for sure know this

A nurse is reinforcing teaching with a client who is postoperative after having an ileostomy established. Which of the following instructions should the nurse include in the teaching?

Avoid medications in capsule or enteric form.

Treatment for circulatory overload:

-O2 therapy -vital sign monitoring -slow the rate of infusion -admin diuretics as prescribed

Which of the following is an indication of a pt at risk of developing a sodium imbalance?

-vomiting -diarrhea -enemas -diuretics

Diabetes foot care stuff to know:

-wash feet daily w/mild soap & warm water -test water temp 1st -nails cut straight across -no barefoot -lotion, but not between toes -use socks made of cotton only

Proper administration of peritoneal dialysis:

1. warm diasylate prior to infusing 2. should be clear-light yellow in color 3. maintain surgical asepsis of the catheter insertion site & when accessing the catheter 4. keep outflow bag lower than client's abd 5. reposition client if outflow/inflow is inadequate 6. milk catheter if clot forms

A nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the field (Select all that apply) A. provider drops a sterile instrument onto the near side of the sterile field B. nurse moistens a cotton ball with sterile normal saline and places it on sterile field C. procedure is delayed 1hr because the provider receives an emergency call D. nurse turns to speak to someone who enters through the door behind the nurse E. clients hand brushes against the outer edge of the sterile field

B, C, D

4 A nurse is assessing a client who is preoperative and reports an allergy to bananas. The nurse should recognize that the client is at risk for an allergic cross-reactivity to which of the following substances A. Povidone-iodine B. Adhesive tape C. Latex D. Anesthetics

C

A nurse is wearing sterile gloves in prep for performing a sterile procedure. Which of the following objects can the nurse touch without breaking sterile technique (Select all that apply) A. bottle containing sterile solution B. edge of sterile drape at the base of the field C. inner wrapping of an item on the sterile field D. irrigation syringe on the sterile field E. one gloved hand with the other gloved hand

C, D, E

A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease. The client becomes agitated and combative when the nurse approaches him. Which of the following actions should the nurse plan to take?

Calmly ask the client if he would like to listen to some music.

A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first?

Check the client's vital signs.

A nurse caring for a client at risk for increased intracranial pressure is monitoring the client for manifestations that indicate that the pressure is increasing. To do this, the nurse should check the function of the third cranial nerve by performing which of the following data-collection activities?

Checking pupillary responses to light

A nurse has removed a sterile pack from its outside cover and place it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first: A. closest to body B. right side C. left side D. farthest from body

D

Priority action following the placement of an NG tube?

get chest xray to confirm placement

A nurse is caring for a client who has multiple myeloma and has a WBC count of 2,200/mm3 . Which of the following food items brought by the family should the nurse prohibit from being given to the client?

Fresh fruit basket

A nurse is caring for an older adult client who has colon cancer. The client asks the nurse several questions about his treatment plan. Which of the following actions should the nurse take?

Help the client write down questions to ask his provider

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Hypertension

A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Lethargy

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

Maintain the client in Fowler's position.

A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?

Prevent bladder distention.

A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Oxygen saturation 80% Bicarbonate 28 mEq/L Which of the following interpretations of the ABG values should the nurse make

Respiratory acidosis

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure?

Sitting, leaning forward over the bedside table.

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Take temperature once a day

88 A nurse is caring for a client following a below-the-knee amputation. The client states. "My life is over." Which of the following responses should the nurse make? A. "Why do you think your life is over? " B. "You are upset. We can talk about this later." C. "Would you like to meet with another client who is an amputee?" D. "Most people can adjust following this surgery."

a

91A nurse is providing teaching to a client who has left sided heart failure. Which of the following manifestations should the nurse include in the teaching. A. Hacking cough B. neck vein distention c. ankle edema d. Anorexia

a

. 85 A nurse is providing dietary teaching to a client who has heart failure and a new prescription for a 2-g sodium diet. Which of the following client statements should the nurse identify as an understanding of the teaching? A. "I can season my foods with lemon juice." B. "I should us canned instead of frozen vegetables." C. "I can use baking soda when I bake." D. "I should use slat sparing while cooking."

