FINAL EXAM

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include?

"Expect your urine and other secretions to be orange while taking this medication." R: The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

A nurse is reviewing postoperative instructions with a client following cataract surgery. Which of the following client statements indicates an understanding of the instructions?

"I should call my doctor if my vision gets worse."

A nurse is teaching a client who has Parkinson's disease and is prescribed carbidopa-levodopa. Which of the following client statements indicates an understanding of the teaching?

"I should expect that this medication can cause me to be drowsy."

a nurse is teaching a client who has urge urinary incontinence about bladder retraining. which of the following instructions should the nurse include?

"increase the intervals between urination by 15 minutes per day when able to remain continent"

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription?

A client who has epistaxis R: The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse is caring for a client following insertion of a permanent pacemaker. Which of the following client statements indicates a potential complication of the insertion procedure? A. "I can't get rid of these hiccups." b. "I feel dizzy when I stand." c. "My incision site stings." d. "I have a headache."

A. "I can't get rid of these hiccups." Rationale:

A nurse is providing teaching for a client who is 2 days post-op following a heart transplant. Which of the following statements should the nurse include in the teaching? A. "you may no longer be able to feel chest pain." b. "your level of activity tolerance will not change." c. "after 6 months, you will no longer need to restrict your sodium intake." d. "you will be able to stop taking immunosuppressants after 12 months."

A. "you may no longer be able to feel chest pain." Rationale: Heart transplant clients usually are no longer able to feel chest pain due to the denervation of the heart.

a nurse is reviewing the medical history of a client who has end-stage kidney disease. the nurse should identify that which of the following factors in the client's history is a contraindication for receiving hemodialysis

history of hemophilia

A nurse is assessing a client in the emergency room who has a bradydysrhythmia. Which of the following findings should the nurse expect? A. Confusion B. Friction Rub C. Hypertension D. Dry Skin

A. Confusion Rationale: Bradydysrhythmia can cause decreased systemic perfusion, which can lead to confusion. Therefore, the nurse should monitor the client's mental status.

A nurse is caring for a client who has dilated cardiomyopathy. Which of the following findings should the nurse expect? A. Dyspnea on exertion B. Tracheal deviation C. Pericardial rub D. Weight loss

A. Dyspnea on exertion Rationale: The nurse should identify dyspnea on exertion as an expected manifestation of dilated cardiomyopathy. Dyspnea on exertion is due to ventricular compromise and reduced cardiac output.

A nurse is caring for a client who has heart failure and is experiencing atrial fibrillation. The nurse should plan to monitor for and report which of the following findings to the provider immediately? A. Slurred speech B. Irregular pulse C. Dependent edema D. Persistent fatigue

A. Slurred speech Rationale: The greatest risk to this client is injury from an embolus caused by the pooling of blood that can occur with atrial fibrillation. Slurred speech can indicate inadequate circulation to the brain because of an embolus. Therefore, the nurse should report this finding to the provider immediately.

A nurse is reviewing the ECG rhythm strip of a client who is receiving telemetry. Identify the area of the strip the nurse should examine to observe for atrial depolarization. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

A: P wave Rationale: you observe the p wave for atrial depolarization.......so thats A.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm?

Artificial airway cuff leak R: An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound. R: Kinks in the tubing & excess of secretions & biting on the endotracheal tube can cause an obstruction, which causes the high-pressure alarm to sound.

A nurse is providing discharge teaching for a client who has a prescription for the transdermal nitroglycerin patch. Which of the following instructions should the nurse include in the teaching? A. Apply the new patch to the same site as the previous patch. B. Place the patch on an area of skin away from skin folds and joints. C. Keep the patch on 24 hr per day. D. Replace the patch at the onset of angina.

B. Place the patch on an area of skin away from skin folds and joints. Rationale: The nurse should instruct the client to apply the patch to an area of intact skin with enough room for the patch to fit smoothly.

a nurse is reviewing laboratory report of a client who has acute kidney injury (AKI). which of the following findings should the nurse expect?

BUN 30 mg/dL urine output 40 mL in the past 3 hr hematocrit 30%

A nurse is caring for a client who presents to the ER with a BP of 254/138 mmhg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first? A. Initiate seizure precautions. B. Tell the client to report vision changes C. Elevate the head of the clients bed D. Start a peripheral IV

C. Elevate the head of the clients bed Rationale: The greatest risk to this client is organ injury due to severe hypertension. Therefore, the first action the nurse should take is to elevate the head of the client's bed to reduce blood pressure and promote oxygenation.

