Hurst: Content Post Test Review

What signs/symptoms would lead the nurse to suspect that a client diagnosed with cirrhosis may be developing hepatic coma? Select all that apply. 1. Asterixis 2. Fetor 3. Grey Turner's sign 4. Hyperactive reflexes 5. Squiggly handwriting

1. Asterixis 2. Fetor 5. Squiggly handwriting

A client who had a cerebral vascular accident (CVA) is now having Cheyne-Stokes respirations ranging from 12-30 breaths/minute. BP 158/108, HR 46. Based on this assessment, which acid/base imbalance does the nurse anticipate that this client will develop? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

1. Respiratory acidosis

A client who has been given steroids for a prolonged period to treat asthma, reports dizziness, tingling of the fingers, and muscle weakness. What action should the nurse take first? 1. Determine current blood pressure 2. Connect client to a cardiac monitor 3. Administer oxygen 4. Obtain arterial blood gases

2. Connect client to cardiac monitor

The nurse is initiating a client assessment. What signs and symptoms would validate the client's diagnosis of Cushing's disease? Select all that apply. 1. Hypoglycemia 2. Mood alterations 3. Lipolysis 4. Truncal obesity 5. Hirsutism 6. Hyperkalemia

2. Mood alterations 3. Lipolysis 4. Truncal obesity 5. Hirsutism

A client is to begin external beam radiation for Ewing's sarcoma. What symptoms would the nurse teach the client to expect during radiation treatments? Select all that apply. 1. Nausea and Vomiting 2. Skin shedding 3. Erythema with pain 4. Pancytopenia 5. Exhaustion

2. Skin shedding 3. Erythema with pain 4. Pancytopenia 5. Exhaustion

What medication, given to help mature fetal lungs, does the nurse anticipate giving after admitting a client in preterm labor? 1. Magnesium sulfate 2. Terbutaline 3. Betamethasone 4. Nifedipine

3. Betamethasone

While performing wound care to a donor skin graft site, the nurse notes some scabbing around the edges and a dark collection of blood. What is the nurse's next action? 1. Leave the scabbing area alone and apply extra ointment. 2. Notify the primary healthcare provider. 3. Gently remove the debris and re-dress the wound. 4. Apply skin softening lotion for 3 hours and then re-dress.

3. Gently remove the debris and re-dress the wound.

What should the nurse do after administering a chemotherapeutic drug intravenously (IV) to a client in the outpatient infusion unit? 1. Hang a 250 mL normal saline (NS) bag to flush the IV line. 2. Wear shoe covers during disposal of the drug. 3. Place the IV bag and tubing into a chemotherapy waste container. 4. Disposal of personal protective equipment (PPE) in a biohazardous container.

3. Place the IV bag and tubing into a chemotherapy waste container.

A nursing instructor is presenting a discussion on nephrotoxic medications? Which class of medications would the instructor discuss? 1. Opioids 2. Antidiabetic 3. Corticosteroids 4. Aminoglycoside

4. Aminoglycoside

A client is admitted to the emergency room with an open fracture of the left tibia which has been temporarily splinted. Which nursing intervention would the nurse implement? 1. Physically reduce the fracture. 2. Externally rotate the left leg. 3. Position the bed into a high Fowler's position. 4. Cover the fractured site with a sterile dressing.

4. Cover the fractured site with a sterile dressing.

A client in her third trimester comes to the clinic for a routine prenatal visit. The nurse notes a weight gain of 4 pounds (1.8 kg) in a week. What action should the nurse take? 1. Check urine for protein. 2. Educate on proper weight gain during pregnancy. 3. Notify the primary healthcare provider. 4. Send client to the labor and delivery unit.

1. Check urine for protein.

Which clinical manifestation does the nurse expect to see in a client diagnosed with Addison's disease? Select all that apply. 1. Confusion 2. Hypertension 3. Vitiligo 4. Hyperkalemia 5. Hypernatremia 6. Weight gain

1. Confusion 3. Vitiligo 4. Hyperkalemia

What actions would be appropriate for the nurse to take when performing peritoneal dialysis on a client diagnosed with renal injury? Select all that apply. 1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 2. The dialysate is infused through the catheter into the stomach. 3. Once infused, dialysate remains for prescribed dwell time. 4. Withdraws dialysate using a large piston syringe. 5. Assists client to stand if all the drainage is not removed.

1. Dialysate is warmed to body temperature by allowing it to sit out for a short period of time. 3. Once infused, dialysate remains for prescribed dwell time.

