HESI Med Surg 266- may not be complete

During a preoperative assessment phone call, a client states taking several "pills" every day. Which response should the office nurse provide? A. "Bring all your pill containers to your preoperative appointment" B. "Discuss with your healthcare provider which medication to take before surgery". C. "Obtain a copy of your medications records from your healthcare provider" D. " Bring copies of all your prescriptions to your preoperative appointment"

A. "Bring all your pill containers to your preoperative appointment"

A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output

C. Fluid volume excess

A client receives a prescription for heparin sodium 20,000 units in 5% dextrose injection 500 ml to be infused at a rate of 880 units/hour. The nurse should program the infusion pump to deliver how many ml/hr.?

22

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a dependent edema for a client with progressive heart disease. Which is the most important action for the nurse to take?

Review ABGs

1) A client is being treated for acute kidney injury. On examination, the client has a weight gain of 4.4 lbs. (2kg) in 24 hours and exhibits changes in mental status. Which intervention should the nurse implement? a. Assess for dependent pitting edema b. Monitor daily sodium intake c. Record usual eating patterns d. Obtain serum creatinine levels daily

a. Assess for dependent pitting edema

A client with cirrhosis is admitted to the ICU because of deteriorating hepatic function. Which assessment finding warrants immediate intervention by the nurse?

a. Dependent pedal edema Dependent pedal edema is a condition where fluid accumulates in the lower legs and feet due to gravity, causing swelling. This is a serious concern for a client with cirrhosis because it indicates that the liver is not producing enough albumin. Albumin is a protein that helps keep fluid in the bloodstream; without enough of it, fluid leaks into surrounding tissues, causing edema. This can lead to complications such as cellulitis, skin ulcers, and difficulty walking. Therefore, it warrants immediate intervention by the nurse. The nurse should elevate the client's legs, monitor for signs of infection, and notify the healthcare provider for potential adjustment in treatment.

A client is hospitalized for...

a. Muscle weakness is an early sign

The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the clinical indicates a need for additional instructions? a. Oranges b. Kidney beans c. Liver d. Leafy green vegetables

a. Oranges

a client is diagnosed with diverticulosis following a colonoscopy. The client denies any symptoms and asks the nurse what to expect. Which is the best response by the nurse? a. Symptoms may not occur unless sacs become inflamed b. As the sacs enlarge pain may be experience in the lower abdomen c. Episodes of burning pain are commonly experienced d. Appetite loss, with resultant feelings of weakness, are common problems

a. Symptoms may not occur unless sacs become inflamed

While planning for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? a. Diminished blood flow b. Compression of a nerve c. Irritation of nerve endings d. Ischemic tissue changes

b. Compression of a nerve

A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment dinding is most often with hyperthyroidism? a. Periorbital edema b. Increase pulse rate c. Atrophied thyroid gland d. Diarrhea stools

b. Increase pulse rate

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min. respiration 16 breaths/min. oxygen saturation 96%, and blood pressure 116/70 mmhg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most crucial? a. Irregular pulse rate b. Complaint of radiating jaw pain c. St elevation in three leads d. Bile colored emesis

c. St elevation in three leads

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Remind the client to avoid high-fiber foods b. Instruct the client to use antacids only as a last resort c. Teach the client to elevate the head of the bed on blocks d. Encourage the client to lie down and rest after meals

c. Teach the client to elevate the head of the bed on blocks

The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred vision. Which outcome should the nurse include in the plan of care for this client? a. The client will take up to 4 nitroglycerine tablets sublingually for chest pain b. The nurse will encourage the client to walk thirty minutes every day c. The client's daily blood pressure will be less than 140/80 mmhg this month d. The client's blood pressure readings will be less than 160/90 mmhg

c. The client's daily blood pressure will be less than 140/80 mmhg this month

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. Blood ph. level b. Platelet count c. White blood cell (WBC) count d. Hematocrit

c. White blood cell (WBC) count

A client with a renal calculus us complaining of sever right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? a. Impaired renal function related to pain b. Nutritional deficit related to nausea c. Risk for aspiration related to vomiting d. Acute pain related to renal calculus

d. Acute pain related to renal calculus

The nurse has determined that a client with trigeminal neuralgia has a nursing problem of imbalanced nutrition, less than body requirements. Which factor should the nurse identify is most likely the etiology for this problem? a. Nausea b. Fatigue c. Altered taste sensation d. Pain when eating

d. Pain when eating

The healthcare provider prescribes streptomycin 300 mg IM q12 hours for a client with TB. The available vial is labeled 1g/2.5 mL. How many mL? Round to nearest tenth

0.8 ml

A client is receiving an IV infusion of regular insulin 60 units in 100mL of normal saline at 5 units/hour. How many mL/hour? Round to nearest whole number

8 mL

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to tell the healthcare provider? A. Distended, hard, and rigid abdomen B. Bile-stained emesis C. Clay-colored stool D. Radiating, sharp pain in right shoulder.

A. Distended, hard, and rigid abdomen It could indicate a serious complication such as gallbladder perforation or peritonitis, which is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. This is a medical emergency that requires immediate attention. The nurse should report this finding to the healthcare provider immediately because it could lead to severe infection or sepsis if not treated promptly. Other symptoms of this condition may include severe abdominal pain, fever, nausea, and vomiting.

A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider. A. Driving a car B. Walking around the house C. Eating high-fiber foods D. Kegel exercises

A. Driving a car

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? A. Upper mid-abdominal pain described as gnawing and burning B. Frequent use of chewable and liquid antacids for indigestion C. Marked loss of weight and appetite over the last 3 or 4 months D. Severe abdominal cramps and diarrhea after eating spicy foods

A. Upper mid-abdominal pain described as gnawing and burning Peptic Ulcer Disease (PUD) is a condition that involves the formation of open sores or ulcers in the lining of the stomach or the upper part of the small intestine. The most common symptom of PUD is a burning or gnawing pain in the middle or upper stomach between meals or at night. This pain can last from a few minutes to a few hours and can be mild or severe. Therefore, if a client reports experiencing a gnawing and burning sensation in the upper mid abdominal area, it supports the medical diagnosis of PUD. This is because the reported symptoms align with the typical symptoms of PUD.

The nurse is assessing a client who is receiving enteral feedings. Which clinical data indicates the client may not be tolerating the tube feedings? Select all that apply. A Abdominal tympany B Abdominal cramping. C Flatulence. D Nausea and vomiting. E Absent bowel sounds.

B Abdominal cramping. D Nausea and vomiting. E Absent bowel sounds.

