FUNDS HESI

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?

"I'm glad I don't have to lie still for this procedure."

The nurse is giving client instructions over the telephone about preparing for a mammography. The nurse should make which statement to the client?

"If possible, avoid using underarm deodorant on the day of the test."

A nursing instructor asks a nursing student about a client admitted with tuberculosis (TB). What comment by the student indicates that there is a need for further teaching?

"It is a fast-growing infectious disease."

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation?

Requires nasogastric suction

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance?

Respiratory acidosis from inadequate ventilation

Arterial blood gas analysis yields the following results: pH 7.48 (7.48), Paco2 32 mm Hg (32 mm Hg), Pao2 94 mm Hg (94 mm Hg), HCO3 level 24 mEq/L (24 mmol/L) for a client seen in the health care clinic. The nurse interprets that the client has which acid-base disturbance?

Respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client?

Respiratory depression

The nurse is reviewing the results of the electrolyte panel for a client seen in the health care clinic. The nurse determines that the client's potassium level is normal if which value is noted?

4.0 mEq/L (4.0 mmol/L)

A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal?

400 mg/dL (4.0 g/L)

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum protein level is normal if which value is noted on the laboratory report?

7.0 g/dL (70 g/L)

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report?

8600 mm3 (8.6 × 109/L)

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's fasting serum glucose level is normal if which value is noted?

99 mg/dL (5.5 mmol/L)

A fasting blood glucose screening test is performed on a pregnant client. The results indicate that the blood glucose level is 140 mg/dL (8 mmol/L). The nurse should anticipate that which treatment measure would most likely be prescribed next for the mother?

A 3-hour glucose tolerance test

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia?

A client admitted 6 hours ago with a 40% burn injury

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit?

A client with an ileostomy

The nurse is providing information to a client scheduled for a lumbar puncture. Which information should the nurse provide to the client?

A signed informed consent form will be required.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the emergency response plan specific to the facility.

An assistive personnel (AP) is caring for a client who has an indwelling urinary catheter. Which action by the AP would indicate the need for further instruction in the care of the client?

Allowed the drainage tubing to rest under the leg

A client is admitted with possible hepatic encephalopathy. The nurse determines that which noted serum laboratory abnormality supports this suspicion?

Ammonia level of 98 mcg/dL (60 mcmol/L)

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present?

An increase in blood pressure and increased respirations

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3-

The nurse provides instructions to a client who is scheduled for an electroencephalogram. Which statement by the client indicates a need for further instruction?

"All medications need to be withheld on the day of the test."

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

Which statement should the nurse initially make to a client who is anxious about having a magnetic resonance imaging test?

"Can you tell me what you know about this test?"

A client is donating blood for a family member who is having surgery. The nurse tells the client that an indirect Coombs' test will be performed on the blood. The client asks the nurse about the purpose of the test. Which response should the nurse provide to the client?

"The test detects circulating antibodies against red blood cells (RBCs)."

The nurse is explaining to a client what electroencephalography (EEG) involves. What response by the client indicates that further teaching is needed?

"This test is minimally invasive."

The nurse is performing a change-of-shift assessment on a client. The client had an arterial blood gas specimen drawn during an admission workup on the previous day and has a hematoma at the puncture site. What is the priority nursing intervention?

Apply a warm compress.

When communicating with a client who speaks a different language, which best practice should the nurse implement?

Arrange for an interpreter to translate.

The nurse checks the laboratory results of a serum medication level assay for a newly admitted client with a history of heart failure taking digoxin 0.125 mg orally daily. Which value would indicate a therapeutic level?

0.6 ng/mL (0.76 nmol/L)

The nurse is explaining an upper gastrointestinal series to a client and provides the client with the preprocedure and postprocedure instructions. The nurse informs the client that after this procedure, the stools can be expected to remain white for what time period?

1 to 2 days

The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply.

1. Bipolar disorder 2.Aggressive behavior 3. Attention-deficit hyperactivity disorder (ADHD) 4. Sleep problems

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply.

1. Blood transfusions 3. Bleeding or hemorrhage 5. Ingestion of potassium in medications 6.Failure to restrict dietary potassium

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Segmented neutrophils 40% (0.40) 4. White blood cells, 3000 mm3 (3.0 × 109/L)

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

1. Tall peaked T waves 2. Widened QRS complexes

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the urine specific gravity is normal if which value is noted on the laboratory results?

1.019

A client has a urine specific gravity level of 1.034. The nurse determines that which causes or conditions can be related to this level? Select all that apply.

1.Glycosuria 2.Albuminuria 3.Dehydration

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

1.Nausea 2.Confusion 3.Tachycardia 4.Lightheadedness

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the serum lipase level is normal if which value is noted on the laboratory report?

100 U/L (100 U/L)

The nurse just completed an assessment and reviewed the laboratory test results for an adult female client seen in the clinic. The client complains of being tired. The nurse determines that the hemoglobin level is normal if which value is noted on the laboratory report?

14 g/dL (140 mmol/L)

The nurse is reviewing the results of the electrolyte panel for a client seen in the clinic. The nurse determines that the client's sodium level is normal if which value is noted?

142 mEq/L (142 mmol/L)

The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse reports to the client that the total cholesterol level is within the recommended guidelines if which value is noted on the laboratory report?

146 mg/dL (4 mmol/L)

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.25 mmol/L)

A client has been admitted to the hospital for gastroenteritis and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value?

15 mg/dL (5.4 mmol/L)

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the client's platelet level is normal if which value is noted?

160,000 mm3 (160 × 109/L)

The nurse in the respiratory care unit completes a lung assessment and reviews the laboratory results of a serum medication level assay for a client with obstructive pulmonary disease receiving theophylline. The nurse determines that a therapeutic medication level has been achieved by indication of which value?

18 mcg/mL (100 mcmol/L)

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed?

Asks the athletes to take a salt tablet before football practice

The nurse is caring for an 8-month-old infant. A urinalysis has been prescribed, and the nurse plans to collect the specimen. Which method should be used for urine collection in an infant?

Attaching a urine collection device to the infant's perineum

The nurse is collecting a 24-hour composite urine specimen. Besides electrolytes and glucose, what other components are measured? Select all that apply.

2.Protein 3.Minerals 4.Creatinine 5.17-ketosteroids 6.Catecholamines

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

2.Raisins 3.Potatoes 4.Cantaloupe 6. Strawberries

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse determines that the blood urea nitrogen (BUN) level is normal if which value is noted on the laboratory report?

20 mg/dL (7.1 mmol/L)

The nurse is caring for a client who had intracranial surgery and is now suspected of having developed diabetes insipidus (DI). What initial prescription should the nurse expect from the primary health care provider (PHCP)?

24-hour fluid intake and output without restricting food or fluid intake

A client with a history of heart failure is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?

3.2 mEq/L (3.2 mmol/L)

The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding?

Ceftriaxone

The nurse is preparing to care for a client following a gastroscopy procedure. Which priority component should the nurse include in the nursing care plan?

Check the gag reflex by using a tongue depressor to stroke the back of the client's throat.

A client is to undergo pleural biopsy at the bedside. When planning for any potential complications of the procedure, the nurse should have which item(s) available at the bedside?

Chest tube and drainage system

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid?

Client with an ischemic stroke

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit?