a

12 A nurse is caring for a client who has been receiving total parental nutrition (TPN) for 1 week. For which of the following findings should the nurse notify the provider? A. Calcium level 11.5 mg/dL B. Serum albumin level 3.9g/dl C. Output 200 mL more than intake over the past 12 hr. D. Fasting blood glucose level 105 mg/dL

a

18 A nurse is performing skin cancer screening on a group of clients. Which of the following findings should the nurse Identify as an indication of melanoma?A. Flat lesion with irregular borders B. Raised lesion with a rolled borderC. Scaly lesion with the crusted appearance D. Reddened lesion with dilated blood vessels

a

2 A nurse is monitoring a client who is receiving 2 units packed RBCs. Which of the following manifestations indicates a hemolytic transfusion reaction? A. Chills B. Hypertension C. Bradycardia D. Back pain

a

23 A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea10 min after the infusion begins. Which of the following actions should the nurse take first ? A. Stop the infusion. B. Collect a urine sample. C. Check the client's vital signs. D. Administer oxygen to the client.

a

30 A nurse is preparing to perform ocular irrigation for a client following a chemical splash to the eye. Which of the following actions should the nurse plan to take first? A. Instill 0.9% sodium chloride solution into the affected eye. B. Administer proparacaine eye drops into the affected eye. C. Place a strip of PH paper onto the cul-de-sac of the affected eye. D. Collect information about the irritant that caused the injury.

a

32 A nurse is collecting data from a client who has toxoplasmosis and is HIV positive. Which of the following questions should the nurse ask to gather data about toxoplasmosis? A. "Do you have any household pets, such as a cat?" B. "Was anyone in your family recently exposed to a viral disease?" C. "Are your immunizations current?" D. "Have you a been out of the country in the past 30 days?"

a

37 A nurse is caring for a client who has a newly inserted chest tube. The nurse should clarify which of the following prescriptions with the provider A. Vigorously strip the chest tube twice daily. B. Notify the provider when tiddling ceases. C. Administer morphine 2 mg IV bolus every 3hr PRN for pain. D. Assist the client out of bed three times daily

a

54 A nurse is reviewing the medical record of a client to identify risk factors for colorectal cancer. The nurse should identify which of the following findings as increasing the client's risk? A. History if Crohn's disease B. BMI of 24 C. Diet high in fiber D. Age 46 years

a

70. A nurse is reviewing a client's cardiac monitor for dysrhythmias. Which of the following findings should the nurse identify as an indication for the placement of a permeant peacemaker? A. Complete AV block with rates slower than 40/mm B. Sinus tachycardia with rates faster than 80/mm C. Vasovagal bradycardia without syncope D. Asymptomatic second-degree AV block

a

86 A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? A. Obtain a stool specimen with gloves B. Wash hands with alcohol-based hands rub C. Clean surfaces with chlorhexidine D. Place the client in a protective environment

a

13 A nurse is setting up a sterile field before preforming a dressing change on a client who is postoperative. Which of the following actions should the nurse plan to take to maintain the sterile field? (Select all that apply) A. Grasp 2.5 cm (1 in) of the outer edge to open the surgical wrapB. Open the first flap of the sterile package toward the nurse's bodyC. Place a surgical pack with a sterile drape on the work surfaceD. Select a work surface at the nurse's waist level E. Apply sterile gloves before opening the pack

a, c

Priority action for symptomatic sinus bradycardia:

atropine & isoproterenol then pacemaker

19 A nurse is caring for a client who has diabetes insipidus. Which Of the following medications should the nurse plan to administer. A. Lithium B. DesmopressinC. Regular insulin D. Furosemide

b

3 A nurse is caring for a client who had a total hip arthroplasty. Which of the following actions should thenurse take to prevent hip dislocation? A. Remove the wedge device when turning B. Place two bed pillows between the legs when in bed C. Encourage the client to lean forward when attempting to stand D. Elevate the knees higher than the hips when sitting