A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition? A Colloidal oatmeal-based lotion B Topical corticosteroids. C Topical analgesics. D Topical antifungal

B Topical corticosteroids. Topical corticosteroids are often prescribed to treat psoriasis. They work by reducing inflammation, relieving itching, and blocking the overproduction of skin cells. These effects can help to reduce the symptoms of psoriasis, including the silvery, scaly areas on the elbows and palms mentioned in the question. The nurse should teach the client how to apply the topical corticosteroid correctly. This usually involves applying a thin layer of the medication to the affected areas of skin once or twice a day. The nurse should also educate the client about potential side effects, which can include skin thinning and irritation. It's important for the client to follow the prescribed treatment plan and to continue using the medication even if symptoms improve, as stopping suddenly can cause psoriasis to flare up

Which nursing problem should be included in the plan of care for the client with heart failure? A. Ineffective tissue perfusion, peripheral, related to venous engorgement. B. Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility C. Pain related to myocardial ischemia secondary to cell destruction D. Imbalance nutrition, more than body requirement, related to excessive caloric intake

B. Activity intolerance related to oxygen deficit secondary to inefficient cardiac contractility

When providing care for an unconscious client who has seizures, which nursing intervention is most essential? A. Keep the room at a comfortable temperature. B. Ensure oral suction is available. C. Maintain the client in a semi Fowler's position. D. Provide frequent mouth care.

B. Ensure oral suction is available. The answer is "Ensure oral suction is available" because when a client is having a seizure, they may produce excess saliva or vomit, which can lead to choking or aspiration if not properly managed. Aspiration can cause serious complications such as pneumonia. An unconscious client cannot manage their own secretions, so it's crucial for the nurse to have oral suction available to clear the client's airway and prevent these complications. This is considered the most essential intervention because maintaining a clear airway is always the top priority in patient care, especially for unconscious clients or those having seizures.

An adult woman with Grave's disease is admitted with severe dehydration and malnutrition. She is currently restless and refusing to eat. What action is most important for the nurse to implement? A. Teach the client relaxation techniques B. Maintain a patent intravenous site C. Determine the client's food preference D. Keep room temperature cool

B. Maintain a patent intravenous site the most important action for a nurse to implement in this case would be to maintain a patent IV site. This is because the woman is severely dehydrated and malnourished, and she is refusing to eat. A patent (open and functioning) IV site would allow the healthcare team to provide necessary fluids and nutrients directly into her bloodstream, bypassing the need for oral intake. This would help to address her immediate physical needs and stabilize her condition.

A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with someone he casually met. Which action should the nurse implement? A. Identify all sexual partners in the last four days B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Observe the perineal areas for a chancroid-like lesion

B. Obtain a specimen of urethral drainage for culture The nurse should obtain a specimen of urethral drainage for culture because the male patient's symptoms suggest a possible sexually transmitted infection (STI). Burning during urination is a common symptom of STIs such as gonorrhea or chlamydia. The fact that the patient had sexual intercourse with a casual partner four days ago further increases the likelihood of an STI. A culture of urethral drainage can help identify the specific bacteria causing the infection, which is crucial for determining the appropriate treatment.

The nurse is assessing a client who is one-day post parathyroidectomy and finds that the client is experiencing stridor. After notifying the HCP the nurse should prepare for which procedure? A. Pacemaker placement B. Tracheostomy placement C. Nasogastric tube insertion D. Central line insertion

B. Tracheostomy placement Stridor is a high-pitched, wheezing sound caused by disrupted airflow. It often indicates a blockage or obstruction in the upper airway. After a parathyroidectomy, stridor can be a sign of laryngeal edema or vocal cord paralysis, both of which can obstruct the airway and lead to respiratory distress. The nurse's first step should be to notify the healthcare provider, as the question states. After that, the nurse should prepare for a procedure to secure the airway and ensure the client can breathe. In this case, the procedure is a tracheostomy placement. A tracheostomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is inserted through this opening to provide an airway and to remove secretions from the lungs. This procedure is often done in emergency situations when the airway is blocked.

A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the health care provider? A. Blood glucose B. Troponin I C. Hematocrit D. Oxygen saturation

B. Troponin I

To reduce the risk for pulmonary complications for a client with ALS, which interventions should the nurse implement? Select all that apply a. initiate passive range of motion b. establish a regular routine c. teach the client breathing exercises d. perform chest physiotherapy e. encourage use of incentive spirometer

C, D, E c. Teach The Client Breathing Exercise: Breathing exercises can help to improve lung capacity and efficiency. They can also help to strengthen the muscles used for breathing, which can be particularly beneficial for clients with ALS, as the disease often weakens these muscles. d. Chest Physiotherapy: This is a group of therapies for mobilizing pulmonary secretions. It includes postural drainage, chest percussion, and vibration. These techniques help to clear mucus from the lungs, reducing the risk of infection and improving lung function. e. Encourage use of incentive spirometer: An incentive spirometer is a device used to help patients improve the functioning of their lungs. It encourages deep and sustained breaths, which can help to prevent the development of atelectasis (collapsed lung) and pneumonia, both of which are potential pulmonary complications of ALS.

A client with history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Call the clinic if undesirable side effects of medications occur B. Avoid crowded enclosed areas to reduce pathogen exposure C. Increase the daily intake of oral fluids to liquefy secretions D. Teach anxiety reduction methods for feelings of suffocation

C. Increase the daily intake of oral fluids to liquefy secretions

A male client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 F (39.4C) and an infusion of normal saline is initiated at 250 ml/hr. which assessment finding should the nurse report to the healthcare provider immediately? A. Petechial hemorrhage under client's eyes B. Dark green colored emesis C. Right lower abdomen rebound tenderness D. Severe headache with photosensitivity

C. Right lower abdomen rebound tenderness

The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB? A. Hemoccult test on sputum collected from hemoptysis B. Chest x-ray or computerized tomography (CT) C. Sputum culture positive for Mycobacterium tuberculosis D. Positive purified protein derivative (PPD) skin test

C. Sputum culture positive for Mycobacterium tuberculosis in practice, the initial step may involve imaging studies for screening, but the definitive confirmation of active TB is achieved through a positive sputum culture. The other options (A and D) are not direct confirmatory tests for active TB. The hemoccult test is used for detecting blood in the stool (not sputum), and the PPD skin test indicates exposure to the tuberculosis bacillus but does not confirm active disease. a definitive diagnosis of active tuberculosis (TB) is confirmed by a positive culture for Mycobacterium tuberculosis. However, the reason why "B. Chest x-ray or computerized tomography (CT)" might be considered as an acceptable answer is that imaging studies, such as chest x-ray or CT, are often used as initial screening tools for suspected TB cases.

