Hesi Med-Surge

4- Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is 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

- The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness

B. Enlarged vein

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. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity

B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 F. Abdominal obesity

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. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96%

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

A client with a bariatric surgery 2 months ago, and a week ago, has vomiting, nausea anorexia, fever, put in NPO. What should the nurse do next?

Insert nasogastric tube with low suction intermittent

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Teach the client techniques for performing intermittent catheterization

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 PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula

A. Albuterol 2.5 to 5 mg per nebulization

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110 mmol/L or SI), hematocrit of 34% and microcytic and hypochromic red blood cells. Based on the findings, which dinner selection should the nurse suggest for the patient? A. Beef steak with steam broccoli and orange slices B. Cheese pasta and a lettuce and tomato salad C. Broil white fish with a baked sweet potato D. Grill shrimp and seasoned rice with asparagus salad.

A. Beef steak with steam broccoli and orange slices

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands?

A. Has everyone at home already had varicella?

- 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. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen

A. Irregular apical pulse

A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus

A. Leukopenia

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?

Administer opioid and non-opioid medication simultaneously

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

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

The nurse is caring for a client diagnosed with psoriasis vulgaris who receiving a psoralen and ultraviolet a light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? A. Thick skin plaques topped by silvery white scales B. Requires sunglasses because sunlight hurts eyes C. Tenderness upon palpation and generalized erythema D.Brown, rough, greasy, wart-like papules on the face

C. Tenderness upon palpation and generalized erythema

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond?

Confirm that this is an effective technique to help with ambulation

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? A. Encourage turning and deep breathing. B. Auscultate for presence of bowel sounds C. Monitor hemoglobin and hematocrit D. Administer IV antibiotics as prescribed

D. Administer IV antibiotics as prescribed

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) .What is the best initial nursing action? A. Administer a PRN dose of an antispasmodic agent B. Measure the client's intake and output C. Provide additional oral fluid intake D.Increase the flow of the bladder irrigation

D. Increase the flow of the bladder irrigation

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

D. Initiate airborne particulate isolation precautions

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

D. Maintain traction while the client uses a female urinal

After several days of coughing and taking acetaminophen to treat temperature of 101 F, 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. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose

D. Obtain a fingerstick glucose

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l

D. potassium of 2.5 meq/l

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Encourage turning and deep breathing b. Auscultate for presence of bowel sounds c. Administer IV antibiotics as prescribed d. Monitor hemoglobin and hematocrit

c. Administer IV antibiotics as prescribed

A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?

Potassium 6.5 mEq/L (mmol/L)

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement?

Provide an eye shield to be worn while sleeping

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse?

Serum sodium of 185 mEq/L

A client with Parkinson Disease presenting mask like face. What other sign alert the nurse for rapid intervention?

Swallowing inability

After teaching a female client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Elimination of which food choices by the client indicates teaching is successful

Whole milk and daily ice cream servings

The nurse is caring for a patient prescribed warfarin (Coumadin) orally. The nurse reviews the patient's prothrombin time (PT) level to evaluate the effectiveness of the medication. The nurse should also evaluate which of the following laboratory values? a) International normalized ratio (INR) b) Partial thromboplastic time (PTT) c) Sodium d) Complete blood count (CBC)

a) International normalized ratio (INR)

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. Eats a vegetarian diet with cheese 2 to 3 times a day b. Experiences additional stress since adopting a child c. Jogs more frequently than usual daily routine d. Drinks several bottles of carbonated water daily

a. Eats a vegetarian diet with cheese 2 to 3 times a day

The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage clients use of picture charts b. Ask the client simple questions c. Speak slowly to the client d. Teach the client use of basic sign language

a. Encourage clients use of picture charts

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

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

The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. Notify the health care provider of the clients medication history b. Have the client sign the surgical and transfusion permits c. Observe the heparin injection sites for signs of bruising d. Ensure that the potential for bleeding is explain to the client.