A client with chronic liver disease has ascites and is being treated with an albumin infusion. What should the nurse anticipate and monitor in this client? 1. Fluid volume excess 2. Cellular edema 3. Severe hypotension 4. Decreasing CVP

1. Fluid volume excess

treatment. The client states she wants to continue breast feeding. What interventions should the nurse include? Select all that apply. 1. Get plenty of bed rest. 2. Wear a support bra. 3. Place chilled cabbage leaves on breasts. 4. Take antibiotic prior to breast feeding. 5. Offer the unaffected breast first at each feeding. 6. Take cool showers to relieve breast discomfort.

1. Get plenty of bed rest. 2. Wear a support bra.

Which medication prescription should the nurse question for a client diagnosed with nephrotic syndrome? 1. Ibuprofen 2. Enalapril 3. Prednisone 4. Cyclophosphamide

1. Ibuprofen

The nurse on a medical unit is reviewing the data on a client admitted to a medical unit. Which data supports the diagnosis of glomerulonephritis? Select all that apply. 1. Malaise 2. Blood pressure - 16O/92 3. 24 hour urinary output - 960 mL 4. Costovertebral angle tenderness 5. Urine specific gravity of 1.040

1. Malaise 2. Blood pressure - 16O/92 4. Costovertebral angle tenderness 5. Urine specific gravity of 1.040

Which selection by the client indicates to the nurse that the client understands food allowed during a vanillylmandelic acid (VMA) test? Select all that apply. 1. Milk 2. Caffeine 3. Citrus fruit 4. Chicken 5. Vanilla ice cream

1. Milk 4. Chicken

Which signs/symptoms would lead the clinic nurse to suspect that a client may have bacterial meningitis? Select all that apply. 1. Nuchal rigidity 2. Photophobia 3. (+) Kernig 4. (-) Brudzinski 5. Fever 102.8 F (39.3 C) 6. Reports headache 9/10

1. Nuchal rigidity 2. Photophobia 3. (+) Kernig 5. Fever 102.8 F (39.3 C) 6. Reports headache 9/10

The nurse is performing a neurological assessment on an adult client suspected of having a traumatic brain injury (TBI). Which signs/symptoms would indicate to the nurse that the client's ICP is increasing. Select all that apply. 1. Projectile vomiting 2. Narrowing pulse pressure 3. Delay in verbal response 4. DTR: left 2+/4+, right 2+/4+ 5. (-) Babinski 6. Glasgow Coma Scale Score 13

1. Projectile vomiting 3. Delay in verbal response.

The nurse is preparing a class on cancer prevention. Which risk factor should the nurse discuss with the class as being a preventable risk factor? Select all that apply. 1. Smoking tobacco 2. Drinking alcohol 3. Eating a high fiber diet 4. Increasing fish consumption 5. Protect skin from sunlight by using tanning beds

1. Smoking tobacco 2. Drinking alcohol

The emergency department nurse is monitoring a client being admitted in diabetic ketoacidosis (DKA). Which arterial blood gas value would be expected? Select all that apply. 1. pH 7.32 2. PaCO2 32 3. HCO3 25 4. PaO2 78 5. SaO2 82

1. pH 7.32 2. PaCO2 32

A nurse has performed teaching with a client diagnosed with Cushing's disease. Which statement by the client would best indicate understanding of the teaching? 1. "The increased level of ADH will cause my potassium level to be too high." 2. "I will be retaining sodium and water due to the increased amount of aldosterone." 3. "I will be losing lots of fluid due to the hormonal imbalance I have." 4. "I will feel jittery and nervous due to the elevated thyroxine levels."

2. "I will be retaining sodium and water due to the increased amount of aldosterone."

The nurse completed discharge teaching on a client with two fractured ribs. Which statement by the client would indicate the need for further teaching? 1. "I will take deep breaths using my incentive spirometer every 2 hours." 2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs." 3. "I will talk to my healthcare provider before taking the narcotic pain medicine that I currently have at home." 4. "I will notify my healthcare provider if I develop any change in my respirations or secretions."

2. "I will wrap my chest in an elastic bandage to support and immobilize my ribs."

The nurse is preparing a teaching plan for a client newly diagnosed with fluid retention and heart failure. What should the nurse advise the client to avoid? Select all that apply. 1. Broiled, fresh fish 2. Effervescent soluble medications 3. Seasoning with lemon pepper 4. Chicken noodle soup 5. Deli-ham sandwiches

2. Effervescent soluble medications 4. Chicken noodle soup 5. Deli-ham sandwiches

A client, with a T5 injury, has not had a bowel movement in three days. Today, the client reports a headache rated 10/10. The nurse takes the client's vital signs: BP 180/110, HR 52, RR 20. What action by the nurse takes priority? 1. Administer hydralazine 20 mg IV. 2. Elevate head of bed 45 degrees. 3. Remove impaction with topical anesthetic. 4. Close air vents in the room.