In assessing a client following lithotripsy with stent, which data indicates to the nurse that the procedure was successful? A. Urine is pale pink with no observable blood clots B. Client denies urinary frequency, urgency or dysuria C. Stone fragments are collected when straining the client's urine D. Serum creatinine and BUN levels are within normal limits

C. Stone fragments are collected when straining the client's urine

The nurse brings a scheduled dose of docusate calcium to a male client who has cirrhosis of the liver. The client states that he never had bowel problems and does not need a stool softener. Which action should the nurse take? A. Document the client's refusal to take the prescribed medication B. Listen to the client's bowel sounds to determine the need for the medication C. Whithold the medication until consulting the healthcare provider D. Explain the importance of taking measures to reduce the risk off bleeding.

C. Withhold the medication until consulting with the healthcare provider

The nurse is assessing a client who has returned from surgery following a thoracotomy . Which finding indicates the client is experiencing the client is experiencing adequate gas exchange? A. The client demonstrates effective coughing and deep breathing exercises. B. Current arterial blood gas results are pH 7.30, Pa 0275, and PaCO2 48 C. The client's pulse rate is 82 and respiratory rate is 16 breaths per minute D. An oxygen saturation reading of 96% is obtained using pulse oximetry

D. An oxygen saturation reading of 96% is obtained using pulse oximetry

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity B. Palpable cervical lymph nodes. C. Jugular vein distention D. Carotid bruit

D. Carotid bruit A carotid bruit may indicate carotid artery disease, which is a risk factor for stroke. Nuchal rigidity (Option A) is associated with meningitis, not specifically with an increased risk of stroke. Palpable cervical lymph nodes (Option B) and jugular vein distention (Option C) are not directly related to the risk of stroke.

Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome? A. Visible swelling of the neck, with no pain B. Husky voice and complaints of hoarseness C. Warm, soft, moist, salmon-colored skin D. Central-type obesity, with thin extremities

D. Central-type obesity, with thin extremities Cushing's syndrome is a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol. Some of the common symptoms of Cushing's syndrome include: 1. Central obesity: This is characterized by a rounded, "moon" face, excess fat in the neck and upper back, and a protruding abdomen. The fat distribution is central, meaning it is concentrated in the body's core and not evenly distributed throughout the body. 2. Thin extremities: While the body's core accumulates fat, the arms and legs (the extremities) often remain thin. This is due to muscle wasting and fat redistribution caused by excess cortisol. Therefore, in a client diagnosed with Cushing's syndrome, the nurse should document these characteristic physical findings: central-type obesity and thin extremities.

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Ask the client to choose which medication is needed for the pain D. Compare the client's pain scale rating with the prescribed dosing.

D. Compare the client's pain scale rating with the prescribed dosing

An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal

D. Continue to monitor the fingers until color returns to normal

An adult male client is admitted for Pneumocystis carinii pneumonia (PCP) secondary to acquired immune deficiency syndrome (AIDS). While hospitalized, the client receives IV pentamidine isethionate therapy. In preparing this client for discharge, which important aspect regarding his medication therapy should the nurse explain? A. AZT (Azidothymidine) therapy must be stopped when the IV or aerosol pentamidine is being used B. IV pentamidine may offer protection against other AIDS-related conditions, such as Kapoi's sarcoma C. IV pentamidine will be given until oral pentamidine can be tolerated D. If will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

D. If will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best indication that the client is adhering to the prescribed diabetic regimen? a. Hemoglobin A1C of 6.2% b. Postprandial plasma glucose of 225 mg/dl (12.49 mmol/l). c. Fasting plasma glucose of 189 mg/dl (10.49). d. High-density lipoprotein of 40 mg/dl (1.03Mmol/l).

Hemoglobin A1C of 6.2%

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure? a. I have a headache that gets worse when I sit up b. I feel sick to my stomach and am going to throw up c. I am having pain in my lower back when I move my legs d. My throat hurts badly when I swallow and when I talk

a. I have a headache that gets worse when I sit up The client's headache worsening when sitting up after a lumbar puncture indicates a complication called post-dural puncture headache, which can be explained by imagining a leak in a water balloon causing the water level to drop when pressure is applied. Post-lumbar puncture headache is a common complication of the procedure. The headache is typically described as a dull or throbbing pain that is worse when the client is upright and improves when the client is lying down. Option B, feeling sick to the stomach and vomiting, may be a side effect of the procedure or a reaction to the anesthesia, but it is not a complication of the procedure. Option C, pain in the lower back when moving the legs, may be a normal side effect of the procedure, but it is not a complication. Option D, a sore throat, is not related to the lumbar puncture procedure.

When planning care for a client with rheumatoid arthritis, which intervention is most important to the nurse to include? a. Implement measures to manage chronic pain b. Schedule rest periods between activities to minimize fatigue c. Teach coping skills for living with chronic illness d. Provide assistive devices to empower client independence

a. Implement measures to manage chronic pain

A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15 mm induration. Which intervention should the nurse implement first? a. Initiate airborne particulate isolation precaution b. Provide a mask for the client to wear in public c. Collect a sputum specimen for acid-fast bacillus d. Administer the initial dose of rifampin and isoniazid

a. Initiate airborne particulate isolation precaution

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Irregular apical pulse b. Purple marks on skin of the abdomen c. Pitting ankle edema d. Quarter size blood spot on dressing

a. Irregular apical pulse

An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular , respirations 38 breaths/min. blood pressure 168/100 mmhg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg iv, which assessments should the nurse obtain to determine the client's response to treatment? Select all that apply a. Lung sounds b. Skin elasticity c. Urinary output d. Oxygen saturation e. Pain scale

a. Lung sounds c. Urinary output d. Oxygen saturation

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs. Heart rate 140 beats/min, respirations 26 breaths/min, and blood pressure 140/90 mmhg. Which interventions is most important for the nurse to implement? a. Medicate for pain and monitor vital signs according to protocol b. Encourage the client to splint the incision with a pillow to cough and deep breathe c. Administer intravenous fluid bolus as prescribed by the healthcare provider d. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter

a. Medicate for pain and monitor vital signs according to protocol

An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenlt becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement? Select all that apply a. Observe respiratory rate and pattern b. Palpate for bladder pain or distention c. Check a blood sample for glucose level d. Report any changes in blood pressure e. Prepare to administer regular insulin

a. Observe respiratory rate and pattern c. Check a blood sample for glucose level d. Report any changes in blood pressure

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? a. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L) b. Client's pulse oximeter reading is 96% c. Surgical consent form is not signed d. Preoperative chest x-ray report is not available

a. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L)

A client with chronic obstructive pulmonary disease (COPD) is admitted for a non-emergent cholecystectomy. The admission arterial blood gas (ABG) results are pH 7.35, PaCO2 48 mmHg, HCO3 28 mEq/L. Based on these findings, which intervention should the nurse implement? a. Prepare the client for surgery b. Obtain sputum specimen c. Insert additional IV catheter d. Administer PRN bronchodilator

a. Prepare the client for surgery The ABG results indicate a compensated respiratory acidosis, which may not require immediate intervention before the surgery. Therefore, the priority at this time would be to prepare the client for the planned cholecystectomy.

