h + i exam 1
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? Tachypnea Pneumonia Pleural effusion Wheezes
Pleural effusion
A client with influenza is admitted to an acute care facility. The nurse monitors the client closely for complications. What is the most common complication of influenza? Meningitis Pulmonary edema Pneumonia Septicemia
Pneumonia
A client with active genital herpes is admitted to the labor and birth unit during the first stage of labor. Which plan of care does the nurse anticipate for this client? Administer valacyclovir 500 mg orally every 6 hours while in active labor. Start an IV and give penicillin G every 4 hours until birth. Administer tocolytics as prescribed until the active lesions are healed. Prepare the client and partner for a cesarean birth as soon as possible.
Prepare the client and partner for a cesarean birth as soon as possible.
A nurse is taking a manual measure of a client's blood pressure. The nurse knows that which factors related to blood flow underlies the ability to hear blood pressure by auscultation (listening)? The movement of smooth muscle surrounding vessels produces noise that is audible by stethoscope. The force of blood with each cardiac contraction produces friction on vessel walls that can be heard and felt. Pressure pulsation that exceeds the velocity of blood flow is audible and coincides with systolic BP. Turbulent flow of blood during systole produces sound while laminar flow during diastole is silent.
Pressure pulsation that exceeds the velocity of blood flow is audible and coincides with systolic BP.
When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true? Pressures may vary 10 mm Hg or more between arms. Pressures must be equal in both arms. Pressures may vary, with the higher pressure found in the left arm. Pressures should not differ more than 5 mm Hg between arms.
Pressures should not differ more than 5 mm Hg between arms.
A nurse is admitting a client with toxic epidermal necrolysis. What is the nursing priority in preventing sepsis? Preventing infection Assessing for hemorrhage Hydrating to prevent renal failure Limiting protein to limit liver failure
Preventing infection
The parents of an infant born with hydrocephalus are concerned about the size of the baby's head. The doctors are telling them that the infant needs the surgical placement of a shunt. The nurse caring for the infant in the neonatal intensive care unit explains that placement of a shunt will: reverse any neurologic deficits that are present. not affect the size of the infant's head. increase intracranial pressure. decrease the likelihood of further neurological deficits.
decrease the likelihood of further neurological deficits.
The practitioner examines his client's foot and observes the great toe to be black and dry. The practitioner explains to the client that the dead tissue is caused by: caseous necrosis. liquefaction necrosis. gas gangrene. dry gangrene.
dry gangrene.
A child is admitted to the emergency department with an acute asthma attack. Which early assessment finding does the nurse expect? expiratory wheezing decreased respiratory rate inspiratory stridor cyanosis
expiratory wheezing
A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate? infection cord compression fetal distress related to hypoxia central nervous system (CNS) involvement
fetal distress related to hypoxia
A lead nurse is removing personal protective equipment after dressing the infected wounds of a client. Which is the priority nursing action? remove the garments that are most contaminated make contact between two clean surfaces make contact between two contaminated surfaces handwashing before leaving the client's room
handwashing before leaving the client's room
What is the most common viral infection? gonorrhea human papillomavirus (HPV) trichomoniasis chlamydia
human papillomavirus (HPV)
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypocalcemia. hypoglycemia. hypokalemia. hypothyroidism.
hypokalemia.
The nurse is caring for a 3-year-old client being treated for severe status asthmaticus. After comparing clinical manifestations with laboratory results (reported below), a nurse determines evidence that this client has progressed to which condition? respiratory acidosis metabolic alkalosis metabolic acidosis respiratory alkalosis
respiratory acidosis
A client the nurse is caring for has developed a bladder infection while in the hospital. The client has had a Foley catheter for two weeks. The client's family asks you how the client got this infection. What would be the nurse's best response? "People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital." "People in hospitals sometimes exhibit signs of infections they had before being admitted." "Sometimes people in hospitals get exposed to microorganisms that their visitors bring in." "People in hospitals are surrounded by infectious agents, so they can get infections they didn't have before being admitted."
"People in hospitals are often more susceptible to infections because they are already ill and they are exposed to germs while they are in the hospital."
