Critical Care- Wk 6 Quiz/Wk 7 Exam

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? Cloudy, turbid CSF Decreased white blood cells Decreased protein Increased glucose

Cloudy, turbid CSF

Assessment findings reveal that a client admitted to the hospital has a contact type I hypersensitivity to latex. Which preventive nursing intervention is best in planning care for this client? A) Report the need for desensitization therapy. B) Convey the need for pharmacologic therapy to the health care provider. C) Communicate the need for avoidance therapy to the health care team. D) Discuss symptomatic therapy with the health care provider.

Communicate the need for avoidance therapy to the health care team.

The nurse is performing a rapid neurologic assessment on a trauma client. Which assessment finding is normal? A) Decerebrate posturing B) Increased lethargy C) Minimal response to stimulation D) Constriction of pupils

Constriction of pupils

Which statement indicates to the nursing instructor that the nursing student understands the normal healing process of bone after a fracture? "A callus is quickly deposited and transformed into bone." "A hematoma forms at the site of the fracture." "Calcium and vascular proliferation surround the fracture site." "Granulation tissue reabsorbs the hematoma and deposits new bone."

"A hematoma forms at the site of the fracture."

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A) "After this therapy, I will not need to have any more." B) "I will need to avoid people with a cold or flu." C) "I will probably lose my hair during this therapy." D) "The goal of this therapy is to put me in remission."

"After this therapy, I will not need to have any more."

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.) A) "Allow others to perform your care during periods of extreme fatigue." B) "Drink small quantities of protein shakes and nutritional supplements daily." C) "Perform a complete bath daily to reduce your chance of getting an infection." D) "Provide yourself with four to six small, easy-to-eat meals daily." E) "Perform your care activities in groups to conserve your energy." F) "Stop activity when shortness of breath or palpitations are present."

"Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." "Provide yourself with four to six small, easy-to-eat meals daily." "Stop activity when shortness of breath or palpitations are present."

When preparing a client for allergy testing, the nurse provides the client with which instruction? A) "Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response." B) "It is okay to use your fluticasone propionate (Flonase) nasal spray before testing." C) "Aspirin in a low dose may be taken before testing." D) "You can take antihistamine nasal sprays before testing."

"Antihistamines should be discontinued 2 weeks before the test to avoid suppressing the test response."

The nurse is about to administer a contrast medium to the client undergoing diagnostic testing. Which question does the nurse first ask the client? A) "Are you taking ibuprofen daily?" B) "Are you in pain?" C) "Are you wearing any metal?" D) "Do you know what this test is for?"

"Are you taking ibuprofen daily?"

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? A) "The last tetanus injection was less than 5 years ago." B) "Burn wound conditions promote the growth of Clostridium tetani." C) "The wood in the fire had many nails, which penetrated the skin." D) "The injection was prescribed to prevent infection from Pseudomonas."

"Burn wound conditions promote the growth of Clostridium tetani."

The nurse is taking a history for an 80-year-old female patient who reports progressive fatigue, shortness of breath, and headaches. what is the priority assessment question the nurse should ask? A) "Can you tell me about your diet?" B) "Have you been feeling depressed lately?" C) "What medications do you routinely take?" D) "Do you have a history of cardiovascular disease?"

"Can you tell me about your diet?"

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care? A) "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B) "Ambulated in hallway for 40 feet and denies shortness of breath at rest or with ambulation. T.Y., LPN" C) "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D) "Vital signs 37.0° C, heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"

"Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP"

A client with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct? "Simple fracture involves a break in the bone, with skin contusions." "Compound fracture does not extend through the skin." "Simple fracture is accompanied by damage to the blood vessels." "Compound fracture involves a break in the bone, with damage to the skin."

"Compound fracture involves a break in the bone, with damage to the skin."

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A) "Are your feet or hands cold, even when you are in bed?" B) "Do you feel more tired after you get up and go to the bathroom?" C) "How much exercise do you get?" D) "What is your endurance level?"

"Do you feel more tired after you get up and go to the bathroom?"

The nurse is assessing a client for hematologic function risks and seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? A) "Do you seem to have excessive bleeding or bruising?" B) "Does anyone in your family bleed a lot?" C) "Tell me what you eat in a day." D) "Where do you work?"

"Does anyone in your family bleed a lot?"

The spouse of the client with Alzheimer's disease is listening to the hospice nurse explaining the client's drug regimen. Which statement by the spouse indicates an understanding of the nurse's instruction? A) "Donepezil (Aricept) will treat the symptoms of Alzheimer's disease." B) "Memantine (Namenda) is indicated for treatment of early symptoms of Alzheimer's disease. C) "Rivastigmine (Exelon) is used to treat depression." D) "Sertraline (Zoloft) will treat the symptoms of Alzheimer's disease."

"Donepezil (Aricept) will treat the symptoms of Alzheimer's disease."

A client has received contrast medium. Which teaching does the nurse provide to avoid any neurologic health problems after the procedure? A) "Practice memory drills this afternoon." B) "Drink at least 1000 to 1500 mL of water today." C) "Avoid sunlight." D) "Rest in bed for 24 hours."

"Drink at least 1000 to 1500 mL of water today."

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? A) "Every bedroom should have a separate smoke detector." B) "Every room in the house should have a smoke detector." C) "If you have a smoke detector, you don't need a carbon monoxide detector." D) "The kitchen and the bedrooms are the only rooms that need smoke detectors."

"Every bedroom should have a separate smoke detector."

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction? A) "Frequent handwashing is an important habit for me to develop." B) "Getting an annual 'flu shot' would be dangerous for me." C) "I must take my penicillin pills as prescribed, all the time." D) "The pneumonia vaccine is protection that I need."

"Getting an annual 'flu shot' would be dangerous for me."

The nurse's friend fears that his mother is getting old, saying that she is becoming extremely forgetful and disoriented and is beginning to wander. What is the nurse's best response? A) "Have you taken her for a check-up?" B) "She has Alzheimer's disease." C) "That is a normal part of aging." D) "You should look into respite care."

"Have you taken her for a check-up?"

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies? A) "Do you support each other?" B) "How do you plan to manage this situation?" C) "How have you handled similar situations before?" D) "Would you like to see a counselor?"

"How have you handled similar situations before?"

The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? A) "Can you prepare your own meals?" B) "Has your weight changed by 5 pounds or more this year?" C) "How is your energy level compared with last year?" D) "What medications do you take daily, weekly, and monthly?"

"How is your energy level compared with last year?"

The nurse is reviewing discharge teaching with a client who suffered an anaphylactic reaction to a bee sting. Which statement by the client indicates the need for further teaching? A) "I must wear a medical alert bracelet stating that I am allergic to bee stings." B) "I need to carry epinephrine with me." C) "My spouse must learn how to give me an injection." D) "I am immune to bee stings now that I have had a reaction."

"I am immune to bee stings now that I have had a reaction."

The nurse had educated the pt. with a shellfish allergy about signs and symptoms of angioedema. Which patient statement requires further nursing education? A) "I can eat shrimp because it is not a shellfish." B) "There is an epinephrine injector in my purse at all times." C) "Symptoms of angioedema include swelling of eyes, lips, and tongue." D) "When I see a new physician, I will report that I have a shellfish allergy."

"I can eat shrimp because it is not a shellfish."

The nurse is caring for a client with burns to the face. Which statement by the client requires further evaluation by the nurse? A) "I am getting used to looking at myself." B) "I don't know what I will do when people stare at me." C) "I know that I will never look the way I used to, even after the scars heal." D) "My spouse does not stare at the scars as much now as in the beginning."

"I don't know what I will do when people stare at me."

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? "I can no longer become pregnant." "If I become pregnant, I cannot give birth." "I may still be able to get pregnant." "My children will be paralyzed."

"I may still be able to get pregnant."

The nurse is teaching a client newly diagnosed with migraines about trigger control. Which statement made by the client demonstrates good understanding of the teaching plan? A) "I can still eat Chinese food." B) "I must not miss meals." C) "It is okay to drink a few wine coolers." D) "I need to use fake sugar in my coffee."

"I must not miss meals."

The nurse is teaching a client about cyclosporine (Sandimmune) therapy after liver transplantation. Which client statement indicates the need for further teaching? A) "I will be on this medicine for the rest of my life." B) "I must undergo regular kidney function tests." C) "I must regularly monitor my blood sugar." D) "My gums may become swollen because of this drug."

"I must regularly monitor my blood sugar."

A female client with newly diagnosed migraines is being discharged with a prescription for sumatriptan (Imitrex). Which comment by the client indicates an understanding of the nurse's discharge instructions? A) "Sumatriptan should be taken as a last resort." B) "I must report any chest pain right away." C) "Birth control is not needed while taking sumatriptan." D) "St. John's wort can also be taken to help my symptoms."

"I must report any chest pain right away."

Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option? A) "I don't feel strong enough, but my wife said she would help." B) "I was a nurse, so I can take care of myself." C) "I will have lots of medicine to take." D) "We live 5 miles from the hospital."

"I was a nurse, so I can take care of myself."