2. Elevate head of bed 45 degrees.

A client comes to the clinic and states that she believes she is pregnant. What probable signs of pregnancy does the nurse expect to see? Select all that apply. 1. Amenorrhea 2. Facial chloasma 3. Fetal movement 4. Breast tenderness 5. Positive pregnancy test 6. Urinary frequency

2. Facial chloasma 5. Positive pregnancy test

A client is admitted following a severe burn. What changes related to fluid status would the nurse anticipate? Select all that apply. 1. Fluid volume excess 2. Hypovolemia 3. Third spacing 4. Increased urine output 5. Low CVP 6. Increased urine specific gravity

2. Hypovolemia 3. Third spacing 5. Low CVP 6. Increased urine specific gravity

The nurse performs an assessment on a client who reports abdominal pain. Based on the assessment findings, what problem does the nurse suspect? 1. Cirrhosis 2. Pancreatitis 3. Peptic ulcer 4. Ulcerative colitis

2. Pancreatitis

A client is admitted with prolonged nausea and vomiting. The client's admission sodium level is 149 mEq/L (149 mmol/L). What action by the nurse would be most appropriate at this time? 1. Administer 3% NS at 150 mL/hr 2. Perform neurological assessment 3. Increase oral intake of sodium 4. Decrease fluid intake

2. Perform neurological assessment

A client presents to the emergency department (ED) with flu symptoms, fever, and chills. The nurse notes that the vital signs are: T 102.8°F (39.3°C), P 128, RR 30, B/P 154/88. ABG results are: pH-7.5, PaCO2 32, HCO3 23. What acid/base imbalance does the nurse determine that this client has developed? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

2. Respiratory alkalosis

What is the best position for the nurse to place a client for a thoracentesis of the right lung? 1. Lying supine with pillow removed and head of bed flat 2. Sitting on side of bed and leaning over the bedside table 3. Lying on the right side with the head of bed at 45 degrees 4. Lying supine with the left arm raised over the head

2. Sitting on side of bed and leaning over the bedside table

A client was diagnosed with a fractured ulna 8 hours ago. Which assessment data may indicate a compartment syndrome? Select all that apply. 1. The pain is located at the elbow area. 2. The prescribed opioid does not relieve the pain. 3. When forearm is elevated, the swelling in the forearm is reduced. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing. 5. When placing a cold compress on the forearm, the pain level is reduced.

2. The prescribed opioid does not relieve the pain. 4. The pain in the forearm is described as a 9 on a 10 scale and throbbing.

The nurse is providing stump care discharge instructions to the client with a right below-the-knee amputation (BKA). The client responds, "What is the purpose of the compression sock on my stump?" Which statement by the nurse is appropriate? 1. "The compression sock on the stump will increase your balance when crutch walking." 2. "Phantom limb pain will decrease by applying the compression sock tightly around the stump." 3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." 4. "The application of a compression sock will decrease the risk of the incidence of deep vein thrombosis (DVT)."

3. "A compression sock is applied to shape the stump smaller and rounder on the bottom."

The client has been instructed on crutch safety. The nurse identifies that further teaching is needed when the client makes which statement? 1. "The crutches are adjusted according to my height." 2. "I will support my weight on the hand grips when not walking." 3. "I plan to place my affected leg on the step first when ascending stairs." 4. "I will position the crutches 1 -2 inches below the axilla when walking with crutches."

3. "I plan to place my affected leg on the step first when ascending stairs."

What is the most important action for the nurse to take prior to a client having a liver biopsy? 1. Make certain the consent has been signed. 2. Obtain vital signs. 3. Check clotting study results. 4. Position client supine with right arm above head.

3. Check clotting study results.

What interventions should the nurse include when caring for a client who is receiving total parenteral nutrition (TPN)? Select all that apply. 1. Change tubing and filter every 48 hours. 2. Monitor IV drip rate hourly. 3. Compare new bag with prescription prior to infusing. 4. Weigh weekly. 5. Cover TPN with dark bag. 6. Check urine for protein.