A client tells the nurse that he has recently begun to take over-the-counter (OTC) calcium supplements to ensure that his blood will clot. The best response by the nurse would be: "It will not cause problems, and it will keep your bones strong." "Take the supplement twice a day with milk to increase absorption." "This is not necessary, unless it has been prescribed by your health care provider." "It is a good idea; you will prevent bleeding."
"This is not necessary, unless it has been prescribed by your health care provider."
In talking to a mother who is 6 hours post-delivery, the mother reports that she has changed her perineal pad twice in the last hour. What question by the nurse would best elicit information needed to determine the mother's status? "What time did you last change your pad?" "Are you in any pain with your bleeding?" "How much blood was on the two pads?" "When did you last void?"
"How much blood was on the two pads?"
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with sickle cell disease. The nurses in the group make the following statements. Which statement is most accurate regarding this condition? "The trait or the disease is seen in one generation and skips the next generation." "Males are much more likely to have the disease than females." "The disease is most often seen in individuals of Asian decent." "If the trait is inherited from both parents the child will have the disease."
"If the trait is inherited from both parents the child will have the disease."
The nurse recognizes the role of the lungs in acid-base balance is regulation of which of the following? H2O HCO3 CO2 Hydrogen
CO2
In children with otitis media, a procedure known as a myringotomy may be performed. Which statement is most accurate regarding this procedure? The purpose of this procedure is to decrease or stop the drainage. A small incision is made in the earlobe during this procedure. During this procedure, small tubes are inserted into the tympanic membrane. This procedure is performed as soon as otitis media is diagnosed.
During this procedure, small tubes are inserted into the tympanic membrane.
The older adult client with a history of congestive heart failure is upset following the death of her husband yesterday. The practitioner observes the client for which of the following? Anemia Cerebrovascular accident Renal failure Dysrhythmias
Dysrhythmias
Following a voiding cystogram, the client has a nursing diagnosis of risk for infection related to the introduction of bacterial following manipulation of the urinary tract. An appropriate nursing intervention for the client is to: Encourage high fluid intake. Monitor for hematuria. Apply moist heat to the flank area. Strain all urine for 48 hours.
Encourage high fluid intake.
The nurse is caring for a postoperative client in traction. Which activity would be most beneficial for preventing atelectasis in this client? Have client remain on bed rest with the head of bed kept flat. Encourage the client to cough and breathe deeply several times per hour. Offer the client an incentive spirometer every shift. Administer oxygen via nasal cannula at 4 L/min.
Encourage the client to cough and breathe deeply several times per hour.
A 6-month-old infant is brought to the clinic. The mother reports the infant has been lethargic and not eating well. The infant's anterior fontanel is sunken. Which additional information is a priority for the nurse to assess? Skin color and cap refill Number of wet diapers the in the last 24 hours Number of feeds in the last 24 hours Number of hours infant has slept in the last 24 hours
Number of wet diapers the in the last 24 hours
A nurse needs to measure the blood pressure of a client who has just undergone a bilateral mastectomy. How should the nurse measure the blood pressure? Radial artery Over the client's thigh Brachial artery Over the lower arm
Over the client's thigh
The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action? Apply a cervical collar and request a cervical exam. Assess the child's breathing by using a pulse oximeter. Perform a jaw-thrust technique to assess the patency of the airway. Ask the child to rate the pain from 0-10 or use a picture scale.
Perform a jaw-thrust technique to assess the patency of the airway.
A client experiencing a sinus arrest would demonstrate which symptom or finding? Spontaneous persistent sinus bradycardia Prolonged periods of asystole demonstrated on an electrocardiogram Heart rate of greater than 100 beats/min P-wave that occurs more frequently than expected
Prolonged periods of asystole demonstrated on an electrocardiogram
What is the highest nursing priority in the plan of care for a client with peripheral vascular problems? Monitor skin integrity. Promote arterial and venous circulation. Relieve pain caused by decreased circulation. Provide a self-care program for the client and family.
Promote arterial and venous circulation.