a. Notify the health care provider of the clients medication history

To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), which interventions should the nurse implement? SATA a. Perform chest physiotherapy b. Initiate passive range of motion exercise c. Encourage use of incentive spirometer d. Teach the client breathing exercises e. Establish a regular bladder routine

a. Perform chest physiotherapy c. Encourage use of incentive spirometer d. Teach the client breathing exercises

A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. Place the client in high fowler position b. Perform passive range of motion exercises 'c. Increase the client's activity level d. Administer oxygen per nasal cannula

a. Place the client in high fowler position

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. White blood cell count d. Hemoglobin levels

a. Platelet count

An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg pO daily. Which laboratory values should the nurse monitor? a. Serum iron and ferritin b. Platelet count and hematocrit c. Neutrophils and eosinophils d. Serum electrolytes

a. Serum iron and ferritin

A nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium 185 mEq/L b. Apical rate of 110 beats per minute c. Dry skin with inelastic turgor d. Polyuria and excessive thirst

a. Serum sodium 185 mEq/L

A client with acute renal injury (AKI) weights 50 kg and has potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first? a. Sodium polystyrene sulfonate 15 grams by mouth b. Sevelamer one table by mouth c. Calcium acetate one tablet by mouth d. Epoetin alfa, recombinant 2,500 unit subcutaneously

a. Sodium polystyrene sulfonate 15 grams by mouth

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 thisfinding to the healthcare provider, the nurse should review which of the client's laboratory values? a. White blood cell (WBC) count b. Blood pH level c. Platelet count d. Hematocrit

a. White blood cell (WBC) count

. A hospitalized client with peripheral arterial disease (PAD) isinstructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? a. "whenever I am sitting in a chair I will keep my legs up to reduce swelling" b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown" c. "I will try to keep moving if leg pain occurs to help promote good circulation" d. "I will use my swimming pool early in the day while the water is still very cool.

b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"

. A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first? a. Remove all of the morphine patches b. Administer a narcotic antagonist c. Measure the clients blood pressure d. Apply oxygen per face mask

b. Administer a narcotic antagonist

An older client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Administer a prescribed sedative b. Assist client to an upright position c. Apply a high-flow venturi mask d. Encourage client to drink water

b. Assist client to an upright position

While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. The client reports join pain and trouble twisting a doorknob due to weakness. Which action should the nurse take in response to these findings? a. Explain the relief of the migraine pain will reduce related symptoms b. Consult with the occupational therapist for a functional assessment c. Implement fall precautions to reduce the client's risk for injury d. Gather additional assessment data about the pain and weakness

b. Consult with the occupational therapist for a functional assessment

The nurse is performing the postoperative assessment of a client with an abdominal aortic aneurysm. Which finding is most important for the nurse to provide in the preoperative report? a. Respirations 20 breaths/minute b. Diminished peripheral pulses c. Hypoactive bowel sounds d. S3 hear sound on auscultation

b. Diminished peripheral pulses

A client with gout arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation above the ankle area. The client receives prescription for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Encourage active range of motion to limitstiffness b. Drink at least 8 cups (1920 mL) of water per day c. Use electric heating pad when pain is at its worse d. Eat high protein foods to achieve ideal body weight

b. Drink at least 8 cups (1920 mL) of water per day

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Color and consistency of feces b. Eating patterns and dietary intake c. Level and amount of physical activity d. Presence and activity of bowel sounds

b. Eating patterns and dietary intake

The nurse observes pitting edema in both hands and all fingers of a client with diffuse systemic sclerosis (Scleroderma). Which action should the nurse include in the plan of care? a. Cover areas liberally with lubricant b. Examine skin for ulcerations c. Observe for scleral jaundice d. Apply cold packs as needed

b. Examine skin for ulcerations

The nurse is caring for a client who is newly diagnosed with adrenocortical insufficiency. The client is experiencing chronic fatigue and weakness. Which intervention should the nurse implement? a. Begin education about fluid restriction and ways to incorporate into ongoing therapy b. Explain that the hormone therapy will be needed for a time until adrenal glands are stimulated c. Provide encouragement that symptoms will rapidly improve as hormone therapy is initiated d. Advise the client to schedule energy intensive activities for later in the day

b. Explain that the hormone therapy will be needed for a time until adrenal glands are stimulated