3. Compare new bag with prescription prior to infusing. 5. Cover TPN with dark bag.

The nurse is caring for a surgical client who developed a pulmonary embolus (PE). Which diagnostic test would be the most sensitive for providing a definitive diagnosis for a PE? 1. D-dimer 2. Pulmonary function test 3. Pulmonary angiography 4. Chest X-ray

3. Pulmonary angiography

A client returns to the room post appendectomy. In what position should the nurse place the client? 1. Sims' 2. Prone 3. Semi-fowler's 4. Right lateral

3. Semi-fowler's

A nurse on a surgical unit is assigned a client who had a total thyroidectomy 3 days ago. As the nurse enters the room which nursing assessment is the priority for this client? 1. Eating a soft diet. 2. Positioned at 15 degrees in bed. 3. States hands are tingling. 4. Expresses frontal neck pain level of 5 out of 10.

3. Stats hands are tingling.

A client was admitted with reports of prolonged diarrhea. The client's admission potassium level was 3.3 mEq/L (3.3 mmol/L) and is receiving an IV of D5 ½ NS with 20 mEq KCL at 125 mL/hr. The UAP reports an 8 hour urinary output of 200 mL. The previous 8 hour urinary output was 250 ml. What should be the nurse's priority action? 1. Encourage the client to increase PO fluid intake. 2. Administer a supplemental PO dose of potassium. 3. Stop the IV potassium infusion. 4. Administer polystyrene sulfonate PO

3. Stop the IV potassium infusion.

A client weighing 166 pounds (75 kg) is brought to the emergency room with burns to the front and back of both legs and feet. Using the American Burn Association formula to calculate the amount of fluid needed for the first 24 hours, the nurse should set the infusion rate at what for the first eight hours? (Round to nearest whole number).

338 ml/hr. (2700 ml in first 8 hrs)

The nurse has presented information regarding true versus false labor to a woman in her third trimester of pregnancy. Which statement by the woman would indicate to the nurse that the client understands the information provided? 1. "With false labor the discomfort starts in the back and radiates to the abdomen." 2. "I will experience irregular contractions with both true and false labor." 3. "Contractions during true labor will increase in duration but will decrease in frequency." 4. "Pain increases with a change in activity if I am having true labor."

4. "Pain increases with a change in activity if I am having true labor."

The family of a client being treated for bleeding esophageal varices asks the nurse why the client is receiving octreotide. How should the nurse respond? 1. "Octreotide is an antibiotic given to decrease the risk of developing an infection." 2. "Taking this medication forms a protective barrier over the varices to prevent bleeding recurrence." 3. "Octreotide helps eliminate ammonia from the body." 4. "This medication lowers the pressure in the liver, so bleeding stops."

4. "This medication lowers the pressure in the liver, so bleeding stops."

What immediate action should the occupational health nurse take once flames have been extinguished from a burned victim? 1. Remove jewelry. 2. Wrap in a clean blanket. 3. Cover burns with clean, dry cloth. 4. Briefly soak burned area in cool water.

4. Briefly soak burned area in cool water.

During a clinic visit 3 months following a client's diagnosis of type 2 diabetes, the client reports following a 1200 calorie diet and did not bring their glucose-monitoring record. The nurse will anticipate the prescription of which laboratory test? 1. Fasting blood glucose test 2. Urine glucose test 3. Glucose tolerance test (GTT) 4. Glycosylated hemoglobin level (HbA1C)

4. Glycosylated hemoglobin level (HbA1C)

The client has been prescribed 0.6 units of insulin/kg /day. The client weighs 214 pounds (97 kg). What is the amount of insulin the client can receive in a day? (Round to the nearest whole number)

58 units/day

A client in her first trimester of pregnancy has been attending educational sessions on pregnancy. What statements by the client would indicate to the nurse that client teaching has been successful? Select all that apply. 1. "Good food sources of iron includes spinach, raisins, and dark chocolate." 2. "I will eat at least 40 grams of protein a day." 3. "Taking folic acid will help prevent heart defects from occurring." 4. "Swimming is an acceptable exercise for me while I am pregnant." 5. "I can gain 2 pounds (0.9 kg) per week during my first trimester." 6. "I need to stay out of hot tubs while pregnant."

1. "Good food sources of iron includes spinach, raisins, and dark chocolate." 4. "Swimming is an acceptable exercise for me while I am pregnant." 6. "I need to stay out of hot tubs while pregnant."

A client who has terminal cancer tells the nurse that the opioid prescription, which is at the highest recommended dose, is not relieving the pain. What should the nurse tell the client? 1. "I will ask your primary healthcare provider to increase your dose of medication." 2. "You cannot have a higher dose of pain medication since you are at the maximum dose." 3. "Opioid addiction is a major concern. You don't want to take too much of this medication." 4. "Let's try some lemon essential oil to decrease your pain level."