A nurse is admitting a client who has a leg ulcer and a history of DM. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? A. Explore the clients family history of peripheral vascular disease B. Note the presence or absence of pain at the ulcer site C. Inquire about the presence or absence of claudication D. Ask if the client has had a recent infection

C. Inquire about the presence or absence of claudication Rationale: Knowing if the client is experiencing claudication helps differentiate venous from arterial ulcers. Clients who have arterial ulcers experience claudication, but those who have venous ulcers do not.

A nurse is assessing a client who had a right hemispheric stroke. Which of the following neurologic deficits should the nurse expect?

impulsive behavior

A nurse is caring for a client in the first hour following an aortic aneurysm repair. Which of the following findings can indicate shock and should be reported to the provider? A. Serosanguinous drainage on dressing B. Severe pain with coughing C. Urine output of 20 ml/hr D. Increase in temp from 36.C (98.2F)- 37.5C (99.5F)

C. Urine output of 20 ml/hr Rationale: Urine output less than 30 mL/hr is a manifestation of shock. Urine output is decreased due to a compensatory decreased blood flow to the kidneys, hypovolemia, or graft thrombosis or rupture.

A nurse in the emergency department is caring for a client who had an anterior MI. The client's history reveals she is 1 week post-op open cholecystectomy. The nurse should recognize that which of the following interventions is contraindicated? A. Administering IV morphine sulfate B. Administering oxygen at 2:/min via nasal cannula C. Helping the client to the bedside commode D. Assisting with thrombolytic therapy

D. Assisting with thrombolytic therapy Rationale: The nurse should recognize that major surgery within the previous 3 weeks is a contraindication for thrombolytic therapy.

A nurse is caring for a client who has a history of DVT and is receiving warfarin. Which of the following client findings provides the nurse with the best evidence regarding the effectiveness of the warfarin therapy? A. Hemoglobin 14 g/dl B. Minimal bruising of extremities C. Decreased Blood pressure D. INR 2.0

D. INR 2.0 Rationale: The nurse should identify that an INR of 2.0 is within the desired reference range of 2.0 to 3.0 for a client who has a deep-vein thrombosis and is receiving warfarin to reduce the risk of new clot formation and a stroke.

A nurse is caring for a client who is receiving heparin therapy and develops hematuria. Which one of the following actions should the nurse take if the clients aPTTis 96 seconds? A. Increase the heparin infusion flow rate by 2 ml/hr B. Continue to monitor the heparin infusion as prescribed C. Request a prothrombin time D. Stop the heparin infusion

D. Stop the heparin infusion Rationale: The nurse should identify that the client's aPTT is above the critical value and the client is displaying manifestations of bleeding. Therefore, the nurse should discontinue the heparin infusion immediately and notify the provider to reduce the risk of client injury.

A nurse is watching a client's ECG monitor and notes that the client's rhythm has changed from a normal sinus rhythm to supraventricular tachycardia. The client is conscious with a HR of 200-210 bpm and has a faint radial pulse. The nurse should anticipate assisting with which of the following interventions? A. Initiate chest compressions b. Vagal stimulation c. Administration of atropine IV d. Defibrillation

b. Vagal stimulation Rationale: The nurse should identify that vagal stimulation might temporarily convert the client's heart rate to normal sinus rhythm. The nurse should have a defibrillator and resuscitation equipment at the client's bedside because vagal stimulation can cause bradydysrhythmias, ventricular dysrhythmias, or asystole.

A nurse is assessing a client who has left-sided HF. Which of the following manifestations should the nurse expect to find? A. Inc abdominal girth b. Weak peripheral pulses c. Jugular vein distention d. Dependent edema

b. Weak peripheral pulses Rationale: Weak peripheral pulses are related to decreased cardiac output resulting from left-sided heart failure.

a nurse is planning care for a client who is postoperative following a nephrectomy. which of the following assessments is the nurse's priority?

blood pressure

a nurse is teaching a client who has multiple sclerosis and has a new prescription for glatiramer acetate. Which of the following statements indicates that the client understands the teaching?

"I will avoid going to the store when it is crowded."

A nurse is providing teaching to a client who has chronic asthma and a new prescription of montelukast. Which of the following client statements indicates an understanding of the teaching?

