access for administering antibiotics. The nurse should use the arterial line to obtain arterial blood gas samples and monitor hemodynamic pressures.

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? A. Temperature 37.2 C (99 F) B. Blood pressure 100/70 mmHg C. Weight loss D. Restlessness

D. Restlessness Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? A. WBC count B. Temperature C. Blood pressure D. Serum creatinine

D. Serum creatinine A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? A. Creatine kinase (CK-MB) 85 mg/dL B. High-density lipoprotein (HDL) 65 mg/dL C. Alanine aminotransferase (ALT) 28 units/L D. Troponin I 8 ng/mL

D. Troponin I 8 ng/mL Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contradiction for the surgery and notify the provider? A. Hydrocondone B. Bupropion C. Lactulose D. Warfarin

D. Warfarin Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

A nurse is caring for a client. For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Emphysema - Breath Sounds - ABG - RR - HR - Cough Asthma - Breath Sounds - RR - Cough Pneumonia - Temperature - Breath Sounds - ABG - RR - HR - Cough

A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include?

Walk for 30 min four times per week Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.