After being seen in the oncology clinic, a client with severe bone marrow suppression is admitted to the hospital. The client's cancer therapy consisted of radiation and chemotherapy. When developing the care plan for this client, which nursing diagnosis takes priority? Anxiety Imbalanced nutrition: Less than body requirements Risk for infection Risk for injury
Risk for infection
A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension? Malignant Primary Essential Secondary
Secondary
The nurse is caring for a client who has a diagnosis of human immunodeficiency virus (HIV). Part of this client's teaching plan is educating the client about his or her medications. What is essential for the nurse to include in the teaching of this client regarding medications? Side effects of drug therapy The action of each antiretroviral drug The use of condoms What vaccinations to have
Side effects of drug therapy
For a client with anorexia nervosa, which goal takes the highest priority? The client will make a contract with the nurse that sets a target weight. The client will identify self-perceptions about body size as unrealistic. The client will verbalize the possible physiological consequences of self-starvation. The client will establish adequate daily nutritional intake.
The client will establish adequate daily nutritional intake.
A nurse is providing health education regarding self-care to a patient with an immunodeficiency. What teaching point should the nurse emphasize? The importance of aggressive treatment of acne The need to keep fingernails and toenails closely trimmed The need for thorough oral hygiene The importance of avoiding alcohol-based cleansers
The need for thorough oral hygiene
The nurse is teaching a group of nursing students about the mechanism of action of common diuretics. What best reflects the mechanism of these drugs? They block uric acid and glucose in the renal tubules. They block the reabsorption of sodium and chloride in the nephron. They promote release of aldosterone from the adrenal glands. They enhance absorption of potassium in the loop of Henle.
They block the reabsorption of sodium and chloride in the nephron.
The nurse educator is differentiating primary immunodeficiency diseases from secondary immunodeficiencies. What is the defining characteristic of primary immunodeficiency diseases? They have a genetic origin. They require IVIG as treatment. They are the result of intrauterine infection. They are communicable.
They have a genetic origin.
A client has been diagnosed with obstructive sleep apnea and is having a discussion about possible treatment options with the primary care provider. Which options will likely be discussed? Select all that apply. Skeletal muscle relaxants Positive airway pressure devices Surgery Nebulized bronchodilators Weight loss
Weight loss Positive airway pressure devices Surgery
What postpartum client should the nurse monitor most closely for signs of a postpartum infection? a client who conceived following fertility treatments a client who had a nonelective cesarean birth a primiparous client who had a vaginal birth a client who had an 8-hour labor
a client who had a nonelective cesarean birth
The nurse is caring for a client receiving an aminoglycoside (antibiotic) that can be nephrotoxic. Which will alert the nurse that the client may be experiencing nephrotoxicity? a decrease in urine output yellowing of the skin ringing noise in the ears visual disturbances
a decrease in urine output
A client has come to the office for her first postpartum visit. On evaluating her blood work, the nurse would be concerned if the hematocrit is noted to have: acutely decreased. slightly decreased. acutely increased. slightly increased.
acutely decreased.
Which problem-based nursing care plan will the nurse indicate as priority for the child following cardiac surgery for tetralogy of Fallot? acute parental anxiety surgical site infection risk fluid overload risk altered cardiopulmonary tissue perfusion risk
altered cardiopulmonary tissue perfusion risk
A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? calcium carbonate naloxone atropine sodium bicarbonate
atropine
Which complication is common in neonates who receive prolonged mechanical ventilation at birth? hydrocephalus renal failure esophageal atresia bronchopulmonary dysplasia
bronchopulmonary dysplasia
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypocalcemia. hypothyroidism. hypoglycemia. hypokalemia.
hypokalemia.
The nurse caring for an older adult client diagnosed with diarrhea is administering and monitoring the client's medications. Because one of the client's medications is digitalis (digoxin), the nurse monitors the client closely for: hypokalemia. hyponatremia. hyperkalemia. hypernatremia.
hypokalemia.
Early signs of hypervolemia include a decrease in blood pressure. thirst. moist breath sounds. increased breathing effort and weight gain.
increased breathing effort and weight gain.
A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider? initial BP 140/85 mm Hg; current BP 130/80 mm Hg initial BP 120/80mm Hg; current BP 130/88 mm Hg initial BP 100/70 mm Hg; current BP 140/90 mm Hg initial BP 110/60 mm Hg; current BP 112/86 mm Hg
initial BP 100/70 mm Hg; current BP 140/90 mm Hg
A client with a history of type 1 diabetes is demonstrating fast, deep, labored breathing and has fruity odored breath. What could be the cause of the client's current serious condition? ketoacidosis hepatic disorder hyperosmolar hyperglycemic nonketotic syndrome All options are correct.
ketoacidosis
The client is experiencing nausea and vomiting following surgery. What will the nurse expect the surgeon to order? ondansetron chlorpromazine omeprazole nizatidine
ondansetron
A major complication of prolonged bed rest is an increased risk of kidney stones. The nurse knows that this is most likely related to: increased urine levels of citrate. frequency of urination. a limited access to fluids while hospitalized. saturation of urine with calcium salts.
saturation of urine with calcium salts.