"I will take this medication every night even if I don't have symptoms." R: Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

A nurse is developing a teaching plan for a client who has Ménière's disease. Which of the following instructions should the nurse include?

"Move your head slowly to decrease vertigo."

a nurse is providing teaching to a male client who has a continent internal ileal reservoir following surgery to treat bladder cancer. which of the following client statements indicates an understanding of the teaching?

"i must insert a catheter through my stoma to drain the urine."

a nurse is providing discharge teaching to a client who has chronic kidney disease (CKD). which of the following statements by the client indicates an understanding of the teaching?

"i will decrease my intake of foods that are high in phosphorus."

a nurse is providing teaching to a client who has chronic kidney disease (CKD). which of the following statements by the client indicates an understanding of the teaching?

"i will weight myself every morning."

a nurse is planning education about cyclosporine for a client who had a kidney transplant 2 days ago. which of the following statements should the nurse plan to include?

"you will need to continue taking this medication to protect your new kidneys"

A nurse is assessing a client who has a new diagnosis of osteoarthritis. Which of the following findings should the nurse expect?

-Crepitus with joint movement -decreased range of motion of the affected joint -joint pain that resolves with rest

A nurse is assessing a client who has pulmonary edema related to heart failure. Which of the following findings indicates effective treatment of the client's condition? A. Absence of adventitious breath sounds B. Presence of a nonproductive cough C. Decrease in respiratory rate at rest D. Sao2 86% on room air

A. Absence of adventitious breath sounds Rationale: Adventitious breath sounds occur when there is fluid in the lungs. The absence of adventitious breath sounds indicates that the pulmonary edema is resolving.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority?

Administer heparin via continuous IV infusion R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement?

Airborne R: The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack?

Albuterol R: The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first?

Apply Supplemental oxygen R: When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen?

Arterial blood gases R: When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client?

Container of Sterile Water R: The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect?

Blood-tinged sputum R: The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client who has advancing amyotrophic lateral sclerosis. Which of the following interventions is the nurse's priority?

monitor pulse oximetry findings

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

Continuous bubbling in the water seal chamber R: Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

A nurse is assessing a client who is 4 he postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider?

Decreased oxygen saturation R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing?

High-Fowler's position with the arms support on the over-bed table. R: The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider?

Intercostal Retractions R: The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen?

Nonrebreather mask R: The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2. - nasal cannula= 1-6L - simple face mask 40-60% - Partial rebreather mask 60-70%

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect?

PaO2 58 mm Hg R: The nurse should expect the client to have lower partial pressures of oxygen.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding?

Persistent cough R: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

A nurse is teaching an assistive personnel (AP) about providing care to a client following a total hip arthroplasty. Which of the following instructions should the nurse include?

Place an abductor pillow between the client's legs when turning the client

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments?

Presence of gag reflex R: The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider.

Productive cough with green sputum R: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. Expected findings: -increased anterior posterior chest - clubbing of fingers - pursed lip breathing w/ exertion

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include?

Provide a diet that is high in calories and protein R: The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect?

Temperature 38.8C (101.8F)

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client?

Tachycardia R: The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis.

A nurse is planning to teaching a client who has epilepsy and a new prescription for phenytoin. Which of the following instructions should the nurse plan to include?

Take medication at a consistent time each day to maintain therapeutic blood levels

A nurse is working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax?

Tracheal deviation to the unaffected side R: The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suction. Which of the following actions should the nurse take?

Use a rotating motion when removing the suction catheter. R: The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

a nurse in an emergency department is caring for a client who reports costovertebral angle tenderness, nausea, and vomiting. which of the following laboratory values should the nurse report to the provider?

WBC count 15,000/mm3

a nurse is planning care for a group of clients. which of the following clients should the nurse plan to monitor for signs of nephrotoxicity?

a client who is receiving gentamicin for the treatment of a wound infection

a nurse is monitoring a client following hemodialysis. the nurse should recognize that which of the following factors places the client at risk for seizures?

a rapid decrease in fluid

a nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. upon detecting an output obstruction, which of the following actions should the nurse take first?

check the irrigation tubing for kinks

a nurse is planning care for a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL) to treat urolithiasis. which of the following actions should the nurse plan to take?

apply electrodes for cardiac monitoring

a nurse is caring for a postoperative client following arteriovenous (AV) fistula creation in the left arm. which of the following actions should the nurse take?

auscultate for bruits in the client's fistula very 4 hr

a nurse is teaching a client who has a diagnosis of acute pyelonephritis. which of the following instructions should the nurse include in the teaching?