A client uses triamcinolone, a corticosteroid ointment to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment for the client to see the healthcare provider b. Advise the client to apply plastic wrap over the ointment to promote healing c. Instruct the client to continue the ointment until all erythema is relieved d. Explain that the client needs to complete all prescribed doses of the medication

a. Schedule an appointment for the client to see the healthcare provider The client's symptoms of increased erythema (redness) and purulent exudate (pus) suggest a possible infection or worsening of the skin condition. Triamcinolone is a corticosteroid that reduces inflammation and itching, but it does not treat infections. Therefore, the client should not continue using the ointment without medical advice (option b), nor should they cover the area with plastic wrap (option c), which could exacerbate the infection. Completing all doses of the medication (option a) is not relevant if the condition is worsening. The best course of action is to schedule an appointment with the healthcare provider (option d) to evaluate the client's condition and adjust the treatment plan if necessary.

The nurse is assessing a client whose child was sent home with pediculosis capitis. The client reports having lice and nits in the hair follicle and on the scalp. Which finding should the nurse associate with pediculosis on further inspection? a. Small red bumps on the scalp, neck and shoulders b. Painful blisters on the scalp c. Hair loss d. Dandruff

a. Small red bumps on the scalp, neck, and shoulders Pediculosis capitis, commonly known as head lice, is an infestation of the hair and scalp by the human head louse. It is a common condition, especially in children. The symptoms of pediculosis capitis include itching, visible lice on the scalp, and the presence of nits (lice eggs) on hair shafts. However, one of the most telling signs of a lice infestation is the presence of small red bumps on the scalp, neck, and shoulders. These bumps are a result of an allergic reaction to lice bites. When a louse bites, it injects saliva into the scalp to prevent blood from clotting as it feeds. This saliva can cause an allergic reaction in some people, leading to the formation of these small red bumps. Therefore, if a client reports having small red bumps on the scalp, neck, and shoulders, the nurse should associate this finding with pediculosis capitis on further investigation.

The nurse has conducted a cancer prevention community education program. In elevating the participants' understanding of the carcinogens, which statement indicates an accurate understanding? a. Substances that change a cell so that it becomes cancerous are potential sources of cancer. b. Carcinogens are in the environment and cannot be avoided c. Environmental factors such as sunlight and chemicals can cause cancer to spread. d. Carcinogens are substances that contain cancerous cells

a. Substances that change a cell so that it becomes cancerous are potential sources of cancer

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain

a. low back pain and hypotension Low back pain and hypotension may indicate a severe transfusion reaction, such as hemolytic transfusion reaction, and require immediate medical attention. These symptoms suggest a potentially life-threatening reaction that necessitates urgent evaluation and intervention by the healthcare provider.

The nurse is assessing a client who has a bowel obstruction. Which observation should the nurse expect to find? Select all that apply a. Abdomen soft on palpation b. Abdominal distention c. Dullness on percussion d. Peristaltic waves observed e. High-pitched bowel sounds

b. Abdominal distention c. Dullness on percussion e. High-pitched bowel sounds When assessing a client with a bowel obstruction, the nurse should expect to find the following observations: Abdominal distention: Small bowel obstruction (SBO) refers to a complete or partial blockage in the small intestine, which can lead to abdominal distention. Dullness on percussion: This can be an indication of fluid or gas accumulation in the obstructed bowel, leading to dullness on percussion. High-pitched bowel sounds: Bowel sounds may be reduced and high-pitched in the case of a small bowel obstruction. The abdomen is usually not soft on palpation in the presence of a bowel obstruction, and peristaltic waves are not observed. Therefore, options B, C, and E are the correct answers.

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? Select all that apply a. Hypothyroidism b. Abdominal obesity c. Hyperglycemia d. Blood pressure of 150/96 e. Elevated high-density lipoproteins f. Increased triglyceride levels

b. Abdominal obesity c. Hyperglycemia d. Blood pressure of 150/96 f. Increased triglyceride levels

A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse perform? a. Assess right radial pulse volume b. Administer a PRN analgesic c. Implement distraction techniques d. Measure the blood pressure

b. Administer a PRN analgesic

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a. Obtain a soft diet for the client. b. Administer a topical analgesic per PRN protocol. c. Cleanse the tongue and mouth with glycerin swabs. d. Encourage frequent mouth care.

b. Administer a topical analgesic per PRN protocol.

A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make? a. Evidence of the spread of the disease to the kidney. b. Confirmation of the autoimmune disease process. c. Representative of a decline in the client's condition. d. Indication of the onset of joint degeneration.

b. Confirmation of the autoimmune disease process. Raised levels of serum rheumatoid factor are diagnostic of rheumatoid arthritis. In response to an autoimmune reaction, the body creates the autoantibody known as the rheumatoid factor. It is a byproduct of the immune system and may be measured to diagnose inflammatory autoimmune disorders. When the rheumatoid factor is high, it means that the body is creating an abnormally high amount of this antibody, which points to an aberrant immunological response and the existence of the illness. Therefore, this observation should be interpreted by the nurse as further evidence of an autoimmune disease process.

When preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should describe which situation as requiring the most immediate action by the client or family? A. Hypoglycemia shock B. Decreased renal glucose threshold C. Ketoacidosis angina. D. Somogyi effect (rebound hyperglycemia)

Hypoglycemic shock Hypoglycemic shock, also known as insulin shock, is a severe form of hypoglycemia that can be life-threatening if not treated immediately. It occurs when the level of glucose in the blood drops too low, usually below 70 mg/dL. This can happen if a person with diabetes takes too much insulin, doesn't eat enough food, or exercises without adjusting their insulin dosage or eating more food. Symptoms of hypoglycemic shock can include confusion, dizziness, feeling shaky, and changes in behavior. If left untreated, it can lead to seizures, loss of consciousness, and even death. Therefore, when preparing a teaching plan for a client newly diagnosed with diabetes mellitus, the nurse should emphasize the importance of recognizing the signs of hypoglycemic shock and taking immediate action. This could include eating or drinking something with sugar, checking blood sugar levels, and seeking medical attention if symptoms do not improve.