The nurse is instructing a client for whom a positron emission tomography (PET) scan has been requested. Which statement indicates to the nurse that the client understands the instructions? A) "It's okay to have a cup of coffee before the test." B) "Because I am diabetic, I will take my insulin just before the test." C) "I can continue to smoke cigarettes up to 4 hours before the test." D) "I will drink plenty of fluids after the test."

"I will drink plenty of fluids after the test."

The nursing instructor asks the student nurse caring for a client with Alzheimer's disease who has been prescribed donepezil (Aricept) how the drug works. Which response by the nursing student best explains the action of donepezil? "The reuptake of serotonin is blocked." "Donepezil prevents the increase in the protein beta amyloid." "It delays the destruction of acetylcholine by acetylcholinesterase." "Dopamine levels are increased."

"It delays the destruction of acetylcholine by acetylcholinesterase."

A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? A) "It is to dissolve blood clots." B) "It might cause me to get injured more often." C) "It should prevent my blood from clotting." D) "It will thin my blood."

"It should prevent my blood from clotting."

A 37-year-old man with polycystic kidney disease is on the kidney transplant list. He is to receive 2 units of leukocyte-poor packed red blood cells to treat a low hemoglobin. He asks the nurse why he needs this type of blood. What is the nurse's best response? A) "It causes fewer blood reactions for pre-transplant patients." B) "It is less likely to cause hemolysis, or destruction of the blood cells, after transfusion." C) "All pre-transplant patients receive leukocyte-poor blood because it is absorbed better by the body." D) "It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

"It will decrease the risk of obtaining white blood cells from the donor that could make it harder for your transplanted kidney to function."

A client is recovering from an above-the-knee amputation resulting from peripheral vascular disease. Which statement indicates that the client is coping well after the procedure? "My spouse will be the only person to change my dressing." "I can't believe that this has happened to me. I can't stand to look at it." "I do not want any visitors while I'm in the hospital." "It will take me some time to get used to this."

"It will take me some time to get used to this."

The clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? A) "Avoid contact sports or activity that may traumatize the site for 24 hours." B) "Inspect the site for bleeding every 4 to 6 hours." C) "Place an ice pack over the site to reduce the bruising." D) "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."

"Place an ice pack over the site to reduce the bruising."

The nurse is preparing a client for discharge on postoperative day 1 after a modified radical mastectomy. Which instruction is most important for the nurse to include in this client's discharge plan? A) "Please report any increased redness, swelling, warmth, or pain to your health care provider." B) "Do not allow anyone to take your blood pressure or draw blood on the side where you had your breast removed." C) "A referral has been made to the American Cancer Society's Reach to Recovery program, and a volunteer will call you next week." D) "Avoid the prone and hunchback positions, and ask your health care provider for any other needed activity restrictions."

"Please report any increased redness, swelling, warmth, or pain to your health care provider."

A client has undergone single-photon emission computed tomography (SPECT). Which instruction does the nurse give the client? A) "Continue to use the ice pack." B) "Call me if you have any itching." C) "Keep the head of the bed flat." D) "Return to your usual activity."

"Return to your usual activity."

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply.) A) "Ask her how she is feeling." Correct B) "Ask her if she needs anything." Correct C) "Tell her to be brave and to not cry." D) "Talk to her as you normally would when you haven't seen her for a long time." E) "Tell her what you know about leukemia."

"Talk to her as you normally would when you haven't seen her for a long time."

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? A) "Do you want to pray about it?" B) "I know, and you will have to learn to adapt to a new body image." C) "Tell me more." D) "There must be a reason."

"Tell me more."

A client with a low platelet count asks why platelets are important. How does the nurse answer? A) "Platelets make your blood clot." B) "Blood clotting is prevented by your platelets." C) "The clotting process begins with your platelets." D) "Your platelets finish the clotting process."

"The clotting process begins with your platelets."

A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond? A) "A pharmaceutical company might be able to help." B) "I might be able to take you." C) "The local American Cancer Society may be able to help." D) "You can take the bus."

"The local American Cancer Society may be able to help."

A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? A) "No, they don't." B) "The number varies with gender, age, and general health." C) "Yes, they do." D) "You have fewer red blood cells because you have anemia."

"The number varies with gender, age, and general health."

The nursing instructor asks the student nurse to explain a type IV hypersensitivity reaction. Which statement by the student best describes type IV hypersensitivity? A) "It is a reaction of immunoglobulin G (IgG) with the host cell membrane or antigen." B) "The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation." C) "It results in release of mediators, especially histamine, because of the reaction of immunoglobulin E (IgE) antibody on mast cells." D) "An immune complex of antigen and antibodies is formed and deposited in the walls of blood vessels."

"The reaction of sensitized T cells with antigen and release of lymphokines activate macrophages and induce inflammation."

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include? A) "Sickle cell disease will be inherited by your children." B) "The sickle cell trait will be inherited by your children." C) "Your children will have the disease, but your grandchildren will not." D) "Your children will not have the disease, but your grandchildren could."

"The sickle cell trait will be inherited by your children."

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client? A) "Avoid large crowds." B) "Drink at least 2 liters of fluid per day." C) "Elevate your lower extremities when sitting." D) "Use a soft-bristled toothbrush."

"Use a soft-bristled toothbrush."

A client has sustained a fracture of the left tibia. The extremity is immobilized using an external fixation device. Which postoperative instruction does the nurse include in this client's teaching plan? "Use pain medication as prescribed to control pain." "Clean the pin site when any drainage is noticed." "Wear the same clothing that is normally worn." "Apply bacitracin (Neosporin) if signs or symptoms of infection develop around pin sites."

"Use pain medication as prescribed to control pain."

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem? A) "Ask your doctor to prescribe more medication." B) "It is too soon for additional medication to be given." C) "I'll turn on some soothing classical music for you." D) "Would you like to try some relaxation techniques?"

"Would you like to try some relaxation techniques?"

The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A) "The doctor will place a small needle in your back and will withdraw some fluid." B) "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C) "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area." D) "You will be sedated, so you will not be aware of anything."

"You may experience a crunching sound or a scraping sensation as the needle punctures your bone."

A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A) "How many hours are you sleeping at night?" B) "You are not getting enough iron." C) "You need to rest more when you are sick." D) "Your cells are delivering less oxygen than you need."

"Your cells are delivering less oxygen than you need."

Hypersensitivities Cytotoxic Reactions Type II

-Body makes autoantibodies directed against self cells that have some form of foreign protein attached to them -Examples: Immune hemolytic anemias, immune thrombocytopenic purpura, hemolytic transfusion reactions, Goodpasture's sydrome, and drug induced hemolytic anemia

Rapid Hypersensitivity Reaction (Type 1)

-Most common type of hypersensitivity from excess Immunity -Results from the increased production of IgE -Example: Anaphylaxis, latex allergy, pollens, bee stings

The nurse recognizes which as type IV (delayed hypersensitivity) reactions? (Select all that apply) A) Sarcoidosis B) Contact dermatitis C) Tissue transplant rejections D) Drug-induced hemolytic anemia E) Positive purified protein derivative (PPD) test

-Sarcoidosis -Contact dermatitis -Tissue transplant rejections -Positive purified protein derivative (PPD) test

Immune function is most efficient when people are which age? A) Infancy B) Teen years C) 20 to 30 years D) 50 years or older

20 to 30 years

The nurse is caring for four patients, and understands that which is at greatest risk of infection? A) 19-year-old with stomach pain B) 24-year-old with chronic kidney disease C) 36-year-old prescribed a 10-day steroid tapper D) 64-year-old with history of prostate hyperplasia

24-year-old with chronic kidney disease

The client has sustained a traumatic amputation of the left arm after a machine accident. In what order should the following nursing actions be taken? 1. Apply direct pressure to the amputated site. 2. Elevate the extremity above the client's heart. 3. Assess the client for breathing problems. 4. Examine the amputation site. 2, 4, 3, 1 3, 4, 1, 2 1, 4, 3, 2 4, 1, 2, 3

3, 4, 1, 2

Which client does the nurse assign as a roommate for the client with aplastic anemia? A) A 23-year-old with sickle cell disease who has two draining leg ulcers B) A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) C) A 30-year-old with leukemia who is receiving induction chemotherapy D) A 34-year-old with idiopathic thrombocytopenia who is taking steroids

A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol)

Which client is at greatest risk for having a hemolytic transfusion reaction? A) A 34-year-old client with type O blood B) A 42-year-old client with allergies C) A 58-year-old immune-suppressed client D) A 78-year-old client

A 34-year-old client with type O blood

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse? A) A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells B) A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C) A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D) A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease

A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells

After reviewing the laboratory test results, the nurse calls the health care provider about which client? A) A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 B) A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 C) A 49-year-old with hemophilia and a platelet count of 150,000/mm3 D) A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%

A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3

Which client does the medical unit charge nurse assign to an LPN/LVN? A) A 23-year-old scheduled for a bone marrow biopsy with conscious sedation B) A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) C) A 48-year-old with chronic microcytic anemia associated with alcohol use D) A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6