A nurse is assessing the blood pressure of a team of healthy athletes at the heath care facility. Which observation can be made by the nurse and athletes by measuring the blood pressure? the oxygen levels in the blood the volume of air entering the lungs the ability of the arteries to stretch the thickness of circulating blood
the ability of the arteries to stretch
Which population group should the nurse routinely screen for heart disease? Hispanic White Asian Black
White
Most urinary tract infections seen in children are caused by: fungal infections. hereditary causes. dietary insufficiencies. intestinal bacteria.
intestinal bacteria.
The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? high Fowler's Fowler's supine orthopneic
supine
When the client who has been diagnosed with hepatitis B has been hospitalized, the type of isolation the nursing staff should observe is: universal precautions. body-substance isolation. reverse precautions. droplet precautions.
universal precautions.
A client reports to the primary health care facility reporting chest pain. After the investigations and initial treatment, the client anxiously inquires if he had a heart attack. What should be the nurse's reply? "Yes, you had a heart attack, but the damage is very minimal." "No; we can assure you that you will not have a heart attack." "Yes, you had a heart attack; this is why you are here with us." "The physician wants to monitor you and control your pain."
"The physician wants to monitor you and control your pain."
A nurse is discussing the use of naso-oral continuous positive airway pressure (NCPAP) with a client. What is the nurse's most appropriate response when the client asks what the purpose of this equipment is? "This device will generate a positive pressure that will promote your taking a breath." "This device will provide white noise to promote your sleeping." "This device will provide better alignment of your trachea." "This device will allow your nurse to suction your airway more easily."
"This device will generate a positive pressure that will promote your taking a breath."
A client's most recent laboratory results suggest the presence of metabolic alkalosis. What action by the nurse best addresses a potential cause of this acid-base imbalance? Assessing the client's bowel sounds and administering scheduled stool softeners Assessing the client's level of consciousness using the Glasgow Coma Scale Repositioning the client frequently to reduce pressure on dependent skin surfaces Administering an antiemetic to treat the client's frequent vomiting
Administering an antiemetic to treat the client's frequent vomiting
The infection control nurse at a large hospital has instituted a new education campaign aimed at reducing the incidence of hospital-acquired pneumonia (HAP). The nurse should identify which client as being particularly susceptible to hospital-acquired pneumonia? A woman who gave birth by cesarean section 24 hours ago An intubated client who is ventilator dependent following a traumatic head injury A middle-aged client who donated a kidney to his brother 48 hours ago An older adult client with Alzheimer disease who is administered antipsychotics to manage his behavior
An intubated client who is ventilator dependent following a traumatic head injury
Which statement regarding antiviral medications is true? Antivirals do not eliminate existing viruses from tissues. Antivirals present relatively low risk for toxicity. Once antivirals are used, protection lasts for 3 weeks after the last dose. Most antivirals temporarily increase viral replication.
Antivirals do not eliminate existing viruses from tissues.