The nurse is providing teaching to a client with type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more b. Family members can help with regular foot exams c. Heat pads are useful if on the lowest setting d. Shoes should be worn outside the house, but it is fine to be barefoot inside

b. Family members can help with regular foot exams

. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Methods for weight gain b. Guidelines for oxygen used c. Strategies for smoking cessation d. Approaches to conserve energy

b. Guidelines for oxygen used

. A client with a 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 medication occur b. Increase the daily intake of oral fluids to liquefy secretions c. Teach anxiety reduction methods for feelings of suffocation d. Avoid crowded enclosed areas to reduce pathogen exposure

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

An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel". The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Maintain prescribed eye drop regimen c. Avoid frequent eye pressure measurements d. Eat a diet high in carotene (vit C)

b. Maintain prescribed eye drop regimen

A client tellsthe clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement? a. Observe the perineal area for chancroid like lesion b. Obtain a specimen of urethral drainage for culture c. Assess for perineal itching, erythema, and excoriation d. Identify all sexual partners in the last 4 days

b. Obtain a specimen of urethral drainage for culture

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portalsite should the nurse provide? ' a. Apply moisture lotions daily to the radiation portal site b. Protect the skin of the radiation portal site from sunlight exposure c. Avoid washing the skin inside the radiation portalsite d. Remove the ink marks of the portal after each radiation treatment.

b. Protect the skin of the radiation portal site from sunlight exposure

The nurse determines that an adult client who is admitted to the post anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6 F(34.8*C), a pulse rate of 88 beast/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement? a. Take the client's temperature using another method. b. Raise the head of the bed to 60 to 90 degrees. c. Ask the client to cough and deep breathe. d. Check the blood pressure every five minutes for one hour.

b. Raise the head of the bed to 60 to 90 degrees.

While caring for a client with Guillain-Barre syndrome, the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Lower leg weakness. b. Sensory loss at T-8. c. Leg pain worsening at night. d. Profuse diaphoresis

b. Sensory loss at T-8.

The healthcare provider prescribes diagnostic test for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Arterial blood gases (ABG) b. Sputum culture and sensitivity c. Computerized tomography (CT) of the chest d. Blood cultures

b. Sputum culture and sensitivity

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. Marked loss of weight and appetite over the last 3 or 4 months b. Upper mid-abdominal pain described as gnawing and burning c. Frequent use of chewable and liquid antacids for indigestion d. Severe abdominal cramps and diarrhea after eating spicy foods

b. Upper mid-abdominal pain described as gnawing and burning

the nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? a. Maintain intervascular infusion rate b. Progress diet slowly from ice chips to clear liquid c. Apply intermittent pneumatic compression devices d. Obtain frequent pain level assessments

c. Apply intermittent pneumatic compression devices

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets b. Elevate extremities on pillows c. Assess pulses with a vascular doppler d. Evaluate edema for pitting

c. Assess pulses with a vascular doppler

The nurse is providing teaching to a client with type 2 diabetes mellitus about managing care at home. Which information stated by the client indicates understanding? a. Avoid seasoning foods with salt and salt-containing spices b. Keep any wounds covered with an antibiotic ointment c. Check blood sugar levels every four to six hours every day d. Soak feet daily in hot water no longer than 10 minutes

c. Check blood sugar levels every four to six hours every day

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 report to the healthcare provider? a. Clay colored stool b. Radiating sharp pain in right shoulder c. Distended, hard and ridged abdomen d. Bile-stained emesis

c. Distended, hard and ridged abdomen

When conducting discharge teaching for a client with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals b. Eat a soft diet with increased intake of milk and milk products c. Eat a high-fiber diet and increase fluid intake d. Eat a bland diet and avoid spicy foods