1. "I will ask your primary healthcare provider to increase your dose of medication."

The nurse is performing a neurological assesment on a client who reports frequent headaches. What question(s) should the nurse ask during this assessment? Select all that apply. 1. "When did the headaches begin?" 2. "What symptoms accompany the headaches?" 3. "Does anything relieve the headaches?" 4. "Does anything make the headaches worse?" 5. "Are you experiencing depression?"

1. "When did the headaches begin?" 2. "What symptoms accompany the headaches?" 3. "Does anything relieve the headaches?" 4. "Does anything make the headaches worse?"

A mom two days post delivery reports abdominal pain while breast feeding her newborn. What should the nurse tell the client? 1. "You are getting a surge of oxytocin when you breast feed." 2. "I need to let the doctor know that you need a pelvic exam." 3. "Lie down so I can massasge your fundus." 4. "You cannot have pain medication while you are breast feeding."

1. "You are getting a surge of oxytocin when you breast feed."

What assessment finding by the nurse would support a client diagnosis of basilar skull fracture? Select all that apply. 1. (+) Halo test 2. Hyper-reflexia 3. Raccoon eyes 4. Battle's sign 5. Kernig sign

1. (+) Halo test 3. Raccoon eyes 4. Battle's sign

What signs/symptoms does the nurse expect to see in a client who has ulcerative colitis? Select all that apply. 1. Abdominal cramping 2. Hematemesis 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding

1. Abdominal cramping 3. Diarrhea 4. Fever 5. Rebound tenderness 6. Rectal bleeding

A client has returned to the room post stem cell transplant. What early signs of rejection should the nurse monitor for in the client? Select all that apply. 1. Abdominal pain 2. Straw colored urine 3. Jaundice 4. Pruritus 5. Diarrhea

1. Abdominal pain 3. Jaundice 4. Pruritus 5. Diarrhea

The nurse is educating a group of college students about cancer prevention and screening. Which secondary prevention actions should the nurse include? Select all that apply. 1. Annual mamogram starting at age 45. 2. Maintain normal body weight. 3. Cancer support group. 4. Colonoscopy beginning at age 45. 5. Limit or eliminate alcohol intake.

1. Annual mamogram starting at age 45. 4. Colonoscopy beginning at age 45.

A client sustains a high-voltage electrical injury while at work. Which interventions should the occupational health nurse initiate? Select all that apply. 1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 5. Perform the rule of nines. 6. Apply cervical collar to neck.

1. Assess entry and exit wound. 2. Monitor vital signs. 3. Place on a spine board. 4. Connect to cardiac monitor. 6. Apply cervical collar to neck.

What signs/symptoms should the nurse assess for when caring for a client at risk for thrombocytopenia? Select all that apply. 1. Conjunctival hemorrhage 2. Petechiae on inside of mouth 3. Purpura 4. Fever 5. Blood oozing from IV site

1. Conjunctival hemorrhage 2. Petechiae on inside of mouth 3. Purpura 5. Blood oozing from IV site

The nurse is caring for a client following a cholecystectomy. The client reports dizziness, sweating and palpitations after eating meals. The nurse would recommend which actions to alleviate these symptoms? Select all that apply. 1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 5. Remain upright for one hour after eating. 6. Lie down on left side after eating.

1. Drink between meals. 2. Reduce intake of carbohydrates. 3. Eat small, frequent meals daily. 4. Sit semi-recumbent for meals. 6. Lie down on left side after eating.

A client has a history of deep vein thrombosis (DVT) and pulmonary embolism (PE). What should be included in the teaching by the nurse as preventive measures for the development of a DVT and PE? Select all that apply. 1. Drink plenty of fluids on a daily basis. 2. Stop and move around every 4 hours when taking a long trip. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

1. Drink plenty of fluids on a daily basis. 3. Perform isometric and stretching exercises in the lower extremities. 4. Need for weight management. 5. Walk around 4-6 times per day.

A client, admitted to the surgical unit post left thoracotomy, is drowsy. Vital signs on admit are T 99.8ºF (37.6ºC), HR 94, R 16/shallow, BP 100/68. ABGs are pH 7.33, PCO2 48, HCO3 24. What action should the nurse initiate? 1. Have client take deep breaths. 2. Administer naloxone. 3. Tell the client to breathe faster. 4. Medicate for pain.