A 48-year-old with chronic microcytic anemia associated with alcohol use

The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A) A 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway B) A 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" C) A 52-year-old who has just had a bone marrow aspiration and is requesting pain medication D) A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism

A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism

Which client is at greatest risk for developing an infection? A) A 54-year-old man with hypertension B) A 17-year-old girl with a fractured tibia in a cast C) A 65-year-old woman who had coronary bypass surgery 4 days ago D) A 71-year-old man in a nursing home

A 65-year-old woman who had coronary bypass surgery 4 days ago

Which nurse does the charge nurse assign to care for a 64-year-old client who has pneumonia and requires IV antibiotic therapy and IV fluids at 200 mL/hr? A) An experienced LPN/LVN who has worked on the medical unit for 10 years B) An RN with experience in the operating room who transferred a month ago to the medical unit C) A float RN with 7 years of experience on the inpatient oncology unit D) An RN who has worked mostly on the same-day surgery unit since graduating a year ago

A float RN with 7 years of experience on the inpatient oncology unit

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? A) Absence B) Myoclonic C) Simple partial D) Tonic

Absence

The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? Achieving the highest level of functioning Increasing cerebral perfusion Preventing further injury Preventing respiratory distress

Achieving the highest level of functioning

A rock climber has sustained an open fracture of the right tibia after a 20-foot fall. The nurse plans to assess the client for which potential complications? (Select all that apply.) Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Congestive heart failure Urinary tract infection (UTI) Osteomyelitis

Acute compartment syndrome (ACS) Fat embolism syndrome (FES) Osteomyelitis

A client newly diagnosed with Parkinson disease is being discharged. Which instruction is best for the nurse to provide to the client's spouse? A) Administer medications promptly on schedule to maintain therapeutic drug levels. B) Complete activities of daily living for the client. C) Speak loudly for better understanding. D) Provide high-calorie, high-carbohydrate foods to maintain the client's weight.

Administer medications promptly on schedule to maintain therapeutic drug levels.

Which client does the neurologic unit charge nurse assign to a registered nurse who has floated from the labor/delivery unit for the shift? A) Older adult client who was just admitted with a stroke and needs an admission assessment B) Young adult client who has had a lumbar puncture and reports, "Light hurts my eyes." C) Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes D) Middle-aged client who has a possible brain tumor and has questions about the scheduled magnetic resonance imaging

Adult client who has just returned from having a cerebral arteriogram and needs vital sign checks every 15 minutes

The nurse has just received report on a group of clients. Which client does the nurse assess first? A) Young adult who was in a car accident and has a Glasgow Coma Scale score of 13 B) Adult who had a cerebral arteriogram and has a cool, pale right leg C) Middle-aged adult who has a headache after undergoing a lumbar puncture D) Older adult who has expressive aphasia after a left-sided stroke

Adult who had a cerebral arteriogram and has a cool, pale right leg

A client with amyotrophic lateral sclerosis is degenerating rapidly and will soon need respiratory support. What does the nurse plan to review with this client? Advance directives How to use the ventilator Funeral plans Nutritional support

Advance directives

Cleansing hands with an alcohol-based hand rub is appropriate in which situation? A) After using the bathroom B) To cleanse visibly soiled or sticky hands C) After handing oral medication to a patient D) After working with a patient who has diarrhea due to Clostridium difficile

After handing oral medication to a patient

The nurse plans to assess a client with type I hypersensitivity for which clinical manifestation? A) Poison ivy B) Autoimmune hemolytic anemia C) Allergic asthma D) Rheumatoid arthritis

Allergic asthma

A client with a migraine is lying in a darkened room with a wet cloth on the head after receiving analgesic drugs. What does the nurse do next? A) Allow the client to remain undisturbed. B) Assess the client's vital signs. C) Remove the cloth because it can harbor microorganisms. D) Turn on the lights for a neurologic assessment.

Allow the client to remain undisturbed.

The nurse refers a client with an amputation and the client's family to which community resource? American Amputee Society (AAS) Amputee Coalition of America (ACA) Community Workers for Amputees (CWA) National Amputee of America Society (NAAS)

Amputee Coalition of America (ACA)

The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? A) An 18-year-old who had an emergency splenectomy B) A 22-year-old with recently diagnosed sickle cell anemia C) A 38-year-old with hemolytic anemia D) A 40-year-old alcoholic with liver disease

An 18-year-old who had an emergency splenectomy

The nurse assesses the client with which hematologic problem first? A) A 32-year-old with pernicious anemia who needs a vitamin B12 injection B) A 40-year-old with iron deficiency anemia who needs a Z-track iron injection C) A 67-year-old with acute myelocytic leukemia with petechiae on both legs D) An 81-year-old with thrombocytopenia and an increase in abdominal girth

An 81-year-old with thrombocytopenia and an increase in abdominal girth

Which statement about why multidrug-resistant organisms and other infections are increasing in incidence is correct? A) Antibiotics have been given to clients for conditions that do not require antibiotics. B) Microorganisms are more susceptible to antibiotics today than when they were given years ago. C) Additional precautions are taken, along with Standard Precautions, to prevent infection. D) Certain antibiotics are effective for specific infections only.

Antibiotics have been given to clients for conditions that do not require antibiotics.

A client is considering treatments for a malignant brain tumor. Which statement by the client indicates a need for further instruction by the nurse? "A combination of treatments might be necessary." "In a craniotomy, holes are cut in the skull to access the tumor." "Antibiotics will help minimize the size of the tumor." "The goal is to decrease tumor size and improve survival time."

Antibiotics will help minimize the size of the tumor

A middle-aged client, who is alert, is admitted to the emergency department with wheezing, difficulty breathing, angioedema, blood pressure of 70/52 mm Hg, and apical pulse of 122 beats/min and irregular. The nurse makes an immediate assessment using the "ABCs" for any client experiencing anaphylaxis. What nursing intervention is the immediate priority? A) Raise the lower extremities. B) Start intravenous (IV) administration of normal saline. C) Reassure the client that appropriate interventions are being instituted. D) Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

Apply oxygen using a high-flow non-rebreather mask at 40% to 60%.

A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? A) Applying pressure to the biopsy site B) Inspecting the site for ecchymoses C) Sending the biopsy specimens to the laboratory D) Teaching the client about avoiding vigorous activity

Applying pressure to the biopsy site

The wife of a client with Alzheimer's disease mentions to the home health nurse that, although she loves him, she is exhausted caring for her husband. What does the nurse do to alleviate caregiver stress? A) Arranges for respite care B) Provides positive reinforcement and support to the wife C) Restrains the client for a short time each day, to allow the wife to rest D) Teaches the client improved self-care

Arranges for respite care

The nurse is assessing a client with suspected serum sickness. Which symptoms are consistent with serum sickness? (Select all that apply.) A) Arthralgia B) Blurred vision C) Lymphadenopathy D) Malaise E) Ptosis

Arthralgia Lymphadenopathy Malaise

A client returns to the neuromedicine floor after undergoing an anterior cervical diskectomy and fusion (ACDF). What is the nurse's first action? Administer pain medication. Assess airway and breathing. Assist with ambulation. Check the client's ability to void.

Assess airway and breathing

A patient with polycythemia vera is admitted with reports of shortness of breath, hypertension, and loss of pulse in her right foot. Which is the priority nursing intervention? A) Assess current hydration status B) Administer oxygen by nasal cannula C) Elevate her lower extremities on pillows D) Evaluate the patient for hypertensive crisis

Assess current hydration status

The nurse prepares to perform a neurovascular assessment on a client with closed multiple fractures of the right humerus. Which technique does the nurse use? Inspect the abdomen for tenderness and bowel sounds. Auscultate lung sounds. Assess the level of consciousness and ability to follow commands. Assess sensation of the right upper extremity.

Assess sensation of the right upper extremity.

A client's left arm is placed in a plaster cast. Which assessment does the nurse perform before the client is discharged? Assess that the cast is dry. Ensure that the client has 4 × 4 gauze to take home for placement between the cast and the skin. Check the fit of the cast by inserting a tongue blade between the cast and the skin. Ensure that the capillary refill of the left fingernail beds is longer than 3 seconds.

Assess that the cast is dry.

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? A) Administer phenytoin (Dilantin). B) Draw the client's blood. C) Assess the need for additional support. D) Start an intravenous (IV) line.