c. Eat a high-fiber diet and increase fluid intake

What 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. Green leafy vegetables c. Fortified milk and cereals d. Red meats and eggs

c. Fortified milk and cereals

The nurse assess a client who is newly diagnosed with hyperthyroidism and observes that the clients eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the clients plan of care? a. Assess for signs of increased ICP b. Prepared to administer intravenous levothyroxine c. Obtain a prescription for artificial tear drops d. Review the clients serum electrolyte value

c. Obtain a prescription for artificial tear drops

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. Profuse diaphoresis and severe, pounding headache b. Complaints of chest pain and shortness of breath c. Pain and a burning sensation upon urination and hematuria d. Hypotension and venous pooling in the extremities

c. Pain and a burning sensation upon urination and hematuria

. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? a. Call the PACU nurse to prepare for prolonged ventilatory support b. Hold a prescription for dantrolene until fever is reduced c. Prepare ice packs for placement in the client's axillary area d. Determine if prescribed antibiotics were administered preoperatively

c. Prepare ice packs for placement in the client's axillary area

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

c. ST elevation in three leads

An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? SATA a. Signs of respiratory tract infection b. Serum creatine and blood urea nitrogen (BUN) c. Skin condition of lower extremities d. Sensation in feet and legs e. Visual acuity

c. Skin condition of lower extremities d. Sensation in feet and legs e. Visual acuity

. A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the clients blood pressure dropsfrom 150/90 mmHG to 80/30 mmHG. Which action should the nurse take first? a. Administer 5% albumin IV b. Monitor blood pressure q45 minutes c. Stop the dialysis treatment d. Lower the head of the chair and elevate feet

c. Stop the dialysis treatment

A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based on? a. Extra pillows can be used if needed to elevate the client's head b. Orthopnea is frequently caused by a clients uncontrolled anxiety c. The procedure is performed with the client in an upright position d. A thoracentesis is a brief procedure that has minimal discomfort

c. The procedure is performed with the client in an upright position

Which client has the highest risk for developing skin cancer? a. a 25 year old dark skinned client whose mother had skin cancer b. a 70 year old fair skinned client who works as a secretary c. a 65 year old fair-skinned client who is a construction worker d. a 16 year old dark skinned client who tans in tanning beds once a week

c. a 65 year old fair-skinned client who is a construction worker

The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicions? a. He refuses to see any of his friends or to return their phone calls b. He has begun to sleep 19 out of 24 hours c. He exhibits angry outburst when the subject of dying is approached d. A change has recently occurred in his handwriting

d. A change has recently occurred in his handwriting

- The nurse teaching 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 prior to collecting the sputum. d. Breathe deeply, followed by coughing up the sputum

d. Breathe deeply, followed by coughing up the sputum

The home health nurse providesteaching about insulin self-injecting to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? a. Lie down flat for better skin exposure b. Select a different injection site c. Keep the skin flat rather than bunched d. Continue with the insulin injection

d. Continue with the insulin injection

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis a. Decreased renin-angiotensin response related to an increase in renal blood flow b. Decreased portacaval pressure with greater collateral circulation c. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules d. Hypoalbuminemia that results in decreased colloidal oncotic pressure

d. Hypoalbuminemia that results in decreased colloidal oncotic pressure

The nurse observes an increase number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Administer a PRN dose of an antispasmodic agent c. Measure the clients intake and output d. Increase the flow of bladder irrigation

d. Increase the flow of bladder irrigation

. During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours and a headache. Which intervention is most important for the nurse to implement first? a. Draw blood cultures b. Administer an antipyretic c. Prepare for a lumbar puncture d. Initiate isolation precautions

d. Initiate isolation precautions

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

d. Irregular apical pulse

A client with herpes zoster (shingles) on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. Noctuia b. Dyspnea c. Frequent cough d. Pain

d. Pain

The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the health care provider? a. Moon facies b. Gastric irritation c. Abdominal striae d. Rapid weight gain

d. Rapid weight gain