Client with diabetes insipidus

A quantitative 72-hour fecal fat collection is prescribed by the primary health care provider. How should the nurse instruct the client to prepare for the specimen collection?

Consume a high-fat diet for 3 days before the test.

The nurse is reviewing the laboratory test results for a client seen in the health care clinic. The nurse notes that the red blood cell (RBC) count is increased. The nurse interprets that this finding may be related to which condition or treatment?

Corticosteroid therapy

The nurse is caring for a client with suspected kidney failure. A 24-hour urine specimen is prescribed. What value measures overall kidney function?

Creatinine clearance levels

The nurse notes that the primary health care provider has documented a suspected diagnosis of herpes zoster in the client's chart. The nurse should prepare the client for which diagnostic test to confirm this diagnosis?

Culture of the lesion

A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?

Custard

The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium?

Decreased blood pressure

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client should expect to note which signs/symptoms?

Decreased respiratory rate and depth

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply.

Dehydration Physiological stress Decreased blood volume

The nurse is preparing an intravenous (IV) set before starting the infusion. After removing the cap from the IV tubing port on the IV bag, the nurse removes the cover from the tubing insertion spike but then touches the spike with a finger. What should the nurse do next?

Discard the IV tubing and use a new set for the infusion.

A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?

Encourage the client to discuss the use of an herbal substance with the primary health care provider (PHCP).

The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed?

Glipizide

The nurse prepares the client for irrigation of an abdominal wound. After preparation, the nurse would appropriately don which item to perform the procedure? Click on the Question Video button to view a video showing preparation procedures.

Gloves, gown, and goggles

Contact precautions are initiated for a client with a health care-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?

Gloves, gown, goggles, and a mask or face shield

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery?

Have the client void immediately before going into surgery. 4.

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test should the nurse assess?

Hepatitis B surface antigen (HBsAg)

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

A nursing student is assigned to an adult client who is scheduled for bone marrow aspiration. The coassigned nurse asks the nursing student about the possible sites that could be used for obtaining the bone marrow. The student demonstrates understanding of the procedure by identifying what as the correct aspiration site?

Iliac crest

The nurse is providing instructions to a client who has had a bone scan. The nurse should instruct the client to take which measure?

Increase fluid intake for the next 24 to 48 hours.

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication?

Increasing restlessness

The nurse is reviewing the laboratory test results for a client with a diagnosis of leukemia. The nurse notes that the granulocyte count is decreased. The nurse interprets that the client is at risk for which condition?

Infection

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion?

Integumentary output

A client's laboratory test results reveal an increased transferrin level and a decreased iron-binding capacity. The nurse interprets that these laboratory results are compatible with anemia because of which problem?

Iron deficiency

The nurse is reviewing the laboratory test results for a client seen in the health care clinic and notes that the red blood cell (RBC) count is decreased. The nurse determines that this finding occurs in which condition?

Iron deficiency

A client experiencing metabolic acidosis is to be admitted to the nursing unit. The nurse plans care knowing that what reaction is the most powerful regulator of acid-base balance?

Kidney

The nurse is teaching a client about an upcoming colonoscopy procedure. The nurse would include in the instructions the fact that the client will be placed in which position for the procedure?

Left Sims'

A client is scheduled to have a needle liver biopsy. During the procedure, the nurse should instruct the client to take which action?

Lie supine with the right arm over the head.

An anxious preoperative client is at risk for developing respiratory alkalosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Lightheadedness and paresthesias

The emergency department nurse is caring for a client with a suspected diagnosis of meningitis. The nurse should prepare the client for which test to confirm the diagnosis?

Lumbar puncture

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in bed on the unaffected side

The client is suspected of having a skeletal muscle disorder. Which isoenzyme value reported with the creatine kinase (CK) level should the nurse assess for elevation?

MM

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Margarine Cream cheese Luncheon meats

A client with diabetes mellitus has a blood glucose level of 644 mg/dL (35.7 mmol/L). The nurse plans care knowing that the client is at risk for the development of which type of acid-base imbalance?

Metabolic acidosis

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder?

Metabolic acidosis

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse knows that the purpose of this type of breathing is to correct what imbalance?

Metabolic acidosis

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance?

Metabolic alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply.

Nausea Confusion Tachycardia Lightheadedness

The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population?

PTSD

The nurse is caring for a client who is receiving immunosuppressant therapy, including corticosteroids, after renal transplantation. The nurse should plan to carefully monitor results of which laboratory test for this client?

Blood glucose level

The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet?

Bowel sounds

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse should plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis?

Potassium

The nurse is monitoring a client who is attached to a cardiac monitor and notes the presence of prominent U waves. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Potassium 3.0 mEq/L (3.0 mmol/L)

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

Potassium level of 3.0 mEq/L (3.0 mmol/L)

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld?

Prednisone

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

Preventing and recognizing hyperglycemia

The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client?

Private room or cohort client

The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client?

Private room or cohort client

The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention?

Private room, gown, gloves, and face shield

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse should take which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? Click on the Question Video button to view a video showing preparation procedures.

Pulling up and releasing the skin on the sternal area

A client with acquired immunodeficiency syndrome is suspected of having cutaneous Kaposi's sarcoma. The nurse should prepare the client for which test to confirm the presence of this type of sarcoma?

Punch biopsy of the cutaneous lesions

A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription?

Question the primary health care provider about whether a portable chest radiograph may be obtained.

The clinic nurse has obtained a throat culture specimen from a client in whom a throat infection is suspected. The nurse calls the laboratory to have the specimen picked up and is told that the laboratory is short staffed and the laboratory assistant will pick up the specimen in 2 hours. Which is the appropriate nursing action?

Refrigerate the specimen.

A magnetic resonance imaging (MRI) study is prescribed for a client with a suspected brain tumor. Which priority action should the nurse include in the client's plan of care to ensure safety?

Remove all metal-containing objects from the client.

A client has a prescription for a set of arterial blood gas (ABG) samples to be drawn on room air. The client currently is receiving oxygen by nasal cannula at a delivery rate of 3 L/min. After reading the prescription, the nurse should take which action?

Remove the nasal cannula for 15 minutes; then have the ABG samples drawn.

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented?

Requires nasogastric suction

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance?

Respiratory acidosis

The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31 (7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client?

Respiratory acidosis

The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, PaCO2 of 58 mm Hg, PaO2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30 (7.30), a Paco2 of 58 mm Hg (58 mm Hg), a Pao2 of 80 mm Hg (80 mm Hg), and an HCO3 of 26 mEq/L (26 mmol/L). The nurse should interpret this to mean that the client has which acid-base disturbance?

Respiratory acidosis

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mmol/L), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition?

Respiratory acidosis without compensation

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition?

Respiratory acidosis, uncompensated

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg (30 mmol/L), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition?

Respiratory alkalosis, compensated

The nurse reviews a client's arterial blood gas values and notes a pH of 7.50 (7.50), a Paco2 of 30 mm Hg (30 mm Hg), and an HCO3 of 25 mEq/L (25 mmol/L). The nurse should interpret these values as an indication of which condition?

Respiratory alkalosis, uncompensated

The nurse is conducting a community surveillance study for the purpose of communicable disease control. The nurse knows that performing an active surveillance method of assessment is best for what reason?

Results in detection of a more accurate number of cases

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action?