b

33 A nurse in a long-term care facility is caring for a bedridden client. Which of the following findings should alert the nurse to a potential complication of the client's immobility? A. Polyuria B. Confusion C. Blurred vison D. Diarrhea

b

34 A nurse is checking a client's ventilator settings. The nurse should understand that positive endexpiratory pressure has which of the following purposes? A. To deliver a set tidal volume B. To prevent alveolar collapse C. To control the rate of ventilations D. To provide positive airway pressure during inspiration

b

39 A nurse is providing discharge teaching for a client who has osteomyelitis in the left leg. Which of the following findings should the nurse identify as requiring a referral? A. The client has a prescription for a furosemide B. The client has a prescription for long term IV antibiotic therapy C. The client has a WBC count of 20,000/mm3. D. The client has type 2 diabetes mellites and HDA1C of 5 %.

b

43 A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? A. Fever B. Cloudy effluent C. Increased heart rate D. Generalized abdominal pain

b

45 A nurse is assessing a client who has acute pancreatitis and has been receiving a total parenteral nutrition for the past 72hr. Which of the following findings requires the nurse to intervene? A. Capillary blood glucose level 164 mg/dL B. Crackles in bilateral lower lobes C. WBC count 13,000/mm3 D. Right upper quadrant pain

b

55 A nurse is completing discharge teaching with a client who has a peripherally inserted central catheter (PICC) line in the left arm. Which of the following instructions should the nurse include in the teaching? A. Do not elevate the arm above the level of the heart B. Use a 10-mL syringe to flush the line C. Change the catheter dressing daily D. Clean the insertion site using 20 mL of hydrogen peroxide

b

57 A nurse is caring for a client who has developed a heart rate of 38/min and reports tremors and feeling faint. Which of the following medications should the nurse anticipate administering? A. Digoxin B. Atropine sulfate C. Diltiazem D. Magnesium sulfate

b

64 A nurse is providing discharge teaching to a client who has heart failure and instructs him to limit sodium intake to 2g per day. Which of the following statements by the client indicates an understanding of the teaching? A. "I can season my food with garlic and onion salts." B. "I can have a frozen fruit juice bar for dessert." C. "I can have mayonnaise on my sandwich." D. "I can drink Vegetable juice with a meal."

b

7 A nurse is preparing to administer peritoneal dialysis to a client. Which of the following actions should the nurse take? A. Chill the dialysate before administration B. Hang the drainage bag below the client's abdomen C. Place the client in high-Fowlers position D. Use clean technique to access the catheter

b

97. a nurse is caring for a client following a bronchoscopy. Which of the following actions should the nurse take first? A. Inform the client they might experience a low grade fever B. Check the clients gag reflex C. Instruct the client to report bleeding D. Provide the client with sips of water

b

1 A nurse is assessing for early signs of compartment syndrome for a client who has a short-leg fiberglasscast. Which of the following findings should the nurse expect? A. Capillary refill less than 2 seconds B. Bounding distal pulses C. Intense pain with movement d. Erythema of the toes

c

14 A nurse is an emergency department is preparing a client for emergency surgery. The clients blood alcohol level is 180mg/dL. Which of the following actions is the nurse's priority? A. Obtain consent for surgery B. Insert an indwelling urinary catheterC. Insert an NG tube D. Apply antiembolic stoking's

c

21 A nurse is providing discharge teaching to a client who has chronic urinary tract infections. The client has a prescription for ciprofloxacin 250 mg PO twice daily. Which of the following instructions should the nurse include in the teaching? A. Monitor heart rate once daily. B. Take a laxative to prevent constipation. C. Drink 2 to 3 L of fluids daily. D. Take an antacid 30 min before taking the medication.

c

42 A nurse is caring for a client following a total knee arthroplasty. The client reports a pain level 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 range-of-motion exercises to the client's knee

c

58 A nurse is reviewing the medical record of a client who has pneumonia. Which of the following serum laboratory values should the nurse expect? A. Hematocrit 35% B. Sodium 130 mg/dL C. WBC count 15,000/mm3 D. BUN 8 mg/dL

c

60 A nurse is caring for a client who has tuberculosis and is taking rifampin. The client reports that her saliva has turned red orange in color. Which of the following responses should the nurse make? A. "You will need to increase your fluid intake to resolve this problem." B. "This finding may indicate possible medication toxicity." C. "This is an expected adverse effect on this medication." D. "Your provider will prescribe a different medication regimen.''