Assess the need for additional support

A client hospitalized for hypertension presses the call light and reports "feeling funny." When the nurse gets to the room, the client is slurring words and has right-sided weakness. What does the nurse do first? Assesses airway, breathing, and circulation Calls the provider Performs a neurologic check Assists the client to a sitting position

Assesses airway, breathing, and circulation

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? A) Assessing neurologic status at least every 2 to 4 hours B) Decreasing environmental stimuli C) Managing pain through drug and nondrug methods D) Strict monitoring of hourly intake and output

Assessing neurologic status at least every 2 to 4 hours

Which nursing activity can the nurse delegate to a home health aide? A) Changing the dressing for a client with a low absolute neutrophil count B) Assisting with bathing for a client with chronic rejection of a liver transplant C) Teaching a client with bacterial pneumonia how to take the prescribed antibiotic D) Assessing incisional tenderness for a client who had a recent kidney transplant

Assisting with bathing for a client with chronic rejection of a liver transplant

The nurse is caring for a client with advanced Alzheimer's disease. Which communication technique is best to use with this client? A) Providing the client with several options to choose from B) Assuming that the client is not totally confused C) Waiting for the client to express a need D) Writing down instructions for the client

Assuming that the client is not totally confused

The nurse is assessing a client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? Amnesia Head laceration Asymmetric pupils Restlessness

Asymmetric pupils

Which task does the nurse plan to delegate to the nursing assistant caring for a group of clients in the neurosurgical unit? A) Prepare a client who is going to radiology for a cerebral arteriogram B) Attend to the care needs of a client who has had a transcranial Doppler study C) Assist the health care provider in performing a lumbar puncture on a confused client D) Educate a client about what to expect during an electroencephalogram (EEG)

Attend to the care needs of a client who has had a transcranial Doppler study

Which statement best exemplifies a client's protection from cancer provided by cell-mediated immunity (CMI) after exposure to asbestos? A) Cytotoxic and cytolytic T cells destroy cells that contain the major histocompatibility complex of a processed antigen. B) Helper and inducer T cells recognize self cells versus non-self cells and secrete lymphokines that can enhance the activity of white blood cells. C) Suppressor T cells prevent hypersensitivity when a client is exposed to non-self cells or to proteins. D) Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.

Balance elicits protection when helper or inducer T cells outnumber suppressor T cells by a ratio of 2:1.

A complete blood count with differential is performed in a client with chronic sinusitis. Which finding does the nurse expect? A) Segmented neutrophils, 62% B) Lymphocytes, 28% C) Bands, 5% D) Basophils, 4%

Basophils 4%

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? Bipolar disorder Diabetes mellitus Glaucoma Hypothyroidism

Bipolar disorder

A client has just returned from cerebral angiography. Which symptom does the client display that causes the nurse to act immediately? A) Bleeding B) Increased temperature C) Severe headache D) Urge to void

Bleeding

The nurse prepares to administer zafirlukast (Accolate) to a client with allergic rhinitis. Zafirlukast works by which mechanism? A) Blocking histamine from binding to receptors B) Preventing synthesis of mediators C) Preventing mast cell membranes from opening D) Blocking the leukotriene receptor

Blocking the leukotriene receptor

What are the risk factors for the development of leukemia? (Select all that apply.) A) Bone marrow hypoplasia B) Chemical exposure C) Down syndrome D) Ionizing radiation E) Multiple blood transfusions F) Prematurity at birth

Bone marrow hypoplasia B) Chemical exposure C) Down syndrome D) Ionizing radiation

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy? A) Bone marrow suppression B) Liver toxicity C) Nausea D) Stomatitis

Bone marrow suppression

A client is admitted with a brain abscess. Which diagnostic assessment intervention does the nurse question as nonspecific to the diagnosis? Bone scan Electroencephalogram (EEG) Throat culture Sinus x-rays

Bone scan

The nurse admits an older adult client who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the client will be placed in which type of traction? Balanced skin traction Buck's traction Overhead traction Plaster traction

Buck's traction

What health care-acquired infection (HCAI) occurs most frequently? A) Pneumonia B) Surgical site infection (SSI) C) Catheter-related bloodstream infection (CR-BSI) D) Catheter-associated urinary tract infection (CA-UTI)

Catheter-associated urinary tract infection (CA-UTI)

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? Chair pad Thromboembolism-deterrent (TED) hose Trapeze Water bottle

Chair pad

What is the best method to prevent autocontamination for a client with burns? A) Change gloves when handling wounds on different areas of the body. B) Ensure that the client is in isolation therapy. C) Restrict visitors. D) Watch for early signs of infection.

Change gloves when handling wounds on different areas of the body.

A client with a traumatic brain injury from a motor vehicle crash is monitored for signs of increased intracranial pressure (ICP). Which sign does the nurse monitor for? Changes in breathing pattern Dizziness Increasing level of consciousness Reactive pupils

Changes in breathing pattern

A client with a compound fracture of the left femur is admitted to the emergency department after a motorcycle crash. Which action is most essential for the nurse to take first? Check the dorsalis pedis pulses. Immobilize the left leg with a splint. Administer the prescribed analgesic. Place a dressing on the affected area.

Check the dorsalis pedis pulses.

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago.

Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago

A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client? A) Evaluating the client's liver function tests (LFTs) and serum creatinine levels B) Evaluating the client's white blood cell (WBC) count level C) Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection D) Recognizing that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML

Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection

A client receiving sumatriptan (Imitrex) for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse? Chest tightness Skin flushing Tingling feelings Warm sensation

Chest tightness

A client is admitted into the emergency department with frontal-temporal pain, preceded by a visual disturbance. The client is upset and thinks it is a stroke. What does the nurse suspect may be occurring? A) Stroke B) Tension headache C) Classic migraine D) Cluster headache

Classic migraine

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit? A) Burn unit client who is being discharged after 6 weeks and needs teaching about wound care B) Recently admitted client with a high-voltage electrical burn C) A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed D) Client receiving IV lactated Ringer's solution at 150 mL/hr

Client receiving IV lactated Ringer's solution at 150 mL/hr

The nurse prepares to assess a client with diabetes mellitus for sensory loss. Which equipment does the nurse use to perform this assessment? A) Glucometer B) Hammer C) Nothing; the client is asked to walk D) Cotton-tipped applicator

Cotton-tipped applicator

A client recovering from a stroke reports double vision that is preventing the client from effectively completing activities of daily living. How does the nurse help the client compensate? Approaches the client on the affected side Covers the affected eye Encourages turning the head from side to side Places objects in the client's field of vision

Covers the affected eye

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? A) Dairy products B) Grains C) Leafy vegetables D) Starchy vegetables

Dairy products

The nurse is monitoring a client after supratentorial surgery. Which sign does the nurse report immediately to the provider? Periorbital edema Bilateral ecchymoses of both eyes Moderate amount of serosanguineous drainage on the head dressing Decorticate positioning

Decorticate positioning

The nurse is performing a neurologic assessment on an 81-year-old client. Which physiologic change does the nurse expect to find because of the client's age? A) Decreased coordination B) Increased sleeping during the night C) Increased touch sensation D) Stability in pain perception

Decreased coordination

A 14-year-old client has severe fatigue, swollen glands, and a low-grade fever. Which blood test result is used to confirm a diagnosis of mononucleosis? A) Decreased mononuclear leukocyte count B) Decreased leukocyte count C) Decreased neutrophil count D) Elevated erythrocyte sedimentation rate

Decreased neutrophil count

Which action does the nurse delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? A) Asking the client about the amount of blood loss with each menstrual period B) Checking for sternal tenderness while applying fingertip pressure C) Determining the respiratory rate before and after the client walks 20 feet D) Monitoring her oral mucosa for pallor, bleeding, or ulceration

Determining the respiratory rate before and after the client walks 20 feet

A client who is receiving an intravenous antibiotic begins to cough and states, "My throat feels like it is swelling." Which action does the nurse take next? A) Infuse normal saline at 200 mL/hr. B) Administer epinephrine (Adrenalin) 1:1000, 0.3 mL subcutaneously. C) Discontinue infusing the antibiotic. D) Give diphenhydramine (Benadryl) 100 mg IV.

Discontinue infusing the antibiotic.

Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room? A) Use space heaters to reduce electrical costs. B) Check water temperature before bathing. C) Do not smoke in bed. D) Wear sunscreen.

Do not smoke in bed.

The nurse is developing a teaching plan for a client with a history of low back pain. Which instructions does the nurse plan to include in teaching the client about preventing low back pain and injury? (Select all that apply.) "Standing for long periods of time will help to prevent low back pain." "Keep weight within 50% of ideal body weight." "Begin a regular exercise program." Correct "When lifting something, the back should be straight and the knees bent." Correct "Do not wear high-heeled shoes."