avoid the use of NSAIDs for pain

A nurse is caring for a client who is in balanced suspension skeletal traction and reports intermittent muscle spasms. Which of the following actions should the nurse take first?

check the position of the weights and ropes

A nurse is providing health teaching for a group of clients. Which of the following clients is at risk for developing peripheral arterial disease? A. A client who has hypothyroidism b. A client who has diabetes mellitus c. A client whose daily caloric intake consists of 25% fat d. A client who consumes two bottles of beer a day

b. A client who has diabetes mellitus Rationale: Diabetes mellitus places the client at risk for microvascular damage and progressive peripheral arterial disease.

A nurse is caring for a client who had an onset of chest pain 24 hr ago. The nurse should recognize that an increase in which of the following is diagnostic of a MI? A. Myoglobin b. C-reactive protein c. Creatine kinase- MB d. Homocysteine

c. Creatine kinase- MB Rationale: Creatine kinase-MB is the isoenzyme specific to the myocardium. Elevated creatine kinase-MB indicates myocardial muscle injury.

A nurse is caring for a client who has viral meningitis. Which of the following actions should the nurse take?

check capillary refill at least every 4 hr

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider?

clear drainage from nose

A nurse is performing a pain assessment for a client who is postoperative. Which of the following findings should the nurse use to determine the severity of the client's pain?

client's report of pain on a pain scale

a nurse is assessing a client who has chronic kidney disease and has completed the third peritoneal dialysis (PD) treatment. which of the following findings should the nurse report to the provider?

cloudy dialysate effluent

a nurse is caring for a client who has acute kidney injury (AKI). which of the following serum laboratory findings should the nurse report to the provider?

creatinine 4 mg/dL

a nurse is performing an admission assessment of a client who has acute glomerulonephritis. the nurse should expect which of the following findings?

dark-colored urine

a nurse is caring for a client who is scheduled for an intravenous urography. which of the following interventions is the nurse's priority?

determine if the client has an allergy to iodine or shellfish

a nurse is reviewing the medical records of four clients. the nurse should identify which of the following disorders as a risk factor for chronic pyelonephritis?

diabetes mellitus

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110 mmHg. Which of the following actions should the nurse take first?

elevated the head of the client's bed

A nurse is planning care for a client following a lumbar puncture. Which of the following actions should the nurse plan to take?

ensure that the client lies flat for up to 12 hr

A nurse is caring for a client who has a history of status epilepticus and requires seizure precautions. Which of the following actions should the nurse take?

establish IV access

A nurse is teaching a client who is postoperative following a right hip arthroplasty. Which of the following images indicates the position the nurse should teach the client to take when sitting in a chair?

feet flat on the floor

a nurse is planning care for a client who has chronic kidney disease and a potassium level of 7.3 mEq/L. which of the following interventions should the nurse plan to take?

infuse regular insulin in dextrose 10% in water

A nurse is planning a presentation about hypertension for a community women's group. Which of the following lifestyle modifications should the nurse include? (Select all that apply.) A. Limited alcohol intake B. Regular exercise program C. Decreased magnesium intake D. Reduced potassium intake E. Smoking cessation

A / B / E Rationale: Limited alcohol intake is correct. Clients who have hypertension should limit alcohol intake. Regular exercise program is correct. Clients who have hypertension should develop a regular exercise program to help reduce blood pressure. Decreased magnesium intake is incorrect. Low magnesium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Reduced potassium intake is incorrect. Low potassium intake is associated with hypertension and is not a lifestyle modification the nurse should include. Tobacco cessation is correct. Clients who have hypertension should have a goal of tobacco cessation because tobacco use exacerbates hypertension.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism?

A client who is 48 hr postoperative following a total hip arthroplasty R: The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? A. Weight gain of 2 lb. in 24 hr b. Increase of 10 mmhg in systolic BP c. Dyspnea with exertion d. Dizziness when rising quickly

A. Weight gain of 2 lb. in 24 hr Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a weight gain of 0.5 to 0.9 kg (1.1 to 2 lb) in 1 day. This weight gain is an indication of fluid retention resulting from worsening heart failure. The client should report this finding immediately.

A nurse is caring for a client who has endocarditis. Which of the following findings should the nurse recognize as a potential complication? A. Ventricular depolarization B. Guillain-Barre syndrome C. Myelodysplastic syndrome D. Valvular disease

D. Valvular disease Rationale: Valvular disease or damage often occurs as a result of inflammation or infection of the endocardium.