When explaining how carbon dioxide combines with water to form carbonic acid as part of an acid-base lecture, the faculty instructor emphasizes that which enzyme is needed as a catalyst for this reaction? Hydrolases Carbonic anhydrase Phenylalanine hydroxylase Trypsin
Carbonic anhydrase
Which assessment should be prioritized in the care of a client who is being treated for a serum potassium level of 2.7 mEq/L (2.7 mmol/L)? Cardiac monitoring looking for prolonged PR interval and flattening of the T wave Detailed fluid balance and monitoring for pitting edema Arterial blood gases checking for respiratory alkalosis Monitoring of hemoglobin levels and oxygen saturation
Cardiac monitoring looking for prolonged PR interval and flattening of the T wave
The nurse is caring for a client with a tumor obstructing the lymphatic system. For which consequence does the nurse assess? Fluid accumulating in the interstitial spaces distal to the tumor Plasma protein accumulating in the circulatory system Fluid being trapped in intercellular spaces The client developing circulatory overload
Fluid accumulating in the interstitial spaces distal to the tumor
After teaching a group of nursing students about diuretics, the instructor determines that the teaching was successful when the group identifies which as a loop diuretic? Hydrochlorothiazide Spironolactone Acetazolamide Furosemide
Furosemide
A client with malignant hypertension is at risk for a hypertensive crisis, including the cerebral vascular system often causing cerebral edema. The nurse would assess this client for which signs and symptoms? Headache and confusion Restlessness and nervousness Stupor and hyperreflexia Papilledema and lethargy
Headache and confusion
Atherosclerosis begins in an insidious manner with symptoms becoming apparent as long as 20 to 40 years after the onset of the disease. Although an exact etiology of the disease has not been identified, epidemiologic studies have shown that there are predisposing risk factors to this disease. What is the major risk factor for developing atherosclerosis? Hypercholesterolemia Familial history of premature coronary heart disease Increasing age Male sex
Hypercholesterolemia
The health care provider is teaching a client about modifiable risk factors for atherosclerosis. The most appropriate information to provide would be: Hypertension 55 years of age Being male Family history of heart disease
Hypertension
The clinic nurse is doing a preoperative assessment of a patient who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the patient's medical history, the nurse notes that this patient had a kidney transplant 8 years ago and that the patient is taking immunosuppressive drugs. For what is this patient at increased risk when having surgery? Infection Adrenal storm Rejection of the kidney Rejection of the implanted lens
Infection
Which serum electrolytes findings should the nurse expect to find in an infant with persistent vomiting? K+, 3.2; Cl-, 92; Na+, 120 K+, 3.4; Cl-, 120; Na+, 140 K+, 3.5; Cl-, 90; Na+, 145 K+, 5.5; Cl-, 110; Na+, 130
K+, 3.2; Cl-, 92; Na+, 120
A nurse notes that the volume of the client's urinary elimination is less than 50 mL/day. What could be the possible cause for the low volume of urination by the client? Endocrine disease Diuretic medication Kidney dysfunction Liver disease
Kidney dysfunction
A male, lifetime smoker has died as a result of chronic obstructive pulmonary disease. Which phenomenon regarding his alveoli would his care team have expected in the weeks prior to his death? The presence of tubercles in the interalveolar spaces Large numbers of alveolar macrophages in septal connective tissue Proliferation of natural killer (NK) cells in the alveolar lumen Compensatory regeneration of type I alveolar cells
Large numbers of alveolar macrophages in septal connective tissue
Which instruction should be given to a woman newly diagnosed with genital herpes? Have your partner use a condom when lesions are present. Use a water-soluble lubricant for relief of pruritus. Obtain a Papanicolaou test every 3 years. Limit stress and emotional upset as much as possible.
Limit stress and emotional upset as much as possible.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Kidney Liver Large intestine Pancreas
Liver
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic alkalosis
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis
Metabolic alkalosis
The nurse is interpreting an electrocardiogram of a 65-year-old woman. Which should the nurse recognize as representing ventricular depolarization? T wave QRS complex P wave ST segment
QRS complex
Which health problem may be identified by a TORCH screening test? Rhinovirus and Ormond disease Tenovaginitis and human papillomavirus Chlamydia and rickets Rubella and herpes
Rubella and herpes
The clinic nurse is caring for a client diagnosed with leukopenia. What does the nurse know this client has? Too many erythrocytes A general reduction in neutrophils and basophils A general reduction in all white blood cells A decrease in granulocytes
A general reduction in all white blood cells
Of the following clients, who would be at highest risk for developing hyperkalemia? A postsurgical client whose thyroidectomy resulted in the loss of some of the parathyroid glands An older adult client experiencing severe vomiting and diarrhea as a result of influenza A male admitted for acute renal failure following a drug overdose A client diagnosed with an ischemic stroke with multiple sensory and motor deficits
A male admitted for acute renal failure following a drug overdose
The administration of immunizations to a client is a form of what type of immunity? Attenuated active immunity Artificial active immunity Passive active immunity Naturally active immunity
Artificial active immunity
The nurse is palpating the skin of a 30-year old client and documents that when picked up in a fold, the skin fold slowly returns to normal. What would be the next action of the nurse based on this finding? Assess the client for dehydration. Document a normal skin finding on the client chart. Report the finding as a positive sign for cystic fibrosis. Assess the client for cardiovascular disorders.