Do not wear high-heeled shoes

A client with severe muscle spasticity has been prescribed tizanidine (Zanaflex, Sirdalud). The nurse instructs the client about which adverse effect of tizanidine? Drowsiness Hirsutism Hypertension Tachycardia

Drowsiness

Which factors indicate that a client's burn wounds are becoming infected? (Select all that apply.) A) Dry, crusty granulation tissue B) Elevated blood pressure C) Hypoglycemia D) Edema of the skin around the wound E) Tachycardia

Dry, crusty granulation tissue Edema of the skin around the wound Tachycardia

What are the typical clinical manifestations of anemia? (Select all that apply.) A) Decreased breath sounds B) Dyspnea on exertion C) Elevated temperature D) Fatigue E) Pallor F) Tachycardia

Dyspnea on exertion Fatigue Pallor Tachycardia

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A) Encouraging participation in wound care B) Encouraging visitors C) Reassuring the client that he or she will be fine D) Telling the client that these feelings are normal

Encouraging participation in wound care

Which intervention most effectively protects a client with thrombocytopenia? A) Avoiding the use of dentures B) Encouraging the use of an electric shaver C) Taking rectal temperatures D) Using warm compresses on trauma sites

Encouraging the use of an electric shaver

A 23-year-old African-American male with a history of sickle cell disease had an emergent open reduction and internal fixation of his right femur after a car crash. What is the initial preoperative nursing priority? A) treating the patient's pain B) Ensuring adequate IV hydration C) Titrating oxygen to an SPO2 > 95% D) Examining the surgical incision for signs and symptoms of infection

Ensure adequate IV hydration

A client with a history of asthma is admitted to the clinic for allergy testing. During skin testing, the client develops shortness of breath and stridor and becomes hypotensive. What is the most appropriate drug for the nurse to give in this situation? A) Epinephrine (Adrenalin) B) Fexofenadine (Allegra) C) Cromolyn sodium (Nasalcrom) D) Zileuton (Zyflo)

Epinephrine (Adrenalin)

Which statement about the transmission of hepatitis C is correct? A) Feces are a likely body fluid by which to transmit the disease. B) Airborne Precautions are used for the prevention of hepatitis C. C) Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection. D) No precautions are necessary with the use of nail clippers or scissors.

Equipment or linen soiled with blood or body fluids should be washed with bleach or a disinfectant to prevent infection.

The nurse is caring for a patient who is admitted to the ED with burns to the lower legs and hands. During the initial management, what is the priority nursing care? A) Assess and treat pain B) Evaluate airway and circulation C) Place two IV catheters and initiate fluid resuscitation D) Use the rule of nines to estimate percent of body surface area burned

Evaluate airway and circulation

True or false: Inflammation means that an infection is always present. A) True B) False

False

Which is a common clinical manifestation of infectious disease? A) Dry and pink skin B) Hypothermia C) Decreased respiratory rate D) Fever

Fever

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? A) Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain B) Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" C) An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans D) Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"

A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours? A) Range-of-motion exercises B) Emotional support C) Fluid resuscitation D) Sterile dressing changes

Fluid resuscitation

A client is prescribed prednisone for treatment of a type I hypersensitivity reaction. The nurse plans to monitor the client for which adverse effects? (Select all that apply.) A) Fluid retention B) Gastric distress C) Hypotension D) Infection E) Osteoporosis

Fluid retention Gastric distress Infection Osteoporosis

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client? A) Administering prophylactic drug therapy B) Frequent and thorough handwashing C) Monitoring laboratory values to look for abnormalities D) Taking vital signs every 4 hours, day and night

Frequent and thorough handwashing

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? A) Avoid large crowds. B) Get the meningococcal vaccine. C) Take a daily vitamin. D) Take prophylactic antibiotics.

Get the meningococcal vaccine.

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? A) Give oxygen per facemask. B) Infuse lactated Ringer's solution at 150 mL/hr. C) Give morphine sulfate 4 to 10 mg IV for pain control. D) Insert a 14 Fr retention catheter.

Give oxygen per facemask.

The daughter of a client who has had a stroke asks the nurse for additional resources. What is the nurse's best response? "Call hospice." "Check the Internet." "Go to the National Stroke Association website." "The charge nurse at the desk has all of the information."

Go to the National Stroke Association website

A 19-year-old man has been having trouble breathing for a week. He has occasional hemoptysis, decreased urine output, hypertension, and tachycardia. further testing reveals that he has areas of consolidation over his lung fields (by chest x-ray) and glomerulonephritis with reduced kidney function. The nurse recognizes that these symptoms are associated with what condition? A) Grave's disease B) Sjogren's syndrome C) Goodpasture's syndrome D) Anaphylactic reaction to an unknown allergen

Goodpasture's syndrome

Which postoperative kidney transplantation client does the nurse assess first for signs and symptoms of hyperacute rejection? A) Older adult with Parkinson disease receiving a donation from an identical twin B) Grand multipara female with a history of subsequent blood transfusions C) Middle-aged man with a 20-pack-year history D) Young adult with type 1 diabetes

Grand multipara female with a history of subsequent blood transfusions

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Apple juice Grape juice Grapefruit juice Milk

Grapefruit juice

Which statement about handwashing is in accordance with recommendations by the Centers for Disease Control and Prevention? A) If gloves are worn between treatments for clients sharing a room, handwashing is not necessary until the nurse has finished assessing the second client. B) Handwashing must be done after contact with the client's intact skin, such as when taking a pulse. C) Handwashing does not need to be done after resetting a client's IV pump. D) If the hands are not visibly soiled, washing the hands is not necessary.

Handwashing must be done after contact with the client's intact skin, such as when taking a pulse.

The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A) Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) B) Determines who prepares the client's meals and plans an interview with him or her C) From a prepared list, finds out the client's food preferences D) Has the client write down everything he or she has eaten for the past week

Has the client write down everything he or she has eaten for the past week

A client has been ordered norepinephrine (Levophed) for treatment of severe hypotension. The nurse plans to monitor the client for which adverse effect? A) Bradycardia B) Headache C) Infection D) Metabolic alkalosis

Headache

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) Alopecia Headaches Dizziness Diplopia Increased blood glucose

Headaches Dizziness Diplopia

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? A) Heart failure B) Diverticulitis C) Hypertension D) Emphysema

Heart failure

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? Check for fecal impaction. Insert a straight catheter. Help the client sit up. Loosen the client's clothing.

Help the client sit up

A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? A) Aplastic anemia B) Hemolytic anemia C) Infectious process D) Leukemia

Hemolytic anemia

A client is admitted to the hospital with suspected Goodpasture's syndrome. Which findings does the nurse expect to observe? A) Bradycardia B) Hemoptysis C) Increased urine output D) Weight loss

Hemoptysis

A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge? A) Heparin (Heparin) B) Hydroxyurea (Droxia) C) Tissue plasminogen activator (t-PA) D) Warfarin (Coumadin)

Hydroxyurea (Droxia)

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? A) Hypercalcemia B) Hyperkalemia C) Hypomagnesemia D) Hyponatremia

Hyperkalemia

The nurse is reviewing the medical record of a client who is prescribed a decongestant. The nurse plans to contact the client's health care provider if the client has which condition? A) Cataracts B) Crohn's disease C) Diabetes mellitus D) Hypertension

Hypertension

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.) A) Capillary refill less than 3 seconds B) Decreased pallor C) Flattened superficial veins D) Hypertension E) Hypotension F) Rapid, bounding pulse

Hypertension Hypotension Rapid, bounding pulse

A client has received preoperative teaching from the nurse for a microdiskectomy. Which statement by the client indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

I can go home the day of the procedure

The nurse is teaching a client and family about home care after a stroke. Which statement made by the client's spouse indicates a need for further teaching? "I should spend all my time with my husband in case I'm needed." "My husband may get depressed." "My husband must take his medicine every day to prevent another stroke." "The physical therapist will show us how to use the equipment so my husband can climb the stairs and get into and out of bed."

I should spend all my time with my husband in case I'm needed

The nurse is providing medication instructions to a client diagnosed with amyotrophic lateral sclerosis who has been prescribed riluzole (Rilutek). Which statement indicates to the nurse that the client understands the instructions? "Riluzole should be taken with food." "I plan to take riluzole once daily." "I will call the health care provider if my pulse goes below 50." "I will need frequent checks of my liver enzymes."

I will need frequent checks of my liver enzymes

A client has sustained a rotator cuff tear while playing baseball. The nurse anticipates that the client will receive which immediate conservative treatment? Surgical repair of the rotator cuff Prescribed exercises of the affected arm Immobilizer for the affected arm Patient-controlled analgesia with morphine

Immobilizer for the affected arm

A client has been admitted with a diagnosis of stroke (brain attack). The nurse suspects that the client has had a right hemisphere stroke because the client exhibits which symptoms? Aphasia and cautiousness Impulsiveness and smiling Inability to discriminate words Quick to anger and frustration

Impulsiveness and smiling

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? A) In a neutral position B) In a position of comfort C) Slightly flexed D) Slightly hyperextended

In a neutral position

A priority problem of hyperthermia is identified by the long-term-care RN who is caring for a client with a urinary tract infection. Which intervention is most appropriate to delegate to a nursing assistant? A) Monitor for improvement after antibiotic therapy is initiated. B) Teach the client the reason for taking antibiotics as prescribed. C) Administer acetaminophen (Tylenol) 650 mg orally for elevated temperature. D) Increase fluid intake by assisting the client to choose preferred beverages.

Increase fluid intake by assisting the client to choose preferred beverages.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A) Fluid overload (overhydration) B) Hemorrhage C) Hypoxia D) Infection

Infection

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow? A) Administer intravenous corticosteroids before starting the transfusion. B) Allow the platelets to stabilize at the client's bedside for 30 minutes. C) Infuse the transfusion over a 15- to 30-minute period. D) Set up the infusion with the standard transfusion Y tubing.

Infuse the transfusion over a 15- to 30-minute period.