1. Have client take deep breaths

A client with deep partial thickness burns to arms and legs is admitted to the burn unit. The nurse knows elevated results are most likely to be noted initially in what laboratory tests? Select all that apply. 1. Hematocrit 2. Albumin 3. Potassium 4. Creatinine 5. Magnesium

1. Hematocrit 3. Potassium 4. Creatinine

What action should the nurse take when caring for a client who has a subarachnoid screw? 1. Keep connections tight. 2. Use clean technique when caring for screw. 3. Clean daily with hydrogen peroxide. 4. Maintain a wet to dry dressing around site.

1. Keep connections tight.

What interventions should the nurse provide when caring for a client prescribed oxytocin IV? Select all that apply. 1. Label IV bag and IV tubing with oxytocin sticker. 2. Monitor for late decelerations. 3. Position client supine. 4. Piggyback oxytocin at the lowest primary IV site. 5. Provide one on one care.

1. Label IV bag and IV tubing with oxytocin sticker. 2. Monitor for late decelerations. 4. Piggyback oxytocin at the lowest primary IV site. 5. Provide one on one care.

A client is admitted with hypocalcemia. Which treatment would the nurse anticipate for this client? Select all that apply. 1. PO Calcium 2. Rapid IV Push Calcium 3. Vitamin D 4. Sevelamer hydrochloride 5. Phosphate supplements

1. PO Calcium 3. Vitamin D 4. Sevelamer hydrochloride

A client's skeletal traction has been accidently released. What signs/symptoms does the nurse expect to see? Select all that apply. 1. Pain 2. Foot drop 3. Muscle spasm 4. Bone displacement 5. Itching under the straps

1. Pain 2. Muscle spasm 3. Bone displacement

The nurse has been assigned to a client with a Steinman pin insertion 48 hours ago. Which pin site care interventions would the nurse implement? Select all that apply. 1. Perform pin care daily. 2. Rinse pins with water. 3. Clean with chlorhexidine. 4. Dry the area with clean gauze. 5. Monitor pin site every 10 hours.

1. Perform pin care daily 3. Clean with chlorhexidine.

The nurse is planning care for a client admitted with a diagnosis of acute renal injury. What interventions should the nurse include in this plan? Select all that apply. 1. Provide meticulous skin care. 2. Reposition every 2 hours. 3. Maintain a high carbohydrate, high protein diet. 4. Provide foods low in phosphate. 5. Monitor intake and output. 6. Give IV medications in smallest volume allowed.

1. Provide meticulous skin care. 2. Reposition every 2 hours. 4. Provide foods low in phosphate. 5. Monitor intake and output. 6. Give IV medications in smallest volume allowed.

Following chemotherapy for acute lymphocytic leukemia (ALL), the client's lab results indicate a white blood count of 1000 cells mm3. What measures should the nurse institute immediately? Select all that apply. 1. Request to change IM antiemetic medication to oral pill. 2. Have client increase fresh fruits and vegetables in diet. 3. Obtain client's temperature at least every two hours. 4. Move client into isolation with a negative flow room. 5. Remove fresh flowers and limit visits from children.

1. Request to change IM antiemetic medication to oral pill. 3. Obtain client's temperature at least every two hours. 5. Remove fresh flowers and limit visits from children.

The nurse is implementing cast care instructions for a client with a plaster cast applied 2 hours ago. Which cast care instruction would be included? Select all that apply. 1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours. 5. Use the palms of hands when moving the cast for first 6 hours.

1. Rest cast on a soft pillow. 2. Keep the cast uncovered until air dried. 3. Mark the cast if there is breakthrough bleeding. 4. Place ice packs on side of the cast for first 24 hours.

A client is admitted to the emergency department (ED) following blunt trauma to the chest from a motor vehicle accident. A hemothorax and pneumothorax are suspected. What signs and symptoms would the nurse anticipate recording to support this diagnosis? Select all that apply. 1. Shortness of breath 2. Decreased heart rate 3. Wheezing in the affected area 4. Chest pain 5. Cough 6. Subcutaneous emphysema

1. Shortness of breath 4. Chest pain 5. Cough 6. Subcutaneous emphysema

A client is admitted to the cardiac floor in heart failure. The lung sounds reveal crackles bilaterally, and the BP is 160/98. The client has been on diuretics at home and the potassium level is 3.3 mEq/L (3.3 mmol/L). Which diuretic would the nurse anticipate being prescribed for this client to minimize potassium loss? 1. Spironolactone 2. Furosemide 3. Bumetanide 4. Hydrochlorothiazide

1. Spironolactone

The nurse is preparing discharge teaching instructions for a client post right radical mastectomy with reconstruction. What instruction should the nurse include? Select all that apply. 1. Squeeze tennis ball with right hand every 2-4 hours while awake. 2. No blood pressure readings in right arm for one year. 3. Wear gloves when gardening. 4. Wear your watch on the left wrist. 5. Brush your hair with your left hand until pain free.