Which nursing assessment is the priority when caring for a client with acute adrenocortical insufficiency? a. Determining fall risk b. Monitoring blood pressure c. Noting areas of skin breakdown d. Evaluating mood and behavioral changes

Monitoring blood pressure Acute adrenocortical insufficiency can lead to hemodynamic instability, including hypotension, which makes monitoring blood pressure a critical nursing assessment in this situation. This assessment is essential for identifying and managing potential complications associated with acute adrenocortical insufficiency.

The nurse auscultates a client's heart sounds and hers a mid-systolic click associated with mitral valve prolapse. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? a. 2D-echocardiography b. 12-lead electrocardiogram c. Troponin and CK-MB levels CT scan of the chest

a. 2D-echocardiography

The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective? a. Absence of coarse crackles b. Increase in breath sounds c. Increase in respiratory rate d. Absence of fine crackles

a. Absence of coarse crackles A) Correct - The absence of coarse crackles indicates that the airway has been cleared of secretions effectively, and the lung sounds are clearer. B) Incorrect - An increase in respiratory rate could indicate distress rather than the effectiveness of the intervention. C) Incorrect - An increase in breath sounds may not necessarily indicate the effectiveness of the intervention, as the quality of breath sounds matters more than the increase. D) Incorrect - The absence of fine crackles might not directly indicate the effectiveness of the intervention, as other factors can influence lung sounds.

The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today, he is experiencing an acute exacerbation and tells the nurse his PERF is 60% of his personal best reading. He is experiencing expiratory and inspiratory wheezes and has a respiratory rate of 24 breaths/min. and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? a. Albuterol b. Salmeterol c. Oxygen d. Epinephrine

a. Albuterol

A male client who feels chronically fatigued has a hemoglobin of 11.0 g/dL (110mmol/L), hematocrit of 34% (0.34), and microcytic and hypochromic red blood cells (RBCs). Based on these findings which dinner selection should the nurse suggest to the client? a. Beef steak with steamed broccoli and orange slices b. Brailed white fish with a sweet potato c. Grilled shrimp and seasoned rice with asparagus salad d. Cheese pasta and a lettuce and tomato salad

a. Beef steak with steamed broccoli and orange slices

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care? a. Begin straining all urine b. Initiated cardiac telemetry c. Implement seizure precautions d. Administer a PRN dose of a laxative

a. Begin straining all urine

An adult client comes to the urgent care clinic 5 days after being diagnosed with influenza. The client is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Check his oxygen saturation b. Administer an oral antipyretic c. Obtain a sputum sample for culture d. Auscultate bilateral lung sounds

a. Check his oxygen saturation The influenza virus is one of the common causes of upper respiratory tract infections. In this case, the patient presents with shortness of breath, fever, and green sputum. The most important thing for the nurse to do is to check the patient's oxygen saturation level. If this is below 94%, then interventions such as administering oxygen may be done already. A low oxygen saturation may lead to a state of hypoxia and important organs, such as the brain, heart, and kidneys, may not be provided with enough oxygen.

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? a. Describe the use of an elimination diet to find trigger foods b. Instruct the client to avoid foods with gluten, such as whole bread c. Advise the client to limit foods that are high in calcium and iron d. Explain that the need to restrict fluids is the primary limitation

a. Describe the use of an elimination diet to find trigger foods

A client who had surgery yesterday is becoming increasingly anxious. The client's respiratory rate has increased to 38 breaths/minute. The client has a nasogastric tube to low intermittent suction with 500 ml of yellow-green drainage over the last four hours. The client's arterial blood gases (ABGs) indicate a decreased CO2 and an increased serum PH. Which serum laboratory value should the nurse monitor first? a. Electrolytes. b. Creatinine. c. Platelet count. d. Albumin.

a. Electrolytes.

A client with metastatic cancer reports of a pain level of a 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care? a. Frequently evaluate the client's pain b. Monitor client for break-through pain c. Administer analgesics on a fixed and continuous schedule d. Replace transdermal analgesic patches every 72 hours

a. Frequently evaluate the client's pain This is important because the client's pain level has not improved after the administration of an IV analgesic, and frequent evaluation will help in assessing the effectiveness of the current treatment and making necessary adjustments

The nurse is assessing a client who has herpes zoster, which question will allow the nurse to gather further information about that condition? a. Has everyone at home already had varicella b. Do your family members share combs and brushes c. Do you have any dry patches on your feet and hands d. Have the antifungal creams been effective

a. Has everyone at home already had varicella

A client with a history of gastrointestinal reflux disease (GERD) reports a new onset of painful swallowing to the home health nurse. How should the nurse respond? a. Explain that this is a common problem in GERD that comes and goes b. Determine if the client has been taking his medications as prescribed c. Measure the client's vital signs and oxygen saturation immediately d. Encourage the PRN use of throat lozenges to reduce his comfort

b. Determine if the client has been taking his medications as prescribed The nurse should first determine if the client has been taking his medications as prescribed (option d). This is because GERD (Gastroesophageal Reflux Disease) is a chronic condition that is often managed with medications. If the client is not taking his medications as prescribed, it could lead to worsening symptoms, including painful swallowing. The other options do not directly address the potential cause of the new symptom. Throat lozenges (option a) may temporarily relieve discomfort but won't treat the underlying issue. Measuring vital signs and oxygen saturation (option b) is not directly related to GERD symptoms. Lastly, while GERD can cause intermittent symptoms (option c), it's important to not dismiss new or worsening symptoms without further investigation.

Following a transurethral resection of the prostate (TURP), a client discharge from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? a. Avoid driving a car for 2 weeks b. Drink 3 liters of water each day c. Eliminate all spicy foods from your diet d. Clamp the catheter when taking a shower

b. Drink 3 liters of water each day

Which dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's syndrome? a. Avoid hot beverages b. Eliminate caffeine intake c. Reduce saturated fat intake d. Increase calcium intake

b. Eliminate caffeine intake Raynaud's Syndrome is a condition that affects blood flow to certain parts of the body, usually the fingers and toes. It is triggered by cold temperatures or stress. Caffeine is a stimulant that can constrict blood vessels, which can exacerbate the symptoms of Raynaud's Syndrome. Therefore, eliminating caffeine intake can help reduce episodes of this condition. This is because without the constriction caused by caffeine, blood flow may improve, potentially reducing the frequency and severity of Raynaud's episodes.

Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Citrus fruits and juices b. Fortified milk and cereal c. Red meals and eggs d. Green leafy vegetables

b. Fortified milk and cereal

A client with Chron's disease is admitted to the medical unit with three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first? a. Send client to X-ray for a flat plate of the abdomen b. Insert a nasogastric tube (NG tube) and attach to low intermittent suction c. Place an indwelling urinary catheter and attach a bedside drainage unit d. Give a prescribed analgesic for a temperature above 101 F

b. Insert a nasogastric tube (NG tube) and attach to low intermittent suction The correct answer is b, insert a nasogastric tube (NGT) and attach to low intermittent suction. This allows the provision of nutrition to the patient and decompresses the abdomen. The tube is attached to a low intermittent suction to prevent adherence to the walls of the stomach.