A client is in skeletal traction. Which nursing intervention ensures proper care of this client? Ensure that weights are attached to the bed frame or placed on the floor. Ensure that pins are not loose, and tighten as needed. Inspect the skin at least every 8 hours. Remove the traction weights only for bathing.

Inspect the skin at least every 8 hours.

A patient is transitioning from IV heparin therapy to oral warfarin. The nurse recognizes which laboratory finding that indicates warfarin treatment efficacy? A) Bleeding time of 5 minutes B) Prothrombin time (PT) of 18 seconds C) International normalized ratio (INR) of 2.5 D) Partial thromboplastin time (PTT) of 24.3 seconds

International normalized ration (INR) of 2.5

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? A) Intramuscular B) Intravenous C) Sublingual D) Topical

Intravenous

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer? A) Intramuscular (IM) morphine sulfate B) Intravenous (IV) hydromorphone (Dilaudid) C) Oral ibuprofen (Motrin) D) Oral morphine sulfate (MS-Contin)

Intravenous (IV) hydromorphone (Dilaudid)

A client with Parkinson disease is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective? A) Involving the client and his wife in developing a plan of care B) Setting up visitations by a home health nurse C) Telling his wife what the client needs D) Writing up a detailed plan of care according to standards

Involving the client and his wife in developing a plan of care

The home health nurse is checking in on a client with dementia and the client's spouse. The spouse confides to the nurse, "I am so tired and worn out." What is the nurse's best response? A) "Can't you take care of your spouse?" B) "Establishing goals and a daily plan can help." C) Involving the client and his wife in developing a plan of care D) "That's not a very nice thing to say."

Involving the client and his wife in developing a plan of care

A client with a spinal cord tumor and a poor prognosis has lost bladder control. The client asks the nurse whether the suggested surgery will be "worth it." What is the nurse's best response? "It should help return bladder control." "Let me call the surgeon so you can ask the rest of your questions." "What do you think?" "What does your family think?"

It should help return bladder control

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? "Begin driving 1 week after discharge." "Avoid using a pillow under the head while sleeping." "Swimming is recommended to keep active." "Keep straws available for drinking fluids."

Keep straws available for drinking fluids

An older adult client has had an open reduction and internal fixation of a fractured right hip. Which intervention does the nurse implement for this client? Keep the client's heels off the bed at all times. Re-position the client every 3 to 4 hours. Administer preventive pain medication before deep-breathing exercises. Prohibit the use of antiembolic stockings.

Keep the client's heels off the bed at all times

A client is eating a soft diet while recovering from a stroke. The client reports food accumulating in the cheek of the affected side. What is the nurse's best response? "Next time you eat, try lifting your chin when you swallow." "Let's advance your diet to solid food." "Let's see if the dietitian can help." "Let's see if the speech-language pathologist can help."

Let's see if the speech-language pathologist can help

A client who has just undergone spinal surgery must be moved. How does the nurse plan to move this client? Getting the client up in a chair Keeping the client in the Trendelenburg position Lifting the client in unison with other health care personnel Log rolling the client

Log rolling the client

The nurse is caring for a client who is scheduled to have a brain biopsy. The nurse anticipates that the health care provider will request which test before the brain biopsy is performed? A) Lumbar puncture (LP) B) Magnetic resonance imaging (MRI) C) Skull x-ray D) Transcranial Doppler ultrasonography (TCD)

Magnetic resonance imaging (MRI)

A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)? Assessing for Turner's sign Maintaining PaCO2 levels at 35 mm Hg Placing the client in the Trendelenburg position Suctioning the client frequently

Maintaining PaCO2 levels at 35 mm Hg

The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range? Dexamethasone (Decadron) Hydrochlorothiazide (HydroDIURIL) Mannitol (Osmitrol) Phenytoin (Dilantin)

Mannitol (Osmitrol)

The nurse has just received change-of-shift report about a group of clients on the neurosurgical unit. Which client does the nurse attend to first? A) Young adult client involved in a motor vehicle crash (MVC) who is yelling obscenities at the nursing staff B) Adult postoperative left craniotomy client whose hand grips are weaker on the right C) Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous D) Older adult client who had a carotid endarterectomy and is unable to state the day of the week

Middle-aged adult client who had a cerebral aneurysm clipping and is increasingly stuporous

Because of a flu epidemic, the respiratory floor of a hospital does not have any open beds. Which client does the nurse determine is ready for discharge at the request of the discharge planner? A) Older adult client with a history of congestive heart failure, oxygen saturation of 91%, and on O2 at 2 L, with white blood cell count (WBC) 15.5, segmented neutrophils (segs) 8.0, bands 5, lungs with slight crackles in bases, able to assist with activities of daily living, and afebrile B) Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile C) Young adult client with crackles in all lung lobes, with productive cough of copious amounts of thick yellow sputum, WBC count 20.0, segs 7.0, bands 10.0, oxygen saturation of 95% on O2 at 2 L, and temperature of 100.4° F (38° C) D) Older adult client with recent history of right hip replacement, with productive cough, WBC count 3.4, segs 6.2, bands 5, lungs with crackles right mid-lobe posterior chest wall, oxygen saturation of 89% with O2 at 2 L, and afebrile

Middle-aged client with history of multiple sclerosis, decreased ability to ambulate since hospitalization, lungs clear, WBC count 9.5, segs 6.0, bands 1.0, oxygen saturation of 93% on room air, and afebrile

A client has Parkinson disease (PD). Which nursing intervention best protects the client from injury? A) Discouraging the client from activity B) Encouraging the client to watch the feet when walking C) Suggesting that the client obtain assistance in performing activities of daily living (ADLs) D) Monitoring the client's sleep patterns

Monitoring the client's sleep patterns

A client is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the client? Mini-Mental State Examination (MMSE; mini-mental status examination) Intracranial pressure monitor Reflex hammer National Institutes of Health Stroke Scale (NIHSS)

National Institutes of Health Stroke Scale

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? Hospital library Internet Provider's office National Spinal Cord Injury Association

National Spinal Cord Injury Association

What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? (Select all that apply.) A) Cardiomyopathy B) Nephrotoxicity C) Ototoxicity D) Stroke E) Diarrhea

Nephrotoxicity C) Ototoxicity

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? Dopamine hydrochloride (Inotropin) Nifedipine (Procardia) Methylprednisolone (Solu-Medrol) Ziconotide (Prialt)

Nifedipine (Procardia)

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention? A) Nosebleed B) Reports of pain C) Decreased urine output D) Increased temperature

Nosebleed

IT has been 12 hours since a patient has been admitted for burns to the face and neck with associated inhalation injuries. The patient had been wheezing audibly and the wheezing has now stopped. What nursing action is appropriate? A) Check the patient's SPO2 level B) Notify the physician immediately C) Re-assess breathing in 1 hour D) Document improvement in patient's condition

Notify the physician immediately

A client has undergone an elective below-the-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the client to notify the health care provider if which change occurs? Observation of a large amount of serosanguineous or bloody drainage Mild to moderate pain controlled with prescribed analgesics Absence of erythema and tenderness at the surgical site Ability to flex and extend the right knee

Observation of a large amount of serosanguineous or bloody drainage

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first? A) Hydrate the client with 1000 mL of IV normal saline. B) Initiate the administration of prescribed antibiotics. C) Obtain requested cultures. D) Place the client on Bleeding Precautions.

Obtain requested cultures.

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit? A) Administering erythropoietin to a client with myelodysplastic syndrome B) Assessing skin integrity on an anemic client who fell during ambulation C) Assisting a client with folic acid deficiency in making diet choices D) Obtaining vital signs on a client receiving a blood transfusion

Obtaining vital signs on a client receiving a blood transfusion

The nurse anticipates providing collaborative care for a client with a traumatic amputation of the right hand with which health care team members? (Select all that apply.) Occupational therapist Physical therapist Psychologist Respiratory therapist Speech therapist

Occupational therapist Physical therapist Psychologist

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? A) Black-brown coloration B) Painful C) Moderate to severe edema D) Absence of blisters

Painful

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A) Painful red and white wounds B) Painless, brownish yellow eschar C) Painful reddened blisters D) Painless black skin with eschar

Painful red and white wounds

The nurse is teaching a client newly diagnosed with multiple sclerosis (MS). Which statement by the client indicates a correct understanding of the pathophysiology of the disease? "I will die early." "I will have gradual deterioration with no healthy times." "Parts of my nervous system have plaques." "This was caused by getting too many x-rays as a child."