Resume full activity level.

A client is experiencing chronic insomnia. The nurse interprets this to mean that which areas of the brain are involved?

Reticular activating system and cerebral hemispheres

The nurse obtains a prescription from a primary health care provider to restrain a client and instructs an assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP?

Safely securing the safety device straps to the side rails

A clinic nurse is reviewing the record of a client with a suspected diagnosis of pernicious anemia. The nurse anticipates that which diagnostic test will be prescribed by the client's primary health care provider?

Schilling test

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution?

Seizure precautions

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

Serous drainage

The nurse is reviewing the laboratory blood test results for a client and notes that the hemoglobin S (Hgb S) value is elevated. The nurse determines that this laboratory finding is associated with which condition?

Sickle cell anemia

The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?

Smoked salami

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse should select which solution to use for the nasogastric tube irrigation?

Sodium chloride

The nurse explaining the procedure of indium imaging to a client with a bone infection should include which information?

Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

A man is admitted to the hospital with the diagnosis of urethritis secondary to chlamydial infection. What precaution should the nurse implement for this client?

Standard

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that 3 enemas have been administered and the client is still passing brown, liquid stool. What should the RN instruct the AP to do?

Stop administering the enemas until the primary health care provider (PHCP) is notified.

A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L (40 mmol/L). How should the nurse interpret this finding?

Suggestive of CF

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Summer squash

An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action?

Support the client's decision not to receive a blood transfusion.

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action should the nurse take?

Take no action

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

Tall peaked T waves Widened QRS complexes

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?

Teach the client and family about the need for hand hygiene.

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process?

Telling the infant's aunt, who is pregnant, that it is acceptable to visit the infant

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings should be anticipated in this client? Select all that apply.

Tetany Hypotension Prolonged QT interval Positive Chvostek's sign

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control?

The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?

The client who is taking diuretics

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?

The client with kidney disease and a 12-year history of diabetes mellitus

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur?

The client's arterial blood gas results will reflect acidosis.

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. How should the nurse describe this test to the client?

The dye injected may cause a warm, flushing sensation.

The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete?

The history

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?

The passage of flatus

A client is scheduled for a Papanicolaou (Pap) smear at the next scheduled clinic visit. The nurse provides instructions to the client regarding preparation for this test. Which statement should the nurse include in the teaching?

The test is painless.

A client is about to undergo a lumbar puncture (LP). The nurse places the client in a side-lying position, with legs pulled up and head bent down onto the chest for which purpose?

To open the spaces between the vertebrae

A client is scheduled for a test to detect kidney tumors or cysts. What test is considered safest for the client?

Ultrasonography

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment?

Urine specific gravity of 1.032

The nurse is reviewing an adult male's serum creatinine level of 4.0 mg/dL (353 mcmol/L). What does this level indicate?

Very high, indicating severe renal failure

The home health nurse visits a client with suspected scabies. Which precaution should the nurse institute during the assessment of the client?

Wear a gown and gloves.

The nurse prepares to give a bath and change the bed linens of a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which would the nurse incorporate into the plan during the bathing of this client?

Wearing a gown and gloves

A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client?

White blood cell (WBC) count of 2000 mm3 (2 × 109/L)

A client returns to the nursing unit after undergoing an esophagogastroduodenoscopy (EGD). Which is the appropriate nursing intervention?

Withhold oral fluids until the client's gag reflex has returned.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg

The home care nurse visits a child recently discharged from the hospital with a diagnosis of hepatitis A virus (HAV) infection. The mother asks the nurse when the child can return to school. The nurse should make which response to the mother?

"One week after the onset of jaundice."

The clinic nurse has provided instructions to a client who will be reporting to the laboratory the next morning to have blood drawn for a complete blood cell count. Which statement made by the client indicates an understanding of the preparation for this laboratory test?

"There is no special preparation for this test."

The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply.

-It is a painless test. -Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed.

The nurse is caring for a client with metabolic alkalosis. The nurse plans care knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply.

Cardiac Nervous Neuromuscular

The nurse is caring for a client with newly diagnosed human immunodeficiency virus (HIV). Besides preventing the transmission of the disease, what are the goals of medication therapy? Select all that apply.

1. Decreasing the viral load 2.Delaying disease progression 5. Maintaining or increasing CD4+ T cell counts 6.Preventing HIV-related symptoms and opportunistic diseases

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse that an interpreter is needed. Which is the best action for the nurse to take?

Page an interpreter from the hospital's interpreter services.

While giving care to a client with an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

Potatoes Raisins Cantaloupe Strawberries

The ambulatory care nurse is preparing a client who is scheduled for a liver biopsy. The nurse reviews the client's record and expects to note which laboratory results documented in the client's chart?

Prothrombin time

The nurse participating in a health fair is setting up a booth on prevention of human immunodeficiency virus (HIV) transmission. A poster is planned that will list sexual behaviors in 1 of 2 columns, "safe" and "not safe." Which behavior should the nurse place in the "not safe" column?

Use of natural skin condoms

The nurse is preparing to insert an intravenous (IV) angiocatheter into a client's inner forearm. Before cannulating the vein, what motion will the nurse implement to cleanse the site?

Using a circular motion from the center outward

A client is diagnosed with respiratory alkalosis induced by gram-negative sepsis. The nurse should plan to carry out which prescribed measure as the most effective means to treat the problem?

Administer prescribed antibiotics.

The nurse is caring for a client who is going to have arthrography with a contrast medium. Which assessment by the nurse would be of highest priority?

Allergy to iodine or shellfish

The nurse is preparing a client who is scheduled to undergo cerebral angiography. The nurse should assess the client for which finding?

Allergy to iodine or shellfish

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?

Assess the patency of the airway.

The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client?

Avoid frequent douching.

The nurse is providing instructions to a client who is scheduled for a hepatobiliary scintigraphy (HIDA) scan. What should the nurse instruct the client to do?

Avoid oral intake except for water on the day of the procedure.

The nurse is caring for a client with acute viral hepatitis A who resides in a group home. Which outcome indicates that the most important goal has been achieved?

Avoids transmitting the virus to others in the group home

The nurse is scheduling diagnostic tests for a client. Which of the diagnostic tests prescribed should be performed last?

Barium swallow

The nurse creates a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included?

Bed rest with elevation of the affected extremity

The nurse is preparing to care for a client who has returned to the nursing unit after cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity after the procedure?

Bed rest with head elevation no greater than 30 degrees

The nurse is preparing to care for a client who has returned to the nursing unit following cardiac catheterization performed through the femoral vessel. The nurse checks the primary health care provider's (PHCP's) prescription and plans to allow which client position or activity following the procedure?

Bed rest with head elevation no greater than 30 degrees

Which car safety device should be used for a child who is 8 years old and 4 feet tall?

Booster seat

A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?

Call the Poison Control Center.

The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first?

Complaints of pain associated with numbness and tingling in both feet

A client with acute glomerulonephritis has had a urinalysis sample sent to the laboratory. The report reveals the presence of hematuria and proteinuria. The nurse interprets these results as which condition?

Consistent with glomerulonephritis

The nurse is reviewing the arterial blood gas analysis results for a client in the respiratory care unit who is receiving nasal oxygen and notes a pH of 7.38 (7.38), Paco2 of 38 mm Hg (38 mm Hg), Pao2 of 86 mm Hg (86 mm Hg), and HCO3 of 23 mEq/L (23 mmol/L). What action should the nurse take in response to these results?