c

67. A nurse is planning care for a client who is receiving heparin IV to treat a pulmonary embolism. Which of the following medications should the nurse plan to have at the bedside? A. Acetylcysteine B. Flumazenil C. Protamine sulfate D. Vitamin K

c

72 A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first? A. Increase the client's fluid intake. B. Administer PRN pain medication C. Check the client's urine output D. Reposition the client in bed

c

75 A home health nurse is assessing the home environment of a client who has cystic fibrosis. Which of the following equipment should the nurse plan to recommend? A. Peak flow meter B. NG tube with suction apparatus C. Chest physiotherapy vest D. Chest tube with a drainage system

c

77 A nurse is assessing a client who has a serum sodium level of 120 mEq /L. Which of the following findings should the nurse expect? A. Decreased bowel sounds B. Increased central venous pressure C. Confusion D. Hyperreflexia

c

8 A nurse is preforming a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? A. Inability to smell B. loss of peripheral vision C. Disequilibrium with movement D. Deviation of the tongue from midline

c

93A nurse is reviewing laboratory results for 4 clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon i. HCT 42% ii. INR of 1.6 c. pallets 95.000/MM3 e. WBC count 8.000 /MM3

c

96 A home health nurse is providing care to an older adult client during the winter. During an in-home visit The nurse notes that the thermostat is set to 12.8 degrees Celsius (55 degrees Fahrenheit ) . The client tells the nurse I keep the heat set low because I cannot afford to pay the bill. Which of the following actions should the nurse take A. contact the clients family members to tell them the client's financial status B. Recommend staying at a local shelter until the client can afford the bill C. Contact the local Department of Health and Human Services for the client D. Provide the client with written information about the degrees of hypothermia

c

44 A nurse in a emergency department is caring for a client who is to receive tissue plasminogen activator (TPA) for the treatment of an ischemic stroke. In which order should the nurse complete the following actions? (Move the steps into the box on the right, placing them into the selected order of performance. Use all the steps.) a- Check for contraindications. b- Transfer the client to the CCU c- Weigh the client d- Administer the TPA

c, a, d, b

Which symptoms indicate adverse effects from the blood transfusion?

chills fever lower back pain tachycardia flushing hypotension chest tightening tachypnea nausea anxiety

17 A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the first sign of deteriorating neurological status?A. Pupillary dilationB. Cheyne-Strokes respirations C. Decorticate posturingD. Altered level of Consciousness

d

22 A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client? A. "List some ways you can cope with the stress of your illness" B. "Name a few things you will change about your diet." C. "Tell me why it's important to have your CD4+ count checked" D. "Describe your daily medication schedule."

d

25 A nurse is caring for a client who has bladder cancer and a WBC count of 900/mm3. Which of the following actions should the nurse take? A. Use contact isolation while providing care. B. Move the client to a negative pressure room. C. Apply pressure to venipuncture pressure room. D. Instruct the client to avoid eating raw fruit.

d

26 A nurse is reviewing the medical record of a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report to the provider? A. Reports pain of 4 on a scale from 0 to 10 when coughing B. WBC count 8,400/mm3 C. Serosanguineous exudate noted on dressing change D. Hemoglobin 10 mg/ dL

d

35 A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Client report of pain at the incision site B. Loose tracheal secretions C. Hypoactive bowel sounds D. High-pitched sound on inspiration

d

38 A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the pan of care? A. Instruct the client to avoid lifting the right arm for 72hr B. Check blood pressure in the right arm C. Insert a saline lock into a site 10 cm (4 in) distal to the graft D. Palpate the site for a thrill

d

40 A nurse is caring for a client who has an IV in the left forearm and whose infusion pump has alarmed several times. Which of the following actions should the nurse take first? A. Ensure the tubing connections are secure B. Reposition the client's left arm C. Flush the IV catheter D. Check the IV site for redness

d

50 A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom D. Place a large-face clock in the client's bedroom

d

51 A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? A. A client who has peritonitis reports generalized abdominal pain. B. A client who is postoperative reports incisional pain. C. A client who has angina reports substernal chest pain. D. A client who has pancreatitis reports pain in the left shoulder.