Parts of my nervous system have plaques

In the emergency department (ED), which is the nursing priority in assessing the client with a spinal cord injury? Patent airway Indication of allergies Level of consciousness Loss of sensation

Patent airway

An older adult client has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this client? Cyclobenzaprine (Flexeril) Ibuprofen (Advil) Meperidine (Demerol) Patient-controlled analgesia (PCA) with morphine

Patient-controlled analgesia (PCA) with morphine

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request? A) Cefaclor (Ceclor) B) Gentamicin (Garamycin) C) Penicillin V (Pen-V K) D) Vancomycin (Vancocin)

Penicillin V (Pen-V K)

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? (Select all that apply.) A) Provides cushions and rugs for comfort B) Performs frequent handwashing C) Places plants in the client's room D) Performs frequent handwashing E) Uses disposable dishes

Performs frequent handwashing Performs frequent handwashing Uses disposable dishes

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? A) Discouraging having food brought in from the client's favorite restaurant B) Providing more palatable choices for the client C) Helping the client lose weight D) Planning additions to the standard nutritional pattern

Planning additions to the standard nutritional pattern

The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age-related? A) Hemoglobin level B) Platelet (thrombocyte) count C) Red blood cell (RBC) count D) White blood cell (WBC) response

Platelet (thrombocyte) count

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? "Every injury is different, and it is too soon to have any real answers right now." "Only time will tell." "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." "Please request a meeting with the health care provider."

Please request a meeting with the health care provider

Which information is most important for the nurse to communicate to the health care provider about a client who is scheduled for cerebral angiography? A) Allergy to penicillin B) History of bacterial meningitis C) Poor skin turgor and dry mucous membranes D) The client's dose of metformin (Glucophage) held today

Poor skin turgor and dry mucous membranes

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? Auscultating bowel sounds every 2 hours Beginning a bladder retraining program Monitoring nutritional status Positioning the client to maximize ventilation potential

Positioning the client to maximize ventilation potential

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? A) Documents the length and time of the seizure. B) Forces a tongue blade in the mouth. C) Restrains the client. D) Positions the client on the side.

Positions the client on the side

A patient has been receiving dressing changes with silver sulfadiazine (Silvadene) for burn injuries over both lower arms. The nurse notices that the patient's white blood cell count has dropped significantly over the past 4 days. How does the nurse interpret the finding? A) Electrolyte imbalance B) Infection is improving C) Impending kidney disease D) Possible allergic reaction to silver sulfadiazine (Silvadene)

Possible allergic reaction to silver sulfadiazine (Silvadene)

A client with early-stage Alzheimer's disease is admitted to the surgical unit for a biopsy. Which client problem is the priority? A) Potential for injury related to chronic confusion and physical deficits B) Risk for reduced mobility related to progression of disability C) Potential for skin breakdown related to immobility and/or impaired nutritional status D) Lack of social contact related to personality and behavior changes

Potential for injury related to chronic confusion and physical deficits

What is the priority nursing intervention in the care of an older patient with a history of diverticular disease and pernicious anemia? A) Preventing falls B) Monitoring intake and output C) Turning the patient every 2 hours D) Encouraging a diet high in vitamin B12

Preventing falls

Which are risk factors for stroke? (Select all that apply.) High blood pressure Previous stroke or transient ischemic attack (TIA) Smoking Use of oral contraceptives Female gender

Previous stroke or transient ischemic attack (TIA) High blood pressure Smoking Use of oral contraceptives

Which actions aid in the prevention and early detection of infection in a client at risk? (Select all that apply.) A) Inspect the skin for coolness and pallor. B) Promote sufficient nutritional intake. C) Encourage fluid intake, as appropriate. D) Monitor the red blood cell (RBC) count. E) Obtain cultures as needed. F) Remove unnecessary medical devices.

Promote sufficient nutritional intake Obtain cultures as needed Remove unnecessary medical devices

A client with a history of atrial fibrillation is receiving sodium heparin 24 hours after receiving thrombolytic therapy for a stroke. Which emergency drug does the nurse ensure is on the floor? Narcan Protamine sulfate Vitamin K Physostigmine

Protamine sulfate

Which intervention is the most appropriate to address the priority problem of feelings of isolation when caring for a client who is placed on Transmission-Based Precautions? A) Encourage family and friends to call the client. B) Provide education on the mode of transmission. C) Encourage the client to watch television. D) Ask a certified hospital chaplain to visit the client.

Provide education on the mode of transmission.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first? A) Apply cool compresses to the client's forehead. B) Encourage the client's use of two methods of birth control. C) Increase food sources of iron in the client's diet. D) Provide pain medications as needed.

Provide pain medications as needed.

Which home health nurse should the nurse manager assign to care for an 18-year-old client with a kidney transplant who has many questions about the prescribed cyclosporine (Sandimmune)? A) RN who has worked for the home health agency for 5 years in maternal-child health B) RN who has extensive critical care nursing experience and has worked in home health for a year C) RN who transferred to the home health agency after working for 10 years in an outpatient dialysis unit D) RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

RN who worked for 5 years in an organ transplant unit and has recently been hired by the home health agency

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? A) Intense pain B) Potential for inadequate oxygenation C) Reduced self-image D) Potential for infection

Reduced self-image

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? A) Reduction of bacterial growth in the wound and prevention of systemic sepsis B) Prevention of cross-contamination from other clients in the unit C) Enhanced cell growth D) Reduced need for a skin graft

Reduction of bacterial growth in the wound and prevention of systemic sepsis

Which nursing intervention is best for preventing complications of immobility when caring for a client with spinal cord problems? Frequent ambulation Encouraging nutrition Regular turning and re-positioning Special pressure-relief devices

Regular turning and re-positioning

The nurse manager for a long-term care facility is in charge of implementing a plan to decrease the spread of infection within the facility. Which part of the plan is most appropriate to delegate to nursing assistants working at the facility? A) Evaluating each other's handwashing technique B) Deciding which brand of handwashing soap to use C) Reinforcing the need for handwashing after caring for clients D) Determining which clients are most likely to infect other residents

Reinforcing the need for handwashing after caring for clients

Which nursing action is most appropriate for the nurse working in an allergy clinic to delegate to a nursing assistant? A) Plan the schedule for desensitization therapy for a client with allergies. B) Monitor the client who has just received skin testing for signs of anaphylaxis. C) Educate a client with a latex allergy about other substances with cross-sensitivity to latex. D) Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

Remind the client to stay at the clinic for 30 minutes after receiving intradermal allergy testing.

A client is being discharged from the hospital after an allergic reaction to environmental airborne allergens. Which instruction is most important for the nurse to include in this client's discharge teaching plan? A) Wash fruits and vegetables with mild soap and water before eating. B) Intermittent exposure to known allergens will produce immunity. C) Remove cloth drapes, carpeting, and upholstered furniture. D) Be cautious when eating unprocessed honey.

Remove cloth drapes, carpeting, and upholstered furniture.

Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A) Drawing a partial thromboplastin time from a saline lock on a client with a pulmonary embolism B) Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure C) Referring a client with a daily alcohol consumption of 12 beers for counseling D) Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia

Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia

A client is brought to the emergency department via ambulance after a motor vehicle crash. What condition does the nurse assess for first? Bleeding Head injury Pain Respiratory distress

Respiratory distress

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action? A) A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP) B) Respiratory rate of 36 breaths/min in a client receiving red blood cells C) Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D) Temperature of 99.1° F (37.3° C) for a client with a platelet transfusion

Respiratory rate of 36 breaths/min in a client receiving red blood cells

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which component of the health care team is a nursing priority? Nutritional therapy Occupational therapy Physical therapy Respiratory therapy

Respiratory therapy

A patient reports increased fatigue, malaise, bleeding gums, and frequent "chills" to the nurse. What is the priority nursing intervention? A) Document assessment findings B) Notify the health care provider of the patient's symptoms C) Obtain vital signs and administer antipyretic medication D) Review laboratory analysis for signs and symptoms of bone marrow suppression

Review laboratory analysis for signs and symptoms of bone marrow suppression

A client recently admitted to the hospital is to receive an antibiotic intravenously for the first time for a urinary tract infection. Before checking the five rights prior to administration, what is the nurse's first action? A) Review the clinical records and ask the client about any known allergies. B) Check with the pharmacy for any known allergies for this client. C) Check the client's identification band for any allergies. D) Ask the nurse who previously cared for the client about any known allergies.

Review the clinical records and ask the client about any known allergies.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A) Asks the client's name B) Checks the client's armband C) Reviews all information with another registered nurse D) Verifies the client's room number

Reviews all information with another registered nurse

A client with dementia and Alzheimer's disease is discharged to home. The client's daughter says, "He wanders so much, I am afraid he'll slip away from me." What resource does the nurse suggest? A) Alzheimer's Wandering Association B) National Alzheimer's Group C) Safe Return Program D) Lost Family Members Tracking Association

Safe Return Program

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? A) Pale, boggy, dry, or crusted granulation tissue B) Increasing wound drainage C) Scar tissue formation D) Sloughing of grafts

Scar tissue formation

A client who is exposed to invading organisms recovers rapidly after the invasion without damage to healthy body cells. How has the immune response protected the client? A) Intact skin and mucous membranes B) Self-tolerance C) Inflammatory response against invading foreign proteins D) Antibody-antigen interaction

Self-tolerance

In assessing a client with back pain, the nurse uses a paper clip bilaterally on each limb. What is the nurse assessing? Gait Mobility Sensation Strength

Sensation

Which information about a client who was admitted with pelvic and bilateral femoral fractures after being crushed by a tractor is most important for the nurse to report to the health care provider? Thighs have multiple oozing abrasions. Serum potassium level is 7 mEq/L. The client is describing pain as level 4 (0-to-10 scale). Hemoglobin level is 12.0 g/dL.