Continue monitoring the client.

A client is undergoing a series of diagnostic tests. The laboratory results indicate an increased blood urea nitrogen (BUN) to creatinine ratio. The nurse determines that which potential conditions could contribute to these results? Select all that apply.

Dehydratoin Catabolic state high-protein diet Obstructive uropathy

A client is scheduled for an intravenous pyelogram. Before the test, which is the priority nursing action?

Determine a history of iodine allergy.

The nurse working in a same-day procedure unit is admitting a client scheduled for an arthrogram using a contrast medium. Which is the priority nursing assessment for this client?

Determine if the client has an allergy to iodine or shellfish.

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?

Determine whether there are medication duplications.

A client with active tuberculosis demonstrates less-than-expected interest in learning about the prescribed medication therapy. The nurse assesses that this client may ultimately need which intervention as a last resort?

Directly observed therapy

A client with a history of atrial fibrillation is brought to the emergency department and states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to take which action?

Draw a sample for prothrombin time (PT) and international normalized ratio (INR).

A client has a problem with sleeping at night. The nurse encourages the client to do which measure to best enhance nighttime sleep?

Drink a glass of milk.

The nurse working in the outpatient radiology department is giving discharge instructions to a client who has had a bone scan. Which instruction should the nurse include in the client's teaching plan?

Drink extra water for a day or so after the procedure.

The nurse employed on a medical unit in a hospital receives a telephone call from the admission office and is told that a client with a diagnosis of mycoplasmal pneumonia will be admitted to the unit. The nurse prepares for the admission and obtains the necessary supplies to place the client on which type of transmission-based precautions?

Droplet precautions

Which is the best nursing intervention regarding complementary and alternative medicine?

Educating the client about therapies that he or she is using or is interested in using

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan?

Elevate and immobilize the grafted extremity.

A client has just returned to a nursing unit following bronchoscopy. Which nursing intervention should the nurse implement?

Ensuring the return of the gag reflex before offering food or fluids

A client is scheduled for oral cholecystography. For the evening meal prior to the test, the nurse should provide a list of foods from which diet type?

Fat-free

The nurse is assisting the primary health care provider in performing a lumbar puncture on a client. The nurse prepares the client for the procedure by placing the client in which position?

Fetal

The nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome (AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which items as part of standard precautions for this client?

Gloves, gown, mask, and protective eyewear

The nurse is instructing a postpartum client with endometritis about preventing the spread of infection to the newborn infant. Which statement should the nurse make to the client?

Hands should be washed thoroughly before holding the infant.

The nurse is preparing to obtain a sputum specimen from a client. Which nursing action will facilitate obtaining the specimen?

Having the client take 3 to 4 deep breaths

Following myelography, how should the nurse plan to best position the client?

Head slightly elevated

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?

Headache, restlessness, and confusion

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

Hemoglobin, 8.0 g/dL (80 mmol/L)

The ambulatory care nurse is seeing a client for a follow-up visit after treatment for toxic shock syndrome (TSS). To assess the client's recovery from TSS, the nurse should ask whether which signs and symptoms have resolved?

High fever, abdominal pain, vomiting, and diarrhea

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time?

High-fiber diet

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Holding the next dose of warfarin

Cardiac magnetic resonance imaging (MRI) is prescribed for a client. When providing teaching, what does the nurse include as one of the major advantages of this test?

It doesn't require any radiation.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?

Leaving the rate of the heparin infusion as is

The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?

Legumes

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level?

Loss of deep tendon reflexes

The nurse is providing instructions to the client scheduled for magnetic resonance imaging. Which instruction should the nurse provide to the client?

Lying still in a flat position for 45 to 60 minutes may be necessary.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.58 mmol/L). Which condition most likely caused this serum phosphorus level?

Malnutrition

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present?

Muscle weakness

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?

Negative

The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?

On the nonoperative side with the legs abducted

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?

Oranges

The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?

Oranges and dark green leafy vegetables

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the primary health care provider (PHCP), and the PHCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

Peas Nuts Cauliflower

The nurse is caring for a client who is on airborne precautions. The nurse notes that the client is scheduled for magnetic resonance imaging (MRI). Which nursing action is most appropriate in preparing the client for the test?

Place a surgical mask on the client for transport.

A client is about to undergo a lumbar puncture (LP). The nurse understands that which is primarily involved in this test?

Removing a sample of cerebrospinal fluid for testing

The nurse is caring for a client who has been diagnosed as having an acute kidney injury (AKI) due to intrarenal causes. What diagnostic test is most effective in confirming this diagnosis?

Renal biopsy

The nurse is providing care to a Hispanic client who is terminally ill. Numerous family members are present most of the time, and many of the family members are very emotional. What is the appropriate action?

Request permission to move the client to a private room and allow the family members to visit.

A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure?

Side-lying with the legs pulled up and the head bent down onto the chest

A man has been admitted to the surgical unit after hernia repair surgery. The medical record reports that the client is human immunodeficiency virus (HIV) positive. The nurse should implement which precautions for this client?

Standard precautions

A client who is admitted for an unrelated medical problem is diagnosed with urethritis caused by chlamydial infection. The assistive personnel (AP) assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. What should the nurse tell the AP?

Standard precautions are sufficient because the disease is transmitted sexually.

The nurse is assigned to care for an infant following a cleft lip repair. The nurse is asked to observe the parent in the procedure for cleaning the lip repair site. The nurse determines that the parent is performing the procedure correctly if the parent uses which solution to clean the site?

Sterile water

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply.

Stroke Sleep apnea Myasthenia gravis Opioid analgesics, sedatives, anesthetics

Which teaching method is most effective when providing instruction to members of special populations?

Teach-back

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm (72 mmol/L), and HCO3− = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is probably hyperventilating.

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next?

The nurse is providing home care instructions to the mother of a child who has bacterial conjunctivitis. The nurse should provide the mother with which information?

The nurse is providing home care instructions to the mother of a child who has bacterial conjunctivitis. The nurse should provide the mother with which information?

The nurse is teaching a client about what to expect during a gallium scan. The nurse should include which item as part of the instructions?

The procedure takes about 30 to 60 minutes to perform.

The nurse is collecting a sputum specimen for culture and sensitivity testing from a client who has a productive cough. The nurse plans to implement which intervention to obtain the specimen?

Use a sterile plastic container for obtaining the specimen.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

VItamin B12

The school nurse prepares a list of home care instructions for the parents of schoolchildren diagnosed with pediculosis capitis. Which instruction should the nurse include in the list?

Vacuum floors, play areas, and furniture to remove any hairs that might carry live nits.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings?

pH 7.25, Paco2 50 mm Hg (50 mm Hg)

A client asks the nurse to explain what is involved in an intravenous fluorescein angiography study of the eye. The nurse should incorporate which statement in the reply?

"Dilating drops will be instilled before the procedure."

The client with a history of lung disease is at risk for developing respiratory acidosis. The nurse asks this client about which symptoms that are characteristic of this disorder?

"Do you have a headache or become confused?"

The nurse is preparing a plan of care for a client and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?

"I cannot have any food containing or prepared with blood."

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep?

"I drink hot chocolate before bedtime."

