Exam 1

A nurse receives report on a group of clients. Which of the following client should the nurse attend to first? a. A client who was admitted with asthma and has an SaO2 of 92% long receiving oxygen at 1 L perminute via nasal cannula b. A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10' c. The client was type II diabetes mellitus in his blood with glucose level is at 80 mg/dL d. A client who had a gastric endoscopy and whose nasogastric tube is draining 30 mL per hour of green fluid

b. A client was admitted with angina and reports left arm pain of 4 on a scale of 0 to 10

A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen. Which of the following actions should the nurse take to help prevent the onset of acute kidney failure? a. Admister 0.9% NA IV at 25 mL/hr. b. Admister 500ml IV fluid bolus c. Administer oral rehydration solution d. Administer a calcium channel blocker

b. Adminster 500ml IV fluid bolus

A nurse is teaching a client who is at risk for osteoporosis. Which for the following instructions should the nurse include? a. Take 400 IU of vitamin D supplement each day. b. Perform moderate-intensity exercise for 150 min per week. c. Take 250 mg of a calcium supplement each day. d. Perform vigorous exercise at least 2 times per week.

b. Perform moderate-intensity exercise for 150 min per week. The client should perform moderate-intensity exercise for 150 min per week to strengthen bones and muscles and decrease the risk of osteoporosis.

A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? a. Half cup non-fat yogurt b. Two tablespoons of peanut butter c. 1 Cup white rice d. One medium baked potato with skin

c. 1 Cup white rice

A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level of 6 on a pain scale of 0 to 10. Which of the following interventions should the nurse take? a. Place pillows under the client's knee b. Gently massage the area around the client's incision c. Apply an ice pack to the client's knee d. Perform a range of motion exercises to the client's knee

c. Apply an ice pack to the client's knee

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify Which of the following clients as emergent? A client who has a punctured femoral artery B. A client who has multiple fractures C. A client who has a red rash over his abdomen D. A client who reports severe flank pain radiating to the groin

A client who has a punctured femoral artery A client who has a punctured femoral artery requires immediate attention because it is life-threatening; therefore, the nurse should identify this client as emergent or red-tagged

A client with an open fracture is at risk for developing osteomyelitis. Which classic symptoms would the nurse assess for to detect development of this complication? Select all that apply. A. Increased pain at the fracture site B. Elevated temperature C. Acute respiratory distress D. Shortening of the affected extremity E. Increased swelling at the fracture sit

A,B,E Increased pain could indicate development of osteomyelitis. Elevated temperature is a classic symptom seen with osteomyelitis as a systemic response to the invading organism. Increased swelling at the site of the fracture could indicate development of osteomyelitis. Acute respiratory distress is suggestive of fat embolism but not bone infection. The extremity does not shorten with osteomyelitis, although this is a classic finding with hip fracture.

A client with a right arm cast for a fractured humerus states, "I haven't been able to straighten the fingers on my right hand since this morning." What action should the nurse take first? A. Assess neurovascular status to the hand. B. Ask the client to massage the fingers. C. Encourage the client to take the prescribed analgesic. D. Elevate the right arm on a pillow to reduce edema

A. Assess the neurovascular status of the hand. This symptom suggests neurologic injury caused by pressure on nerves and soft tissue because of swelling (compartment syndrome). Other symptoms of neurovascular compromise should be assessed and reported to the healthcare provider. Massaging the fingers will not help alleviate the problem. An analgesic will not help with mobility caused by neurologic injury, and there is no evidence that the client is experiencing pain. Elevating the limb could worsen the symptoms at a time when circulation is already impaired from swelling, which led to the neurologic injury.