Serum potassium level is 7 mEq/L.

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? A) Bowel sounds B) Muscle strength C) Signs of infection D) Urine output

Signs of infection

What is the most important environmental risk for developing leukemia? A) Direct contact with others with leukemia B) Family history C) Living near high-voltage power lines D) Smoking cigarettes

Smoking cigarettes

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next? A) Call the Rapid Response Team. B) Obtain vital signs and continue to monitor. C) Slow the infusion rate of the transfusion. D) Stop the transfusion.

Stop the transfusion.

A client in the allergy clinic develops all of these clinical manifestations after receiving an intradermal injection of an allergen. Which symptom requires the most immediate action by the nurse? A) Anxiety B) Urticaria C) Pruritus D) Stridor

Stridor

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) Bite block at the bedside Intravenous access Continuous sedation Suction equipment at the bedside Siderails up

Suction equipment at the bedside Intravenous access Siderails up

Which information does the nurse include when teaching a client about antibiotic therapy for infection? A) Take all antibiotics as prescribed, unless side effects develop. B) Take antibiotics until symptoms subside, and then stop taking the drugs. C) Take antibiotics when symptoms of infection develop. D) Share antibiotics with family members who develop the same infection.

Take all antibiotics as prescribed, unless side effects develop.

A client who was treated last month for a bad case of bronchitis and walking pneumonia reports many of the same symptoms today. Which factor in the client's antibiotic therapy most likely caused the client's relapse? A) Taking the antibiotic before jogging 2 miles daily B) Taking the antibiotic most days C) Taking the antibiotic as prescribed D) Taking the antibiotic with a full glass of water

Taking the antibiotic most days

Which intervention does the nurse suggest to a client with a leg amputation to help cope with loss of the limb? Talking with an amputee close to the client's age who has had the same type of amputation Drawing a picture of how the client sees him- or herself Talking with a psychiatrist about the amputation Engaging in diversional activities to avoid focusing on the amputation

Talking with an amputee close to the client's age who has had the same type of amputation

The nurse is caring for a client postoperatively after an anterior cervical diskectomy and fusion. Which assessment finding is of greatest concern to the nurse? Neck pain is at a level 7 on a 0-to-10 scale. The client is reporting difficulty swallowing secretions. The client has numbness and tingling bilaterally down the arms. Serosanguineous fluid oozes onto the neck dressing.

The client is reporting difficulty swallowing secretions

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. The client demonstrates flaccid paralysis below the level of injury. The client's chest moves very little with each respiration. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg.

The client's chest moves very little with each respiration

Which statement accurately explains otitis media? A) The inflammatory response is triggered by the invasion of foreign proteins. B) Phagocytosis by macrophages and neutrophils destroys and eliminates foreign invaders. C) It is caused by a left shift or increase in immature neutrophils. D) Many immune system cells released into the blood have specific effects.

The inflammatory response is triggered by the invasion of foreign proteins

The nurse is teaching the spouse and client who has had a brain attack about rehabilitation. Which statement by the spouse demonstrates understanding of the nurse's instruction? "My spouse will no longer need to take blood pressure medication." "Rehabilitation and physical therapy are the same thing." "The rehabilitation therapist will help identify changes needed at home." "Frequent stimulation will help with the rehabilitation process."

The rehabilitation therapist will help identify changes needed at home

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? A) Bowel sounds are absent. B) The pulse oximetry level is 91%. C) The serum potassium level is 6.1 mEq/L. D) Urine output since admission is 370 mL.

The serum potassium level is 6.1 mEq/L.

A client in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The client also has a history of hypertension and atherosclerosis. What does the nurse suspect that the client is probably experiencing? Embolic stroke Hemorrhagic stroke Thrombotic stroke Transient ischemic attack

Thrombotic stroke

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? A) Administer a diuretic. B) Provide a fluid bolus. C) Recalculate fluid replacement based on time of hospital arrival. D) Titrate fluid replacement.

Titrate fluid replacement.

The nurse is assessing a client with a neurologic condition who is reporting difficulty chewing when eating. The nurse suspects that which cranial nerve has been affected? A) Abducens B) Facial C) Trigeminal D) Trochlear

Trigeminal

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? A) Blood urea nitrogen (BUN), 36 mg/dL B) Creatinine, 2.8 mg/dL C) Urine output, 40 mL/hr D) Urine specific gravity, 1.042

Urine output, 40 mL/hr

A client has a grade III compound fracture of the right tibia. To prevent infection, which intervention does the nurse implement? Apply bacitracin (Neosporin) ointment to the site daily with a sterile cotton swab. Use strict aseptic technique when cleaning the site. Leave the site open to the air to keep it dry. Assist the client to shower daily and pat the wound site dry.

Use strict aseptic technique when cleaning the site.

Which cranial nerve allows a person to feel a light breeze on the face? A) I (olfactory) B) III (oculomotor) C) V (trigeminal) D) VII (facial)

V (trigeminal)

A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? A) Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). B) Hold the client's hand and ask about concerns. C) Review the client's platelet (thrombocyte) count. D) Verify that the client has given informed consent.

Verify that the client has given informed consent

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data? A) Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion. B) Remain with the client who is receiving the blood for the first 5 minutes of the infusion. C) Use a 22-gauge needle to obtain venous access when starting the infusion. D) Verify with another RN all of the data on blood products.

Verify with another RN all of the data on blood products.

The results of a client's lumbar puncture indicate that the client's protein level is 150 mg/dL. The nurse suspects that the client may have which condition? A) Guillain-Barré syndrome B) Meningismus C) Paraventricular tumor D) Viral infection

Viral infection

The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? A) Add furosemide to the normal saline that is infusing with the blood. B) Administer furosemide to the client intramuscularly (IM). C) Piggyback furosemide into the infusing blood. D) Wait until the transfusion has been completed to administer furosemide.

Wait until the transfusion has been completed to administer furosemide.

A client is being discharged home after surgery for brain cancer. Which statement by the client's spouse indicates a correct understanding of the nurse's discharge teaching? "I will have to quit my job to care for my spouse." "Life will be back to normal soon." "The case manager will provide home care." "We can find a support group through the local American Cancer Society."

We can find a support group through the local American Cancer Society

While in the hospital, the client has developed a methicillin-resistant infection in the foot. The client had undergone surgical débridement for gangrene. Which precaution is best for this client? A) Wear a gown and gloves to prevent contact with the client or client-contaminated items. B) Assign the client to a private room with a negative airflow. C) Wear a mask when working within 3 feet of the client. D) Have the client wear a surgical mask when being transported out of the room.

Wear a gown and gloves to prevent contact with the client or client-contaminated items.

Which precaution is best for the nurse to take to prevent the transmission of Clostridium difficile infection? A) Carefully wash hands that are visibly soiled. B) Wear a mask and gloves when the client's body secretions or body fluids are likely to be handled. C) Wear a mask with eye protection and perform proper handwashing. D) Wear gloves when contact with body secretions or body fluids is expected.

Wear gloves when contact with body secretions or body fluids is expected.

The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan? "Avoid contact sports." "Avoid rigorous exercise." "Wear helmets when riding a motorcycle." "Avoid driving in inclement weather."

Wear helmets when riding a motorcycle

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out? A) Coughing and deep breathing B) Evidence of pus C) Fever of 102° F or higher D) Wheezes or crackles

Wheezes or crackles

The nurse has received report on a group of clients. Which client requires the nurse's attention first? Adult who is lethargic after a generalized tonic-clonic seizure Young adult who has experienced four tonic-clonic seizures within the past 30 minutes Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

Young adult who has experienced four tonic-clonic seizures within the past 30 minutes

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? A) Middle-aged adult who is frantically explaining to the nurse what happened B) Young adult who suffered burn injuries in a closed space C) Adult with burns to the extremities D) Older adult with thick, tan-colored sputum

Young adult who suffered burn injuries in a closed space

The nurse has just received report on a group of clients on the neurosurgical unit. Which client is the nurse's first priority? A) Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10 B) Adult whose deep tendon reflexes have become hyperactive C) Middle-aged adult who displays plantar flexion when the bottom of the foot is stroked D) Older adult who consistently demonstrates decortication when stimulated

Young adult whose Glasgow Coma Scale (GCS) score has changed from 15 to 10

Which client diagnosed with neurologic injury is typically at highest risk for depression? A) Young man with a spinal cord injury B) Older man with a spinal cord injury C) Older man with a mild stroke D) Young woman with a mild stroke

Young man with a spinal cord injury

The client with a history of asthma is prescribed a leukotriene receptor antagonist to prevent allergic rhinitis. The nurse anticipates that which drug will be prescribed? A) Cromolyn sodium (Nasalcrom) B) Desloratadine (Clarinex) C) Fexofenadine (Allegra) D) Zafirlukast (Accolate)

Zafirlukast (Accolate)