A client is receiving combination chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? a. Polycythemia b. Leukopenia c. Ascites d. Nystagmus

b. Leukopenia When a patient is undergoing chemotherapy, the drugs not only kill cancer cells but can also affect healthy cells, including white blood cells. This can lead to leukopenia, leaving the patient more susceptible to infections.

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. Sexual activities may be resumed upon return home b. Light housekeeping is permitted but avoid heavy lifting c. Use a metal eye shield on operative eye during the day d. Administer eye ointment before applying eye drops

b. Light housekeeping is permitted but avoid heavy lifting

A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? a. Log roll the client and place adult disposable briefs beneath the client b. Maintain traction while the client uses a female urinal c. Insert an indwelling urinary catheter preoperatively Release the traction so the client can use a bedpan

b. Maintain traction while the client uses a female urinal

During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a male client recently diagnosed with aplastic anemia. The nurse reviews his stat serum laboratory values which reveal platelets 50,000/mm3, white blood cells 3,000/mm3 (3 x 109/L) and red blood cells 2.5 million/mm3 (2.5 x 1012L). which actions should the nurse implement? Select all that apply a. Initiate sepsis protocol b. Monitor for signs of bleeding c. Implement contact precautions d. Provide a soft-bristle tooth brush e. Infuse blood products as prescribed

b. Monitor for signs of bleeding d. Provide a soft-bristle tooth brush e. Infuse blood products as prescribed

A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? a. Obtain a sample of the drainage to send to the lab b. Prepare the client to return to the operating room c. Bring additional sterile dressing supplies to the room d. Auscultate the abdomen for bowel sounds activity

b. Prepare the client to return to the operating room

While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? a. evaluate for evidence of incontinence b. observe for prolonged periods of apnea c. document details of the seizure activity d. observe for lacerations to the tongue

b. observe for prolonged periods of apnea

female client who works as a data entry clerk is concerned as to how her recent diagnosis of raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? a. obtain a keyboard designed to limit writ flexion b. use a space heater to keep the workplace warm c. take a multivitamin that contains vitamin D daily d. keep both hands elevated during work breaks

b. use a space heater to keep the workplace warm

Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with lens implant? a. Turn, cough, and deep breath every two hours b. Sleep flat in a supine position c. Administer a stool softener d. Observe pupil response of the right eye

c. Administer a stool softener The answer is related to the post-operative care of a patient who has undergone a left eye cataract extraction with lens implant. After this type of surgery, it's important to avoid any activities that could increase pressure in the eye, such as straining during bowel movements. Constipation can lead to straining, so taking a stool softener can help prevent this. Therefore, the nurse should include information about administering a stool softener in the discharge instructions to help the patient manage their bowel movements without straining and potentially harming their eye.

The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? a. Ecchymosis area b. Pulselessness c. Enlarged vein d. Redness

c. Enlarged vein

A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem? a. Brown, foamy urine b. Anorexia c. Hematemesis d. Clay-colored stool

c. Hematemesis

A client with eczema is applying 10% urea cream onto the affected areas. Which finding reflects the expected therapeutic response? a. Reduce pain in eczematous areas b. Healing with a return to normal skin appearance c. Hydration of affected dry skin areas d. Decreased weeping of ulceration in affected areas

c. Hydration of affected dry skin areas

A male client with acquired immune deficiency syndrome (AIDS) and pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to this client's questions? a. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms b. Exposure to multiple environment infectious agents overburdens the immune system until it fails c. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages d. The humoral immune response lacks B cells that form antibodies and opportunistic infections result

c. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages

Which teaching a client with parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? a. Reduce the inflammatory process improving nerve transmission and function b. Shows the scarring in the myelin sheath improving muscle tone and strength c. Increase the amount of dopamine available for muscles to function correctly d. Acts as an antiseizure medication reading the tremors caused by the disease

c. Increase the amount of dopamine available for muscles to function correctly

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? a. Computerized tomography (CT) scan b. Magnetic resonance imaging (MRI) c. Lumbar puncture d. Skull radiography

c. Lumbar puncture

The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? a. "milk" the tube to remove any clots b. Obtain a specimen of the drainage for culture c. Maintain the current IV antibiotics schedule Schedule a portable chest x-ray per PRN protocol

c. Maintain the current IV antibiotics schedule

In providing discharge teaching to a client with chronic obstructive pulmonary disease which instruction is most important for the nurse to emphasize? a. Avoid going outdoors whenever the pollen count is high b. Keep a food diary for one week and bring to next appointment c. Notify the healthcare provider of any change in sputum color d. Stay in the house if the outdoor temperature is hot and humid

c. Notify the healthcare provider of any change in sputum color This instruction is crucial because a change in sputum color can indicate an exacerbation of the client's condition, such as a respiratory infection, which requires prompt medical attention. Monitoring and reporting changes in sputum color can help in the early detection and management of potential complications associated with COPD

A client has an absolute neutrophil count (ANC) of 500/mm3 (0.5 x 109/L) after completing chemotherapy. Which interventions is most important for the nurse to implement? a. Assess vital signs every 4 hours b. Implement bleeding precautions c. Place the client in protective isolation d. Review needs for pneumococcal vaccine

c. Place the client in protective isolation

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test results should the nurse review? a. Amylase b. Glucose c. Platelet count d. White blood cell count

c. Platelet count

A 55-year-old female with symptoms of osteoarthritis asks which form of exercise would be most beneficial. Which is the best response by the nurse? a. Limit your exercise to just your daily activities b. Jogging or running are excellent aerobic exercises c. Swimming is an excellent exercise for you d. Tennis racquetball will increase your muscle strength

c. Swimming is an excellent exercise for you Osteoarthritis is a degenerative joint disease that can cause pain and stiffness, particularly with high-impact activities. Therefore, the best exercise for someone with osteoarthritis is one that is low-impact but still provides aerobic benefits.

The nurse is preparing to discharge a client with a history of celiac disease who now has developed multiple sclerosis which instructions most important for the nurse to include in the discharge teaching plan? a. Increase daily intake of sodium in a diet b. Use a walker when weakness occurs c. Take prescribed cortisone accurately d. Avoid extreme environmental temperatures

c. Take prescribed cortisone accurately

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? a. Give maximum dosage when score reaches 10 b. Alternate IV and IM analgesic medications. c. Educate client on signs and symptoms of narcotic dependency d. Administer opioids and nonopioid medications simultaneously

d. Administer opioids and nonopioid medications simultaneously The use of multimodal analgesia, which involves administering opioids and nonopioid medications simultaneously, is recommended for managing severe cancer pain. This approach can provide more effective pain relief and improve the client's comfort. Therefore, it is the most appropriate intervention for the nurse to implement in this situation.