1. Squeeze tennis ball with right hand every 2-4 hours while awake. 3. Wear gloves when gardening. 4. Wear your watch on the left wrist.

Which assessment findings would indicate to the nurse that a client may have a fracture? Select all that apply. 1. Swelling 2. Deformity 3. Crepitus 4. Discoloration 5. Tenting of skin

1. Swelling 2. Deformity 3. Crepitus 4. Discoloration

The nurse is teaching couples in their final weeks of pregnancy about "Kangaroo Care". What points should the nurse include in this session? Select all that apply. 1. Trust in the newborn is an emotional and physiologic need fulfilled through "Kangaroo Care". 2. "Kangaroo Care" requires skin to skin contact between the newborn and parent. 3. The newborn is held quietly for an hour at least 4 times a day. 4. "Kangaroo Care" will only be encouraged if your newborn is premature. 5. Research shows that skin to skin bonding stabilizes the newborn's heart rate.

1. Trust in the newborn is an emotional and physiologic need fulfilled through "Kangaroo Care". 2. "Kangaroo Care" requires skin to skin contact between the newborn and parent. 5. Research shows that skin to skin bonding stabilizes the newborn's heart rate.

A client is placed on neutropenic precautions. What interventions should the nurse initiate? Select all that apply. 1. Use antimicrobial soap for handwashing. 2. Post neutropenic precautions sign on door. 3. Administer acetaminophen for fever greater than 101 degree F (38.3 degrees C). 4. Administer platelets as prescribed. 5. Vital signs at least every 4 hours.

1. Use antimicrobial soap for handwashing. 2. Post neutropenic precautions sign on door. 5. Vital signs at least every 4 hours.

What interventions would the nurse implement for a client diagnosed with nephrotic syndrome? Select all that apply. 1. Weigh daily 2. Measure abdominal girth 3. Provide skin care 4. Position in semifowlers 5. Intake and output

1. Weigh daily 2. Measure abdominal girth 3. Provide skin care 5. Intake and output

What sign/symptom would indicate to the nurse that a client has had an inhalation injury? Select all that apply. 1. stridor 2. Swallowing difficulty 3. Singed nasal hair 4. Blisters to upper arms 5. Wheezing

1. stridor 2. Swallowing difficulty 3. Singed nasal hair 5. Wheezing

The nurse is reviewing the primary healthcare provider's (PHP) initial prescriptions for a client diagnosed with diabetic ketoacidosis (DKA)? Which prescription from the PHP would the nurse question? Select all that apply. 1. Arterial blood gases 2. 500 ml D5W at 100 mL per hour 3. Serum glucose levels every hour 4. Hourly adjustment of Regular insulin IV according to serum glucose level protocol 5. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV

2. 500 ml D5W at 100 mL per hour 5. 100 mL O.45% sodium chloride (NaCL) with potassium chloride KCL 10mEq IV

The nurse is providing dietary instructions to a client newly diagnosed with type 2 diabetes. Which food examples should make up the highest percentage of this client's recommended diet? 1. Pecans, eggs, pork chop 2. Asparagus, broccoli, cabbage, and cucumbers. 3. Lean hamburger, fish, skinless chicken 4. Whole milk, cheese, dark chocolate

2. Asparagus, broccoli, cabbage, and cucumbers.

A client had radiation seeds implanted to treat prostate cancer. When entering the room to initiate discharge teaching, the nurse observes the spouse emptying the client's urinal. What is the nurse's priority action? 1. Immediately escort spouse to ED to check radiation levels. 2. Begin discharge teaching to the client and spouse. 3. Have spouse wash hands thoroughly and apply sterile gloves. 4. Explain that spouse must remain outside the room until urinal is emptied.