Assess the client for dehydration.
Which assessment finding would indicate to the health care team that a child would need to be reintubated due to improper placement of the endotracheal tube? There's water vapor on the inside of the tube. Symmetrical chest rise is observed. Breath sounds are heard over the abdominal area. Oxygen saturation rises from 78% to 93% after intubation.
Breath sounds are heard over the abdominal area.
A nurse is caring for a full-term neonate who is 24 hours old. Assessment findings include axillary temperature of 96.8° F (36° C), apical heart rate of 188 beats/minute, and respiratory rate of 48 breaths/minute. The mother reports that the neonate is lethargic when she tries to breast-feed and looks "like a rag doll." The mother also has a low-grade fever. Pulse oximetry reveals saturation of 89% on room air, and the neonate has dusky mucous membranes. What are the most appropriate nursing interventions? Select all that apply. Encourage the mother to breast-feed because the neonate is becoming dehydrated. Inform the parents that she wants to monitor the neonate closely. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Keep the neonate in the nursery, monitor vital signs every 2 hours, and inform the physician of the neonate's status when the physician makes routine rounds in the nursery. Provide blow-by oxygen and monitor the neonate's respiratory status.
Inform the parents that she wants to monitor the neonate closely. Observe the neonate carefully, contact the physician, and explain her suspicions of early neonatal sepsis. Provide blow-by oxygen and monitor the neonate's respiratory status.
A client has been prescribed valproic acid for the treatment of myoclonic seizures. When reviewing this client's latest laboratory results for signs of adverse effects, what results should the nurse prioritize? Electrolytes White cell differential Liver enzymes Creatinine clearance
Liver enzymes
Which is the main cause of anemia in a client with active uterine leiomyoma? Hemolysis Poor intake of foods containing iron Pressure of the fibroid on the pelvic veins Menorrhagia
Menorrhagia
A client has sought care because of a knee wound that appears to have become infected. Which process is a component of the cellular stage of inflammation that occurred earlier in his body's response to infection? Constriction of the small blood vessels near the wound Release of histamine Migration of leukocytes to the area of the wound Production of antibodies
Migration of leukocytes to the area of the wound
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen? Face tent Simple mask Nonrebreather mask Nasal cannula
Nonrebreather mask
A client who developed a deep vein thrombosis during a prolonged period of bed rest has deteriorated as the clot has dislodged, resulting in a pulmonary embolism. Which type of shock is this client at risk of experiencing? Distributive shock Obstructive shock Hypovolemic shock Cardiogenic shock
Obstructive shock
The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings? Obtain a 12-lead ECG tracing. Assess the client for pitting edema. Obtain an oxygen saturation level. Assess the client's capillary refill.
Obtain an oxygen saturation level.
The nurse is administering medications to a child with cystic fibrosis. Which method would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease? Draw up in syringe and administer subcutaneously. Pour in medication cup and have the child drink. Shake inhaler and hold close to mouth. Open capsule and sprinkle on food.
Open capsule and sprinkle on food.
A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Renal Musculoskeletal Integumentary Hepatic
Renal
A client with a systemic fungal infection has been prescribed ketoconazole 350 mg PO daily. What assessment should the nurse prioritize before administration? Review of liver enzyme levels Review of potassium, sodium and chloride levels Review of blood urea nitrogen and creatinine levels Assessment of cranial nerve function
Review of liver enzyme levels
A 90-year-old female patient is scheduled to undergo a partial mastectomy for the treatment of breast cancer. What nursing diagnosis should the nurse prioritize when planning this patient's postoperative care? Risk for Infection related to reduced immune function Risk for Impaired Memory related to old age Risk for Delayed Growth and Development related to prolonged hospitalization Risk for Decisional Conflict related to discharge planning
Risk for Infection related to reduced immune function
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? Encourage oral fluids. Start IV fluids with a normal saline solution bolus followed by a maintenance dose. Administer furosemide (Lasix) 20 mg IV Start hemodialysis after a temporary access is obtained.
Start IV fluids with a normal saline solution bolus followed by a maintenance dose.