The nurse teaches a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum? a. Restrict fluids before expectorating the sputum specimen. b. Obtain the specimen before bedtime. c. Avoid mouth care before collecting the sputum. d. Breathe deeply, followed by coughing up the sputum.

d. Breathe deeply, followed by coughing up the sputum

One hour after major abdominal surgery, a client in the post anesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mmhg. Fifteen minutes later, it is 114/72 mmhg. Which action should the nurse take first? a. Review the client's baseline bp trends b. Increase frequency of BP assessment c. Encourage the client to breathe deeply d. Check the abdominal surgical dressing

d. Check the abdominal surgical dressing

When planning care for a client newly diagnose with open angle glaucoma, the nurse identifies a priority nursing problem of, "visual sensory/perceptual alterations." This problem is based on which etiology? a. Limited eye movement b. Photosensitivity c. Blurred distance vision d. Decreased peripheral vision

d. Decreased peripheral vision

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the healthcare provider? a. Sore throat and hoarseness b. No gag reflex after thirty minutes c. Slight blood-tinged sputum d. Dyspnea and dysphagia

d. Dyspnea and dysphagia

A female client who recently married returns to the clinic with recurrent cystitis and urethritis. The client presents with pain on urinating, urinary frequency, and urgency. Which additional information should the nurse obtain? a. Review a recent urinalysis for calcium oxalate precipitants b. Examine client's history for any genetic renal disease c. Ask if she has recently had a streptococcus infection d. Inquire about her hygiene practices after sexual intercourse

d. Inquire about her hygiene practices after sexual intercourse

The nurse is evaluating a male client's understanding of diet teaching about DASH (dietary approaches to stop hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? a. Uses only lactose-free dairy products. b. Enjoys fat free yogurt as an occasional snack food c. No longer includes grains in his daily diet d. Carefully cleans and peels all fresh fruit and vegetables

Enjoys fat free yogurt as an occasional snack food

A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Evaluate the application of the splint to the left leg B. Offer ice chips and oral clear liquids C. Administer oral antispasmodics and narcotic analgesics D. Verify pedal pulses using a doppler pulse device E. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure

A. Evaluate the application of the splint to the left leg D. Verify pedal pulses using a doppler pulse device E. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure The answer to this question involves understanding the nursing interventions for a patient with a fractured femur and diminished distal pulses in the left foot. 1. "Verify pedal pulses using a Doppler pulse device": This is done to assess the blood flow to the foot. A Doppler pulse device uses ultrasound technology to measure the flow of blood through your arteries and veins. If the pulses are diminished, it could indicate a problem with blood flow, which could be due to the fracture or the splint. 2. "Evaluate the application of the splint to the left leg": The nurse should check the splint to ensure it's applied correctly. If it's too tight, it could be restricting blood flow, leading to diminished pulses. 3. "Monitor left leg for pain, pallor, parenthesis, paralysis, pressure": These are the five P's of neurovascular assessment - Pain, Pallor (pale skin color), Paresthesia (abnormal sensation like tingling), Paralysis (loss of muscle function), and Pressure. Monitoring these can help identify complications like compartment syndrome, which can occur after a fracture and can lead to diminished pulses. These interventions are crucial to ensure the patient's safety and to prevent further complications.

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? A. Irregular ulcer shapes and severe edema. B. Hairless lower extremities and cool feet. C. Black ulcers and dependent rubor. D. Absent pedal pulses and shiny skin.

A. Irregular ulcer shapes and severe edema Choice A reason: Irregular ulcer shapes and severe edema are characteristic of venous ulcers, which are caused by impaired venous return and increased capillary pressure. Venous ulcers are usually located near the medial malleolus and have a shallow depth. Choice B reason: Hairless lower extremities and cool feet are signs of arterial insufficiency, which reduces blood flow and oxygen delivery to the tissues. Arterial ulcers are usually located on the toes, heels, or lateral malleoli and have a deep, punched-out appearance. Choice C reason: Black ulcers and dependent rubor are also signs of arterial insufficiency, indicating tissue necrosis and inflammation. Dependent rubor is a reddish-blue color of the lower extremity that occurs when the leg is lowered below the level of the heart. Choice D reason: Absent pedal pulses and shiny skin are also signs of arterial insufficiency, indicating reduced blood flow and atrophy of the skin. The skin may also be dry, scaly, or cracked.

The nurse is developing a plan of care for a client undergoing peritoneal dialysis. Which nursing intervention has the highest priority? A. Maintain accurate intake and output record. B. Turn and position the client at least every 2 hours C. Encourage a high fiber, low protein diet D. Assess peripheral pulses in lower extremities

A. Maintain accurate intake and output record.

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist- hip ratio, with a body mass index of 32 kg/m2. Which actions should the nurse take in response to these findings?. (Select all that apply) A. Measure the client's blood pressure in both arms. B. Discuss the importance of a regular exercise program C. Arrange for immediate transport to a medical family D. Screen for a family history for diabetes mellitus E. Advise the client to restrict fluids and keep feet elevated.

A. Measure the client's blood pressure in both arms. B. Discuss the importance of a regular exercise program D. Screen for a family history of diabetes mellitus (A) Measuring the client's blood pressure in both arms is important when a client has abdominal obesity and a high waist-hip ratio. This assessment can help identify potential vascular abnormalities or conditions such as aortic dissection, subclavian stenosis, or other vascular diseases that may affect blood pressure readings in the arms. Therefore, taking blood pressure in both arms is a crucial step in assessing the patient's cardiovascular health and identifying any potential underlying issues. (B) The client's abdominal obesity and high BMI indicate that they are overweight, which can lead to various health problems. Regular exercise can help reduce body weight and improve overall health. (D) Obesity is a major risk factor for type 2 diabetes. If the client has a family history of diabetes, they are at an even higher risk. Therefore, screening for a family history of diabetes can help in early detection and management of the disease.

A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough

A. Pain

On the third postoperative day, a client who has a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply) A. Present a calm, supportive demeanor. B. Reorient to day and time frequently. C. Administer an as needed (PRN) dose of lorazepam. D. Turn the television on for distraction. E. Apply soft wrist restraints bilaterally.

A. Present a calm, supportive demeanor. B. Reorient to day and time frequently. C. Administer PRN dose of lorazepam. A: The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust. B: The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control. C: Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication. D: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client. E: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.