The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond?

"Living in a prison can predispose a person to different health conditions."

The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?

"Magnetic therapy and massage therapy are a focus of CAM."

An adolescent is diagnosed with conjunctivitis, and the nurse provides information to the adolescent about the use of contact lenses. Which statement by the client would indicate the need for further information?

"My contact lenses can be worn if they are cleaned properly."

The nurse is giving postprocedure instructions to a client returning home after arthroscopy of the shoulder. What is the priority instruction for this client?

"Report any fever or redness and heat at the site to your primary health care provider."

The nurse explains to a client why telemonitoring is needed. What response by the client indicates a need for further instruction?

"Telemonitoring ignores artifact."

A 7-year-old child is diagnosed with viral conjunctivitis. Antibiotic eye drops are prescribed for the child. When the mother asks the nurse when the child can return to school, what should the appropriate response be?

"The child should be kept home until the antibiotic eye drops have been administered for 24 hours."

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

"The enema will be given while I am sitting on the toilet."

A client is scheduled for a digital subtraction angiography study. After being provided information and instructions regarding the test, which statement by the client indicates that the teaching has been effective?

"The purpose of the test is to provide information about the blood vessels."

A client is being scheduled for a positron emission tomography (PET) scan of the brain. The nurse should provide which explanation to the client?

"The test detects abnormal glucose metabolism in the brain."

A young adult client has never had a chest x-ray before and expresses to the nurse a fear of experiencing some form of harm from the test. Which statement by the nurse provides valid reassurance to the client?

"The x-ray exam itself is painless, and a lead shield protects you from the minimal radiation."

A client is about to have arterial blood gases drawn, and the nurse explains what an Allen's test is. What comment shows that the client understands the nurse's explanation?

"This test is done to ensure adequate collateral circulation."

The nurse is explaining to an older client about a creatinine clearance test that has been prescribed. What response by the client indicates that there is a need for further teaching?

"This test measures the levels of all of the medications that I take." 2.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply.

-Prolonged QT interval -Prolonged ST segment

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube?

0.9% sodium chloride

The nurse is caring for a client whose arterial blood gas results reveal alkalosis. What client reactions would the nurse expect to see? Select all that apply.

1. Tetany 3. Tingling 5. Numbness 6.Restlessness

The nurse is caring for a client with diabetic ketoacidosis whose respirations are abnormally deep, regular, and increased in rate. What is the purpose of this type of respiration? Select all that apply.

2.Blow off carbon dioxide 3.Correct metabolic acidosis 4.Correct an acid-base imbalance 5.Cause respiratory compensation

After completing an assessment and reviewing the laboratory test results of a client admitted to the hospital with acute left side abdominal pain, the nurse should take action for which noted serum amylase level?

200 Somogyi units/dL (100 U/L)

The nurse is told to draw an arterial blood gas sample with the client on ambient air. The nurse documents in the record that the client was receiving how much oxygen for this procedure?

21%

The nurse is reviewing the laboratory results of a serum medication level assay for a client seen in the health care clinic who has been taking phenytoin for the control of seizures. The nurse determines that a subtherapeutic level of phenytoin is present and that additional medication is required if which level is found?

3 mcg/mL (12 mcmol/L)

The nurse is reviewing the laboratory test results for an adult male client seen in the health care clinic. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report?

50% (0.50)

A client with diabetes mellitus reports to the clinic for determination of the glycosylated hemoglobin (HbA1c) level. Which value on this laboratory test indicates client compliance with the prescribed diabetic regimen?

6%

A registered nurse (RN) is providing instructions to an assistive personnel (AP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the AP to use which protective item when giving the bed bath?

A gown and gloves

The clinic nurse is providing instructions to a client who is scheduled for a barium enema. What should the nurse instruct the client to do in preparation for this procedure?

A low-fiber diet needs to be maintained for 1 to 3 days before the test

The nurse is planning to obtain blood for arterial blood gas analysis from a client with chronic obstructive pulmonary disease. The nurse should plan time for which activity after the arterial blood specimen is drawn?

Applying pressure to the puncture site by applying a 2 × 2 gauze for 5 minutes

The nurse is observing a second nurse perform hemodialysis on a client. The second nurse is drinking coffee and eating a doughnut next to the hemodialysis machine, while talking with the client about the events of his week. What is the nurse's most appropriate action regarding this observation?

Ask the nurse to refrain from eating and drinking in that area.

A clinic nurse is providing instructions to a female client regarding the procedure for collecting a midstream (clean-catch) urine specimen. What should the nurse instruct the client to do?

Begin the flow of urine and then collect the specimen.

A clinic nurse is providing instructions to a client who is scheduled for a glucose tolerance test. Which instruction should the nurse provide to the client in preparation for the test?

Avoid alcohol, coffee, and tea for 36 hours before and during the test.

The nurse teaches the mother of a child diagnosed with bacterial conjunctivitis about measures to prevent transmission of the infection. Which statement by the mother indicates a need for further teaching?

"It is all right to share towels and washcloths as long as they are bleached after use."

The nurse is caring for a client with possible cholelithiasis who is being prepared for intravenous cholangiography and is teaching the client about the procedure. Which statement indicates that the client understands the purpose of this test?

"They are going to look at my gallbladder and ducts."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?

"Use of an incentive spirometer will help prevent pneumonia."

Which clients are most likely to be at risk for the development of third spacing? Select all that apply.

1.The client with cirrhosis 2.The client with liver failure 5. The client with chronic kidney disease

The nurse in a health care clinic is preparing to conduct a nutritional session with a group of culturally diverse pregnant women. At the first session the nurse will be meeting with each client individually. The nurse prepares a list of items to be included in the session and lists which item as the priority?

Identify the food preferences and methods of food preparation for each client.

The nurse is planning care for a client who has just returned to the nursing unit after an oral cholecystogram. The nurse should expect to delete which prescription on the client's care plan?

Maintain a clear liquid diet for 72 hours.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client?

Monitor the client for dysrhythmias.

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client?

Obtain a telephone consent from a family member, following agency policy.

The nurse is developing a plan of care for a client who is scheduled to return to the nursing unit after a liver biopsy. What is the appropriate position for the client?

On the right side

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care?

Particulate respirator, gown, and gloves

The nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. The nurse anticipates that which diagnostic test will be prescribed to confirm this diagnosis?

Polymerase chain reaction

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level?

Prolonged bed rest

The nurse is teaching a client with acquired immunodeficiency syndrome (AIDS) how to avoid food-borne illnesses. The nurse should instruct the client that which food can cause a food-borne illness?

Raw oysters

The nurse reviews the primary health care provider's (PHCP's) prescriptions for a child with a streptococcal infection. The PHCP prescribes an antistreptolysin O titer. Based on this prescription, which diagnosis should the nurse suspect in the child?

Rheumatic fever (RF)

The nurse is assisting the primary health care provider with a bedside liver biopsy. When the procedure is complete, the nurse assists the client into which position?

Right side-lying, with a small pillow or towel under the puncture site

The nurse is caring for a client with a peptic ulcer who has just had an esophagogastroduodenoscopy (EGD). Which client problem should be the priority?