d

52 a nurse is reviewing the medical record of a client who is to undergo open heart surgery. Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin? A. Rheumatoid arthritis B. Thalassemia C. COPD D. Thrombocytopenia

d

59 A nurse in an emergency department is caring for a client who has sinus bradycardia. Which of the following actions should the nurse take first? A. Prepare the client for temporary pacing B. Initiate IV fluid therapy for the client C. Administer atropine to the client D. Measure the client's blood pressure

d

61 A nurse is providing discharge teaching about foot care to a client who is newly diagnosed with type 1 diabetes mellitus. Which of the following information should the nurse include? A. Inspect the feet every other day B. Apply lotion between the toes. C. Soak the feet twice a day D. Trim toenails straight across

d

62 A nurse is reviewing the following ABG results for a postoperative client pH 7.27.PaCO2 49 mm Hg HCO3 22mEq/L. The nurse should interpret the findings as which of the following imbalances? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

d

65. A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take? A. Allow visitors to hold the clients hand. B. Leave the door to the clients room open C. Place the dosimeter film badge on the clients door D. Wear a lead around the apron when providing client care

d

66. A nurse is a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching A. Limit engaging in sport activities that can cause bruising B. Decrease intake of fresh fruits and vegetables C. Limit socializing in large crowds D. Decrease time spent outdoors

d

69. A nurse is providing discharge teaching to a client who has ileostomy. Which of the following client statements indicates an understanding of the teaching. A. "I will empty my bag when it is full." B. "I will take a laxative when I am constipated." C. "I will eat a high fiber diet." D. "I will expect my stools to be loose."

d

73 A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect? A. Hypermagnesemia B. Diplopia C. Hyperthermia D. Cachexia

d

76 A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock? A. Urine output 45 ml/hr. B. PaCO2 37 mm Hg C. Capillary refill 1.5 seconds D. Potassium 5.2 mEq/L

d

78 A nurse is assessing a client who is receiving valsartan to treat heart failure. Which of following findings should the nurse identify as an indication that the medication is effective? A. Increased heart rate B. Decreased urinary output C. Increased potassium level D. Decreased blood pressure

d

84 A nurse is caring for a client who understands a prescribed surgical procedure but cannot read or write. Which of the following actions should the nurse take? A. Allow the client to sign the consent with an X B. Notify the surgical team that the client is unable to sign the content C. Inform a family member of the need to sign the consent D. Contact the client's power of attorney to sign the consent

d

87 A nurse is preparing to administer a unit of packed RBCs over 1 hr. Which of the following actions should the nurse plan to take? A. Initiate venous access with a 21-gauge needle B. Obtain the client's first set of vital signs 1 hr after initiating the transfusion C. Administer the unit of packed RBCs over 1 hr. D. Use Y tubing with 0.9% sodium chloride when administering the transfusion

d

88.A nurse is contributing to the plan of care for a client who is postoperative following peritoneal lavage for peritonitis. The client has a nasogastric tube to low-intermittent suction and closed- suction drains in place. Which of the following interventions should the nurse include in the plan? 1) Irrigate the nasogastric tube with tap water. 2) Mark abdominal girth once daily. 3) Ambulate the client twice daily. 4) Place the client in a high Fowler's position.

d

Which assessment finding indicates increased intracranial pressure?

decreased level of consciousness

Which electrolyte imbalance increases the risk for digoxin/digitalis/digibind toxicity?

hypokalemia

Which of the following indicates the client's understanding about their diagnosis of diabetes and plan for foot care?

i will wear cotton socks

Priority assessment for hypokalemia:

pts taking digoxin ineffective respirations or diminished breath sounds