A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer? A. Monitor your blood pressure. B. Take a few days off work. C. Learn muscle relaxation techniques. D. Lie down in a dark, quiet room.

D. Lying down in a dark, quiet room is the most appropriate intervention for obtaining pain relief from a migraine headache. This approach minimizes sensory stimuli, reduces external factors that may exacerbate the headache, and promotes relaxation. It is a well-established non-pharmaceutical method for managing migraine pain. (A) Monitoring blood pressure is a general health assessment measure and may not directly contribute to pain relief in a client with migraine headaches. While it's essential to manage blood pressure as part of overall health, this choice does not address the client's specific request for pain relief. (B) Taking a few days off work may provide some relief from external stressors, but it is not a reliable intervention for migraine pain relief. Migraine management typically involves strategies that directly target headache symptoms. (C) Learning muscle relaxation techniques can be helpful in managing migraine headaches. Relaxation techniques, such as progressive muscle relaxation, can reduce muscle tension and help alleviate headache symptoms. However, it may not be the highest-priority intervention.

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first. A. Palpate the right flank for tenderness B. Test her urine for the presence for hematuria C. Evaluate the urine for a strong odor D. Measure her temperature and pulse rate

D. Measure her temperature and pulse rate The nurse should first measure the student's temperature and pulse rate because these are vital signs that can indicate if the student has an infection. Urinary frequency, burning, and lower back pain are symptoms of a urinary tract infection (UTI). A UTI can cause a fever, which would raise the body's temperature and potentially increase the pulse rate. By measuring these vital signs, the nurse can get a better understanding of the student's overall health and determine the severity of the situation. This is the first step in the nursing process, which is assessment. After this, the nurse can proceed with other interventions based on the findings.

While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the HCP, the nurse should evaluate which laboratory value? A. Blood pH level B. Serum albumin. C. Platelet count D. Neutrophil count

D. Neutrophil count The patient is experiencing infection, so a nurse should review the neutrophil count before contacting the HCP. Neutrophils are a type of white blood cell that the body uses to fight off infections. When there's an infection, such as indicated by purulent (pus-filled) drainage from a burn wound, the body typically responds by increasing the production of neutrophils. Therefore, before reporting the finding to the healthcare provider, the nurse should evaluate the neutrophil count. This will provide valuable information about the body's response to the infection and can guide the treatment plan. Other options like platelet count, serum albumin, and blood pH level are less directly related to the body's response to infection.

The nurse observes that a newly admitted client with Parkinson's disease exhibits a mask like facial appearance. Which additional nursing assessment takes priority in response to this finding? A Neck flexion. B Respiratory rate. C Speech patterns. D Swallowing ability.

D. Swallowing ability The answer to this question is rooted in the understanding of Parkinson's disease, a neurodegenerative disorder that affects predominately dopamine-producing neurons in a specific area of the brain. One of the symptoms of Parkinson's disease is a "mask-like" facial expression, which is due to the reduction in spontaneous muscle activity. The priority nursing assessment in response to this finding would be the client's swallowing ability. This is because the same muscle rigidity that causes the mask-like facial appearance can also affect the muscles involved in swallowing. Difficulty swallowing, or dysphagia, is a common symptom in Parkinson's disease and can lead to serious complications such as aspiration pneumonia. Therefore, the nurse should prioritize assessing the client's ability to swallow to ensure they are not at risk of choking or aspiration. This can be done through direct observation during meals, asking the client about any difficulty or discomfort while swallowing, and potentially conducting a formal swallowing assessment or referring the client for a speech-language pathology consultation if concerns are identified.

A male client is admitted to the emergency department while vomiting dark brown, foul-smelling emesis. He reports he had surgical repair of the recurrent inguinal hernia a week ago and complains of intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescriptions should the nurse implement first? a. Send the client to x-ray for a flat plate of the abdomen b. Place an indwelling catheter and attach a bedside drainage unit. c. Give a prescribed analgesic for temperature above 101 degrees F (38.3 C). d. Insert a nasogastric tube (NGT) and attach to low intermittent suction

d. Insert a NGT and attach to low intermittent suction The nurse should first implement the insertion of a Nasogastric Tube (NGT) and attach a low intermittent suction. This is because the patient's symptoms - vomiting dark brown, foul-smelling emesis, intense abdominal pain, and hyperactive bowel sounds - suggest a possible bowel obstruction or gastrointestinal bleeding, both of which are serious conditions. The NGT will help decompress the stomach by removing gas and fluid, which can relieve the patient's symptoms and prevent further complications. The low intermittent suction helps to maintain the patency of the tube and prevent clogging. It also allows for the removal of gastric contents at a safe and controlled rate, which can help to prevent further vomiting and aspiration. This intervention is a priority over other potential interventions because it directly addresses the patient's most serious symptoms and potential complications. It is also a non-invasive procedure that can be performed quickly and safely in the emergency department setting.

After several days of coughing and taking acetaminophen to treat temperatures of 101 F( 38.3 C), a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? a. Obtain sputum for culture b. Administer an antipyretic c. Reassess vital signs d. Obtain a fingerstick glucose

d. Obtain a fingerstick glucose

The nurse is reviewing the echocardiogram results for a client with left-sided heart failure which reveals ineffective ventricular contractions. The client is tachycardic and reports feeling anxious and weak. Which assessment is most important for the nurse to perform? a. Degree of skin elasticity b. Volume of pedal pulses c. Length of capillary refill d. Rhythm of apical pulse

d. Rhythm of apical pulse Assessing the rhythm of the apical pulse is crucial in this situation as it can provide important information about the client's cardiac status and the effectiveness of ventricular contractions. Changes in the rhythm of the apical pulse can indicate cardiac arrhythmias, which may be contributing to the client's symptoms and need to be addressed promptly

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. which outcome should the nurse include in the plan of care for this client? a. The nurse will encourage the client to walk thirty minutes everyday b. The nurse will demonstrate the procedure for accurate eye care c. The clients blood pressure readings will be less than 160/90 mmhg d. The client's hemoglobin A1C will be less than 7.0% (0.07) in 3 months

d. The client's hemoglobin A1C will be less than 7.0% (0.07) in 3 months

1) The nurse is caring for a client on a rehabilitation unit who had a right cerebrovascular accident and is struggling with independent self-care. The nurse places a large mirror in the client's room. Which instruction should the nurse provide the client? a. Mirrors reflect light to brighten the room so you can see better b. Check your appearance before leaving the room c. A home-like environment helps you relax and feel more confident d. Use the mirror to watch yourself while dressing

d. Use the mirror to watch yourself while dressing