Risk for choking and aspiration related to a poor gag reflex postprocedure

A client with trigeminal neuralgia who is receiving carbamazepine 400 mg orally daily has a white blood cell (WBC) count of 2800 mm3 (2.8 × 109/L), blood urea nitrogen (BUN) of 17 mg/dL (6.12 mmol/L), sodium of 141 mEq/L (141 mmol/L), and uric acid of 5 mg/dL (0.3 mmol/L). On the basis of these laboratory values, the nurse should make which interpretation?

The WBC count is low, indicating a blood dyscrasia.

A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?

Three sputum cultures are negative.

The nurse is preparing to provide preoperative teaching to a Spanish-speaking client and the client's family. Which nursing action would be most effective for teaching the client?

The nurse secures the assistance of a professional interpreter to communicate with the client.

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?

Activate the fire alarm.

The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan?

Always apply the condom before inserting the penis into the vagina

Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness?

Arranging for home health care

The nurse has a prescription to collect a 24-hour urine specimen from a client. The nurse is demonstrating correct procedure when which technique is performed?

Ask the client to save a sample voided at the end of the collection time.

The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse prepares to attach the distal end of the IV tubing to a needleless device, the tubing drops and hits the top of the medication cart. Which is the appropriate action by the nurse?

Change the IV tubing.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note?

Changes in mental status

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next?

Check skin turgor over the client's sternum.

The nurse is providing instructions to a client who is scheduled for a gallium scan. Which statement made by the client indicates an understanding of the instructions?

"I need to have an injection 2 to 3 hours before the procedure."

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the Scouts about the methods to prevent Lyme disease. Which statement by one of the Scouts indicates a need for further instruction?

"I should not use insect repellents because it will attract the ticks."

A female client is scheduled to have a chest radiograph. Which question is most important for the nurse to ask when assessing this client?

"Is there any possibility that you could be pregnant?""

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply.

1.Bounding pulse 2.Difficulty breathing 4.Presence of dependent edema 5.Neck vein distention in the upright position

The nurse is implementing the complementary therapy of therapeutic touch when caring for clients. The nurse should implement which action when performing therapeutic touch?

Position hands 2 to 4 in (5 to 10 cm) from the body.

The nurse is caring for a client with chronic kidney disease. Arterial blood gas results indicate a pH of 7.30 (7.30), a Paco2 of 32 mm Hg (32 mm Hg), and a bicarbonate concentration of 20 mEq/L (20 mmol/L). Which laboratory value should the nurse expect to note?

Potassium level of 5.2 mEq/L (5.2 mmol/L)

The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which statement by the client would indicate an understanding of the instructions?

"I should sleep on my left side."

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L). Which patterns would the nurse watch for on the electrocardiogram? Select all that apply.

1.Prolonged QT interval 2.Prolonged ST segment

The nurse is caring for a client with a diagnosis of lung cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L)

The nurse is providing orientation to a newly graduated nurse. During a discussion of isolation procedures, which statement by the graduate nurse indicates a need for further review of isolation guidelines?

"I can reuse a gown if it's not dirty, as long as I hang it up inside the client's room."

A client requires a myelogram, and the ambulatory care nurse is providing instructions to the client regarding preparation for the procedure. Which statement by the client indicates a need for further instruction?

"I need to be sure to eat a full meal before the procedure."

The nurse instructs a female client to obtain a clean-catch urine specimen for culture and sensitivity testing. Which statement by the client indicates that she understands the procedure for collecting the specimen?

"I need to cleanse the labia using cleansing towels, void into the toilet, and then void into the sterile specimen container."

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply.

1. 10% dextrose in water 3.5% dextrose in 0.9% saline 4. 5% dextrose in 0.45% saline 6. 5% dextrose in lactated Ringer's solution

The nurse is working in an illness prevention clinic. An important component of the nurse's practice is to advise high-risk clients to receive an influenza vaccination. Which clients are at high risk for influenza and would benefit from vaccination? Select all that apply.

1. A 47-year-old mother of a child with cystic fibrosis 2. A 54-year-old man scheduled for a routine diabetes check 4. A 35-year-old registered nurse scheduled for an annual pelvic exam 5. An 87-year-old woman from a nursing home scheduled for a surgical follow-up

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply.

1.Contact the surgeon. 2.Instruct the client to remain quiet. 3.Prepare the client for wound closure. 4.Document the findings and actions taken.

The ambulatory care nurse is providing instructions to a client who is scheduled for a colonoscopy and possible removal of a polyp. Which instructions are appropriate for client preparation for this procedure?

A bowel preparation will be needed in preparation for the procedure.

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Cream of wheat, blueberries, coffee

The nurse is annoyed by a healthy Hispanic American client who had minor abdominal surgery 2 days ago. The client claims he cannot get out of bed by himself, and the nurse lectures the client and tells him to try to be tough. What type of cultural behavior is this called?

Cultural imposition

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

Dehydration

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change should the nurse expect to observe based on the client's magnesium level?

Depressed ST segment

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50 (7.50), Pao2 of 90 mm Hg (90 mm Hg), Paco2 of 40 mm Hg (40 mm Hg), and bicarbonate of 35 mEq/L (35 mmol/L). When the nurse notifies the primary health care provider about these levels, the nurse should anticipate receiving from the PHCP which prescription for this client?

Discontinue nasogastric suctioning.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status should avoid which action?

Encouraging the client to breathe slowly and shallowly

The nurse is developing a plan of care for a client who has undergone an esophagogastroduodenoscopy procedure. The nurse should include which intervention in the nursing care plan?

Ensure that a gag reflex is present before allowing the client any oral intake.

The nurse is caring for a client admitted with a diagnosis of systemic lupus erythematosus (SLE). A highly sensitive C-reactive protein (hsCRP) blood test is prescribed. What other blood test is often used along with the hsCRP?

Erythrocyte sedimentation rate (ESR)

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed?

Heparin

A client with pulmonary tuberculosis (TB) is on airborne isolation precautions. Which item(s) is essential for the nurse to wear?

High-efficiency particulate air (HEPA) filter mask

The nurse collects a 24-hour urine specimen for catecholamine testing from a client with suspected pheochromocytoma. The results of the catecholamine test are reported as epinephrine 20 mcg (109 nmol) and norepinephrine 100 mcg (590 nmol). The nurse should make which interpretation about this result?

Higher than normal, indicating pheochromocytoma

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia?

Hyperactive bowel sounds

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder should the nurse monitor for that could accompany the acid-base imbalance?

Hypokalemia

An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

Iron deficiency anemia

A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic?

Is painless and indurated

The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?

Isolate the client in a private room.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

Respirations that are increased in rate Respirations that are abnormally deep

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

Respirations that are increased in rate Respirations that are abnormally deep

The nurse reviews the arterial blood gas results of an assigned client and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and HCO3 of 27 mEq/L (27 mmol/L). The nurse interprets that the client has which acid-base disturbance?

Respiratory acidosis

A hospitalized client has a diagnosis of pelvic inflammatory disease (PID). The nurse should encourage the client to assume which therapeutic position when in bed?

Supine in semi-Fowler's

How should the nurse position the client for pericardiocentesis to treat cardiac tamponade?

Supine with the head of the bed elevated at a 45- to 60-degree angle

The ambulatory care nurse is preparing to assist the primary health care provider in performing a liver biopsy on a client. The client is receiving a local anesthetic for the procedure. The nurse should assist the client into which position for this test to be performed?

Supine with the right hand under the head

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client?