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect?

intention tremors

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching?

"I should remove the old twill ties after the new ties are in place." R: As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A nurse is teaching a client who has osteoporosis and has a new prescription for alendronate. Which of the following information should the nurse include in the teaching?

"Remain upright for 30 minutes after taking this medication."

A nurse is teaching a client and her family about the diagnosis and treatment of Alzheimer's disease. Which of the following statements should the nurse identify as an indication that the family understands the teaching?

"The medications that treat Alzheimer's disease can help delay cognitive changes."

A nurse is caring for a client who was admitted for a treatment of left-sided heart failure with intravenous loop diuretics and digitalis therapy. The client is experiencing weakness and an irregular heart rate. Which of the following actions should the nurse take first? A. Obtain clients current weight B. Review serum electrolyte values C. Determine the time of the last digoxin dose D. Check the clients urine output)

B. Review serum electrolyte values Rationale: Weakness and irregular heart rate indicate that the client is at the greatest risk for electrolyte imbalance, an adverse effect of loop diuretics. The first action the nurse should take is to review the client's electrolyte values, particularly the potassium level, because the client is at risk for dysrhythmias from hypokalemia.

A nurse is caring for a client in the first 8 hr following coronary artery bypass graft (CABG) surgery. Which of the following client findings should the nurse report to the provider? A. Mediastinal drainage 100 ml/hr b. Blood pressure 160/80 mm Hg C. Temperature 37.1° C (98.8° F) D. Potassium 4.0 meq/L

b. Blood pressure 160/80 mm Hg Rationale: The nurse should report an elevated blood pressure following a CABG because increased vascular pressure can cause bleeding at the incision sites.

A nurse is caring for a client who is being treated for HF and has prescriptions for furosemide. The nurse should plan to monitor for which of the following as an adverse effect of this medication? A. SOB b. Lightheadedness c. Dry cough d. Metallic taste

b. Lightheadedness Rationale: Furosemide can cause a substantial drop in blood pressure, resulting in lightheadedness or dizziness.

A client who has a new diagnosis of hypertension has a prescription for an ACE inhibitor. The nurse instructs the client about adverse effects of the medication. The client demonstrates an understanding of the teaching by stating that he will notify his provider if he experiences which of the following? A. Tendon pain b. Persistent cough c. Frequent urination d. Constipation

b. Persistent cough Rationale: A persistent cough is an adverse effect of ACE inhibitors. The client should report this finding to the provider and discontinue the medication.

a nurse is obtaining a urine specimen for culture and sensitivity for a client who has manifestations of a urinary tract infection. which of the following actions should the nurse take?

instruct the client to start urinating then pass the container into the stream

A nurse is planning care for a client who has. closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following interventions is the nurses priority?

maintain a PaCO2 of approximately 35 mmHg

A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

ulnar deviation

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure?

restlessness

A nurse in an emergency department is caring for a client who has sustained a fracture of the femur following a motor-vehicle crash. Which of the following images should the nurse recognize as a comminuted fracture?

several pieces

a nurse is caring for a client who has nephrotic syndrome and has been taking prednisone for 3 days. which of the following findings should the nurse report to the provider as an adverse effect of prednisone?

sore throat

a nurse is caring for a client following extracorporeal shock wave lithotripsy (ESWL) for the treatment of calcium phosphate kidney stones. which of the following actions should the nurse take?

strain all of the client's urine

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider?

Elevated temperature R: The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse is caring for a client who is recovering from a stroke and has right-sided homonymous hemianopsia. To help the client adapt to the hemianopsia, the nurse should take which of the following actions?

remind the client to look consciously at both sides of their meal tray

A nurse is caring for a client who has a history of angina and is schedules for a stress test at 1100. Which of the following statements by the client requires the nurse to contact the provider for possible rescheduling? A. "I'm still hungry after the bowl of cereal I ate at 7am." b. "I didn't take my heart pills this morning because the doctor told me not to." c. "I have had chest pain a couple of times since I saw my doctor in the office last week." d. "I smoked a cigarette this morning to calm my nerves about having this procedure."

d. "I smoked a cigarette this morning to calm my nerves about having this procedure." Rationale: Smoking prior to this test can change the outcome and places the client at additional risk. The procedure should be rescheduled if the client has smoked before the test.

a nurse is providing instructions for reducing the dietary intake of potassium to a client who has chronic kidney disease. which of the following client food selections indicates an understanding of the teaching?

one large raw apple

A nurse in an emergency department is assessing a client who reports sudden, severe eye pain with blurry vision. The provider determines that the client has primary angle-closure glaucoma. Which of the following medications should the nurse expect to administer?

osmotic diuretics via IV bolus

A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis?