A nurse finds that a client did not receive a scheduled dose of furosemide (Lasix). Which of the following should the nurse include in the incident/variance report? (Select all that apply.) A. The date of the incident B. The name of the provider who prescribed the medication C. The potential adverse effects of the medication D. The time the client was to receive the medication E. The client's vital sign

A. The date of the incident D. The time the client was to receive the medication E. The client's vital sign When a nurse discovers a medication error, it is her legal responsibility to complete an incident report. A health care agency can use incident reports to monitor incidents and accidents in order to prevent future occurrences. The report should only include factual information about the incident such as the date. The nurse should include the time the client was to receive the medication because this pertains directly to the incident of the omitted medication.The client's vital signs is correct. The nurse should assess the client as soon as she discovers the error and should include the assessment data in the report

A nurse is providing teaching to a client who has osteoporosis and a new prescription for alendronate. Which of the following adverse effects should the nurse instruct the client to report to the provider? (Select all that apply. A. Tinnitus B. Jaw pain C. Blurred vision D. Drowsiness E. Dysphagia

B,C,E Alendronate can cause osteonecrosis of the jaw, blurred vision, headaches, and dysphagia. It can also cause esophagitis.

The nurse is teaching a postmenopausal client about the use of calcium to reduce the risk of osteoporosis. The client asks: "Why do I have to take vitamin D with my calcium?" What is the nurse's best response? A. "Vitamin D prevents osteoporosis." B. "Vitamin D increases intestinal absorption of calcium." C. "You are most likely to be deficient in vitamin D." D. "Using calcium and vitamin D supplements together prevents osteoporosis."

B. "Vitamin D increases intestinal absorption of calcium." A combination of calcium and vitamin D is recommended for the prevention of osteoporosis. Vitamin D increases the intestinal absorption of calcium and mobilizes calcium and phosphorus into the bone. Vitamin D alone does not prevent osteoporosis. While some older adults may be deficient in Vitamin D, a postmenopausal state does not necessarily cause the deficiency. Lifestyle modifications, such as smoking cessation and exercise, may also help reduce the risk of osteoporosis.

A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? A. Provide the client with antipyretic therapy B. Administer antibiotics to the client. C. Increase the client's protein intake D. Teach relaxation breathing to reduce the client's pain

B. Administer antibiotics to the client. The greatest risk to this client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for an extended time

1.A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis? A. Obesity B. Sedentary lifestyle C. Long-term use of diurectics D. Prolonged stress

B. Sedentary lifestyle A sedentary lifestyle places the client at risk for osteoporosis. Regular, weight-bearing exercises help to build bone tissue. OBESITY is a risk factor for the development of OSTEOARTHRITIS

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching? A. You will need to lie flat for 4 hours following the test." B. You will need to remove all jewelry before the test." C. "You will need to empty your bladder before the test." D. "You will need to fast for 12 hours before the test."

B. You will need to remove all jewelry before the test. The nurse should instruct the client to remove all jewelry or metal objects that can interfere with the test. A DXA scan is the mostly commonly used screening and diagnostic tool for measuring bone mineral density

A nurse in the emergency department is triaging clients following a mass casualty event. The nurse should identify which of the following clients is emergent. A. Levothyroxine B. Calcitonin C. Raloxifene D. Allopurinol

C. Raloxifene Raloxifene is prescribed for the prevention and treatment of osteoporosis in postmenopausal women

A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority? A. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineos C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6 D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

D A client who is postoperative is at risk for hemorrhage. A blood pressure decrease of 15 to 20 points is significant. This client is unstable; therefore, this client is the nurse's priority

A nurse is caring for a client in the ED. Select the 4 assessment findings on day 2 that require immediate follow-up a. Heart rate b. Oxygen saturation c. Edema d. Temperature e. Urine Color f. Pedal pulses

a. Heart rate c. Edema e. Urine Color f. Pedal pulses The client's heart rate has increased, which is a manifestation of unrelieved pain or an emergent condition, such as a pulmonary embolism. Increased sacral edema can cause impaired circulation and skin breakdown. Dark, reddish-brown urine is a manifestation of blood in the urine. Decreased pedal pulses are a manifestation of impaired circulation.