Supine, with the head of the bed elevated about 15 degrees

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mm Hg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?

The client is probably hyperventilating.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)?

The client who has sustained a traumatic burn

A client with tuberculosis (TB) asks the nurse about precautions to take after discharge to prevent infection of others. The nurse develops a response to the client's question based on which correct understanding of TB transmission?

The disease is transmitted by droplet nuclei.

A client is scheduled for an oral cholecystogram. The nurse asks the dietary department to bring low-fat foods for the evening meal for which purpose?

To prevent contraction of the gallbladder before testing

The nurse is providing instructions for a client who will collect a stool specimen for an occult blood test. The nurse instructs the client that it is best to avoid which food for 3 days before collection of the stool specimen?

Turnips

The nurse is admitting a client who is suspected of having tuberculosis (TB) to the nursing unit. The nurse should plan to admit the client to a room that has which properties?

Venting to the outside, 6 air exchanges per hour, and ultraviolet light

The nurse prepares a client for ear irrigation as prescribed by the primary health care provider. Which action should the nurse take when performing the procedure?

Warm the irrigating solution to 98.6° F (37.0° C).

The nurse places a hospitalized client with active tuberculosis in a private, well-ventilated isolation room. In addition, which action should the nurse take before entering the client's room?

Wash hands and place a high-efficiency particulate air (HEPA) respirator mask over the nose and mouth.

The nurse is giving a bed bath to a client and discovers that an additional washcloth and towel are needed. Which is the most appropriate action to take to obtain the needed items?

Wash hands, leave the client's room, and obtain the needed items.

A client with diabetes mellitus is scheduled for a fasting blood glucose level determination in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information about fluid and food intake, the nurse clarifies by stating that which would be acceptable to consume before the test?

Water

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition?

Weight loss and poor skin turgor

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching

The nurse is reviewing the laboratory test results for a client and notes that the differential white blood cell (WBC) count indicates a shift to the right. The nurse suspects that the client's diagnosis is most likely to be which one?

Pernicious anemia

The nurse is developing a plan of care for a client who will be returning to the nursing unit after a percutaneous transhepatic cholangiogram. The nurse should include which intervention in the postprocedure plan of care?

Place a sandbag or other approved device over the insertion site

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record.

The nurse is providing information to a client who is scheduled for an electromyogram. Which statement by the client indicates the teaching has been effective?

"Needles will be inserted into the skeletal muscles."

An ultrasound examination of the gallbladder is scheduled for a client with a suspected diagnosis of cholecystitis. Correct instructions about the procedure should include which statement made by the nurse?

"This test requires that you lie still for short intervals."

The nurse is explaining a preoperative teaching plan to an English-speaking client. What are some other aspects of verbal communication? Select all that apply.

1.Timing 2.Volume 3.Voice tone 6. Ability to share thoughts and feelings

A client with type 2 diabetes mellitus presents to the primary health care provider's office with a glycosylated hemoglobin (HgbA1C) level of 10.5%. Which statement by the client indicates an understanding of this test and its results?

"Well, I have 3 months to really work on watching my diet and lowering my blood sugar. My next glycosylated hemoglobin test should be better then."

The primary health care provider (PHCP) tells a client that a blood transfusion is needed and that a blood sample must be drawn first for blood typing and crossmatching. The nurse explains to the client what a typing and crossmatch test is for and why it is done. What response by the client about blood typing implies to the nurse that further teaching is needed?

"It is an antibody found on the surface of the red blood cell."

The nurse provides home care instructions to a client with hepatitis B. Which statement made by the client indicates the best understanding of how to prevent transmission of the disease?

"My wife should get the vaccine."

A clinic nurse is performing an admission assessment on an African American client scheduled for cataract removal with intraocular lens implantation. Which question should the nurse avoid asking on the initial assessment?

"Do you have any family problems?"

The nurse is providing information to a client about a computed tomography (CT) scan of the head. Which statement should the nurse include when reviewing preparation for the CT with the client?

"Each set of head scans takes less than 5 minutes to perform."

The ambulatory care nurse is providing home care instructions to the client after an arthroscopy of the knee. Which statement by the client indicates a need for further instruction?

"I can apply heat to the site if it becomes uncomfortable."

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement?

"I need to continue to take the aspirin until the day of surgery."

The nurse is preparing a group of Cub Scouts for an overnight camping trip and instructs the scouts about the methods to prevent Lyme disease. Which statement by 1 of the scouts indicates a need for further instruction?

"I should not use insect repellents because it will attract the ticks."

A client is seen in the health care clinic, and a diagnosis of acute sinusitis is made. The nurse provides home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further instruction?

"I should use a hot mist vaporizer to liquefy secretions."

The nurse has instructed a client diagnosed with tuberculosis about how to prevent the spread of infection after discharge from the hospital. The nurse determines that the client needs further reinforcement of information if the client makes which statement?

"I should use disposable plates, forks, and knives."

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply.

1. Ensure adequate fluid intake. 2. Implement safety measures to prevent falls. 4. Instruct the client about foods that contain potassium. 5.Encourage the client to obtain assistance to ambulate.

The nurse is preparing to obtain an arterial blood gas specimen from a client and plans to perform the Allen's test on the client. The nurse would perform the steps in which order to conduct an Allen's test? Arrange the actions in the order that they should be performed. All options must be used.

1. Explain the procedure to the client. 2. Apply pressure over the ulnar and radial arteries. 3. Ask the client to open and close the hand repeatedly. 4. Release pressure from the ulnar artery.. 5. Assess the color of the extremity distal to the pressure point. 6. Document the findings.

The nurse has a prescription to obtain a urinalysis specimen from a client with an indwelling urinary catheter. Which actions should the nurse include in performing this procedure? Select all that apply.

1. Explaining the procedure to the client 2. Clamping the tubing of the drainage bag 4. Aspirating a sample from the port on the drainage tubing 5. Wiping the port with an alcohol swab before inserting the syringe

The nurse is caring for a non-English-speaking client and is attempting to integrate the client's cultural practices into Western medicine. What are some other aspects of culturally competent care the nurse can employ? Select all that apply.

1. Increasing client safety 2. Using spiritual practices 3.Reducing health disparities 4. Increasing client satisfaction 6. Preventing misunderstandings between the nurse and the client

A stool smear for culture needs to be obtained from a client. What steps should the nurse plan to implement when obtaining the specimen? Select all that apply.

1. Wearing sterile gloves 2. Using a sterile container 3. Sending the specimen directly to the laboratory

The nursing instructor determines that the nursing student understands the purposes of standard and transmission-based precautions if which statements are made? Select all that apply.

1."They prevent transmission of organisms from client to client." 2. "They prevent transmission of organisms from primary health care providers to clients." 3. "They prevent transmission of organisms from clients to primary health care providers." 4. "They prevent transmission of organisms from primary health care providers and clients to people outside of the hospital."

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply.

2.Lethargy 3.Headache 4.Weakness 5.Confusion

The nurse is caring for a client who is scheduled to have a lumbar puncture (LP). What are some contraindications for a client to have an LP? Select all that apply.