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

a nurse in a women's health clinic is caring for a client who reports urinary urgency and dysuria. which of the following additional findings should the nurse identify as an indication of a urinary tract infection (UTI)?

pyuria

A nurse a caring for a client who is 72 hr postoperative following an above-the-knee amputation and reports phantom limb pain. Which of the following actions should the nurse take?

request a prescription for gabapentin for the client.

a nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition?

stroke the client's inner thigh

a nurse is performing admission assessment for a client who has severe chronic kidney disease (CKD). which of the following findings should the nurse expect?

tachypnea

A nurse in an emergency department is caring for a client who suddenly lost consciousness and fell while at home. The provider determines that the client had an embolic stroke. Which of the following medications should the nurse expect to adminster?

tissue plasminogen activator

a nurse is caring for a client immediately following a kidney transplant. the nurse should identify which of the following findings as a possible indication of a delay in functioning of the transplanted kidney?

urine output 30 mL/2 hr

a nurse is preparing to assess a client who received hemodialysis 1 hr ago. which of the following assessments should the nurse perform first?

vital signs

A nurse is caring for a client who is scheduled for a coronary artery bypass graft in 2 hr. Which of the following client statements indicates a need for further clarification by the nurse? A. "My arthritis is really bothering me because I haven't taken my aspiring in a week." b. "My blood pressure shouldn't be high because I took my BP medication this morning." c. "I took my warfarin last night according to my usually schedule." d. "I will check my BP because I took a reduced dose of insulin this morning."

C: "I took my warfarin last night according to my usually schedule." Rationale: Clients who are scheduled for a CABG should not take anticoagulants, such as warfarin, for several days prior to the surgery to prevent excessive bleeding.

A nurse is preparing a client for coronary angiography. The nurse should report which of the following findings to the provider prior to the procedure? A. Hemoglobin 14.4 g/dl b. History of peripheral arterial disease. c. Urine output 200 ml/4 hr. D. Previous allergic reaction to shellfish

D. Previous allergic reaction to shellfish Rationale: The contrast medium used for coronary angiography is iodine-based. Clients who have a history of allergic reaction to shellfish often react to iodine and might need a steroid or antihistamine prior to the procedure.

a nurse is planning care for a client who has acute glomerulonephritis. the nurse should plan to provide which of the following interventions?

weigh the client daily

A nurse is assisting The provider who is performing a thoracentesis at the bedside of a client. Which of the following action should the nurse take? (Select all that apply.)

•Wear goggles and mask during the procedure •Cleanse the procedure area with an anti-septic solution • Apply pressure to the site after the procedure

A nurse is caring for a client who has a retinal detachment. Which of the following findings should the nurse expect?

flashes of bright light

A nurse is performing a cardiac assessment on a client. Identify the area the nurse should inspect when evaluating the point of maximal impulse. (You will find "Hot Spots" to select in the artwork below. Select only the hotspot that corresponds to your answer.)

D Rationale: Inspection of this location allows the nurse to assess for pulsations of the apex area of the heart, which is considered the apical pulse or point of maximal impulse. The point of maximal impulse is located at the left fifth intercostal space in the midclavicular line.

A nurse is reviewing the laboratory results of several clients who have peripheral arterial disease. The nurse should plan to provide dietary teaching for the client who has which laboratory values? A. Cholesterol 180 mg/dl, HDL 70 mg/dl, LDL 90 mg/dl b. Cholesterol 185 mg/dl, HDL 50 mg/dl, LDL 120 mg/dl c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl d. Cholesterol 195 mg/dl, HDL 55 mg/dl, LDL 125 mg/dl

c. Cholesterol 190 mg/dl, HDL 25 mg/dl, LDL 160 mg/dl Rationale: These laboratory values for HDL and LDL are outside of the expected reference range and indicate that the nurse should provide dietary teaching to the client. The expected reference range for cholesterol is less than 200 mg/dL; for HDL is above 45 mg/dL for males and above 55 mg/dL for females; and for LDL is less than 130 mg/dL.