2.Clients with infection near the LP site 3.Clients with increased intracranial pressure 4.Clients receiving anticoagulation medications 6. Clients who have severe degenerative vertebral joint disease

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

2.Inhalation of bacterial spores 3.Through a cut or abrasion in the skin 6. Ingestion of contaminated undercooked meat

The nurse manager is giving a staff in-service on providing culturally sensitive education to clients. Which statements indicate to the nurse manager that the staff understands providing culturally sensitive education? Select all that apply.

3. "The population served will determine the culturally sensitive resources to use for teaching." 4. "Assessment of a client's preferred learning approach is essential to facilitate the learning process." 5. "It is important to have an accurate translator when the nurse and client do not speak the same language."

The nurse is calculating a client's fluid intake for a 24-hour period. The client is on hemodialysis and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and supper. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day? Fill in the blank.

30 mL

The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?

A platelet count of 50,000 mm3 (50 × 109/L)

The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up?

A reddish-purple mark on the neck

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited?

Areflexia

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions the client that which could cause a false-negative result?

Ascorbic acid

A computed tomography scan of the chest with contrast is scheduled to be performed in a client suspected of having a pulmonary embolism. In planning the preprocedure care for this client, which nursing action is necessary?

Ask the client about allergies and previous reactions.

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?

Assessing for the return of the gag reflex

The nurse is preparing to care for a client with acquired immunodeficiency syndrome (AIDS). In planning infection control for this client, the nurse should implement which form of isolation to prevent the spread of the AIDS virus to others?

Blood and body fluid precautions

The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

Broth Coffee Gelatin

With a finger sensor, the nurse is measuring a client's oxygen saturation with a pulse oximeter machine and obtains a reading of 78% while the client is on oxygen via nasal cannula at 2 L/min. The client is showing no signs of restlessness or dyspnea. What is the first nursing action?

Check the finger sensor's position and repeat the test.

The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no receptacle is available in the wall socket. The nurse should take which action?

Contact the electrical maintenance department for assistance.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action should the nurse take first?

Contact the primary health care provider (PHCP).

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action?

Continue to monitor the drainage.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator?

Daily weight

Which outcome should the nurse expect to observe in the client who is recovering from viral hepatitis without complications?

Decrease in aspartate aminotransferase (AST)

The nurse is caring for a client who is retaining carbon dioxide (CO2) as a result of an obstructive respiratory disease. The nurse plans interventions knowing that as the client's CO2 level rises, what will occur with the blood pH?

Fall

A registered nurse is evaluating the licensed practical nurse's ability to collect a specimen. The nurse would use this specimen collection container to collect which type of specimen? Refer to figure.

Respiratory secretions

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note?

Hypotension

The client with right-sided pleural effusion by chest x-ray is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Left side-lying position, with the head of the bed elevated 45 degrees

The nurse is assisting the primary health care provider during a colonoscopy procedure. The nurse helps the client to assume which position for the procedure?

Left sims'

The nurse is caring for a client who has undergone renal angiography using the left femoral artery for access. The nurse determines that the client is experiencing a complication of the procedure if which finding is observed?

Pallor and coolness of the left leg

The nurse is planning care for a client returning to the nursing unit after a bone biopsy. Which nursing action would be contraindicated in the postprocedure care for this client?

Place the biopsied limb in a dependent position for 24 hours.

A client with a history of upper gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?

Place the normal report in the client's medical record.

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position?

Supine, with the residual limb supported with pillows

A client is being discharged to home after 2 weeks with a diagnosis of tuberculosis and is worried about the possibility of infecting family members and others. How should the nurse respond to provide reassurance?

The family will be treated prophylactically, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

A client with tuberculosis (TB), whose status is being monitored in an ambulatory care clinic, asks the nurse when it is permissible to return to work. The nurse replies that the client may resume employment when which occurs?

Three sputum cultures are negative.

The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply.

Touch Eye contact Personal space Time orientation

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?

Twitching

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

U waves Inverted T waves Depressed ST segment

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

U waves Inverted T waves Depressed ST segment

A primary health care provider is about to perform a paracentesis for a client with abdominal ascites. The nurse assisting with the procedure should help the client into which position?

Upright

A client recovering from cardiac surgery has a left pleural effusion and is about to undergo a thoracentesis. What position should the nurse place the client in for the procedure?

Upright and leaning forward with the arms on an over-the-bed table

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?

Urinary output of 20 mL/hr

A client has a prescription to have blood drawn to measure peak and trough vancomycin levels to determine the effectiveness of therapy with this medication. The nurse arranges with the laboratory to have the peak level specimen drawn at which time?

1.5 hours after completion of the scheduled infusion

The nurse provides discharge instructions to a client following myelography. Which instructions should the nurse provide? Select all that apply.

1.Avoid bending over. 2.Avoid strenuous 4.Rest with the head elevated.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? Select all that apply.

1.Ensure adequate oxygenation. 2.Provide assistance to prevent falls. 3.Monitor medication administration of diuretics. 5. Prevent complications during potassium administration.

The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.

1.Inhalation of bacterial spores 2.Through a cut or abrasion in the skin 3.Ingestions of contaminated undercooked meat

The nurse in the health care clinic is preparing to obtain a throat swab for culture in a client suspected of having a beta-hemolytic streptococcal infection. Which actions are appropriate in collecting this specimen? Select all that apply.

1.Instruct the client to tilt the head back. 2.Swab the tonsillar pillars and the posterior pharynx wall. 3.Tell the client that the test will help to identify microorganisms.

When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply.

1.Keeping pregnant women out of the client's room. 2.Placing the client in a private room with a private bath. 3.Wearing a lead shield when providing direct client care.

The nurse is admitting a client with suspected ascites. What radiology films would initially be prescribed to diagnose ascites? Select all that apply.

1.Plain film 2.Scout film 4.Flat plate of the abdomen 5.Kidney ureters bladder (KUB)

Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.

1.Platelets, 35,000 mm3 (35 × 109/L) 2.Sodium, 150 mEq/L (150 mmol/L) 3. Segmented neutrophils, 40% (0.40) 4.White blood cells, 3000 mm3 (3.0 × 109/L)

The nurse is caring for a client just admitted to the critical care unit with a diagnosis of myocardial infarction (MI). In the early period after an MI, why are nutrition interventions and education so important? Select all that apply.

1.To reduce angina 2..To cut down on cardiac workload 3.To decrease the risk of dysrhythmias

The nurse is caring for a client with a diagnosis of breast cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L)

The nurse assists a primary health care provider in performing a liver biopsy. After the biopsy, the nurse should place the client in which position?

A right side-lying position with a small pillow or folded towel under the puncture site

A client with urolithiasis is scheduled for extracorporeal shock wave lithotripsy. The nurse should tell the client that which will be necessary before the procedure is performed?

A signed informed consent form

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved?

A urine specific gravity of 1.043

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?

An increased pH and an increased HCO3-

The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?

Placing the client in a semiprivate room at the end of the hallway

The nurse is caring for a client following a craniotomy, in which a large cancerous tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the figure.

Position 1. Fowlers

The nurse is preparing a plan of care for a client with a diagnosis of agranulocytosis who is being admitted to the hospital. The nurse determines that which is the priority when formulating the client's plan of care?

Potential for infection

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate?

Pour the aspirate into the NG tube through a syringe with the plunger removed.

A client is scheduled for a fiberoptic gastrointestinal procedure. The nurse instructs the client to remain on clear liquids the day before the test because a clear liquid diet supports which action?

Providing little or no residue