2. Begin discharge teaching to the client and spouse.

A nurse is caring for a client with a possible diagnosis hyperparathyroidism. Which serum laboratory value would validate this diagnosis? Select all that apply. 1. BUN 12 mg/dL (4.28 mmol/L) 2. Calcium 12 mg/dL (3 mmol/L) 3. Sodium 140 mg/dL (140 mmol/L) 4. Phosphate 2.8 mg/dL (0.9 mmol/L) 5. Potassium 3.5 mEq/L (3.5 mmol/L)

2. Calcium 12 mg/dL (3 mmol/L) 4. Phosphate 2.8 mg/dL (0.9 mmol/L)

What information on burn prevention strategies should the nurse include when providing an education program at a community center? Select all that apply. 1. Have chimney professionally inspected every 5 years. 2. Clean the lint trap on the clothes dryer after each use. 3. Keep anything that can burn at least 1 foot (0.30 meters) away from space heaters. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

2. Clean the lint trap on the clothes dryer after each use. 4. Do not hold a child while holding a hot drink. 5. Home hot water heater should be set at a maximum of 120°F (48.8°C).

Assessment of a trauma client in the emergency department reveals paradoxical chest wall movement, respiratory distress, cyanosis, and tachycardia. The family is asking why the client needs positive end-expiratory pressure (PEEP). What should the nurse inform them regarding the rationale for this treatment? Select all that apply. 1. Ventilation is improved as positive pressure is exerted into the airways as the client begins to take in a breath. 2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process. 4. Allows for positive pressure to be applied continuously during inspiration and expiration. 5. It is less invasive and does not require the client to be on the ventilator.

2. Gas exchange is improved, and the work of breathing is decreased. 3. It expands and realigns the ribs to aid in the healing process.

The nurse is preparing to perform Leopold maneuvers on a newly admitted laboring client. What should the nurse remember when performing this procedure? 1. Ask the client to drink water prior to the procedure. 2. Perform procedure between contractions. 3. Monitor for heart beat acceleration with fetal movement. 4. Connect client to fetal heart monitor.

2. Perform procedure between contractions.

The nurse is planning care for a client admitted for chemotherapy. What interventions should the nurse initiate to prevent infection? Select all that apply. 1. Change IV tubing every 48 hours. 2. Place supplies for client in room. 3. Limit nursing personnel in room. 4. Bathe perineum once daily. 5. Place in protective isolation.

2. Place supplies for client in room. 3. Limit nursing personnel in room.

The nurse is educating a client diagnosed with cirrhosis about the functions of the liver. What functions should the nurse include? Select all that apply. 1. Removes old RBCs from the body. 2. Produces clotting factors. 3. Detoxifies the body. 4. Releases digestive enzymes. 5. Breaks down medications.

2. Produces clotting factors. 3. Detoxifies the body. 5. Breaks down medications.

In what position should the nurse place a client post lumbar puncture? 1. Reverse trendelenburg 2. Prone 3. Side-lying 4. Supine HOB elevated 45 degrees

2. Prone

A client receiving chemotherapy reports nausea and vomiting after every treatment. What interventions should the nurse initiate to reduce this side effect? Select all that apply. 1. Administer antiemetic immediately after treatment. 2. Provide music therapy. 3. Provide ginger ale to drink. 4. Apply acupressure bands to wrists. 5. Place peppermint essential oil diffuser in room.

2. Provide music therapy. 3. Provide ginger ale to drink. 4. Apply acupressure bands to wrists. 5. Place peppermint essential oil diffuser in room.

The nurse is caring for a client being admitted to the emergency department after being stabbed in the chest. An occlusive dressing is covering the chest wound upon arrival. The client's condition begins to deteriorate. Assessment reveals tracheal deviation, diminished breath sounds bilaterally, and asymmetrical chest wall movement. What would be the priority nursing intervention? 1. Administer high flow O2 per face mask. 2. Remove the occlusive dressing. 3. Notify the healthcare provider. 4. Initiate rapid IV resuscitation.

2. Remove the occlusive dressing.

A client arrives at the clinic reporting a sharp pain, rated 10/10, radiating from the right flank around to the lower right abdomen. The client also reports nausea and vomiting. Based on this data, what problem does the nurse suspect? 1. Glomerulonephritis 2. Renal lithiasis (kidney stones) 3. Nephrotic syndrome 4. Acute kidney injury

2. Renal lithiasis (kidney stones)

The nurse is preparing to administer magnesium sulfate IV to an alcoholic client with hypomagnesemia. Prior to the initiation of IV magnesium, which assessment data would be important for the nurse to document? Select all that apply. 1. Liver function 2. Respiratory rate 3. Calcium levels 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

2. Respiratory rate 4. Deep Tendon Reflexes (DTRs) 5. Urinary output

The nurse has initiated discharge instructions for a client diagnosed with glomerulonephritis. What statement by the client would indicate to the nurse that further teaching is needed? 1. "I will have protein in my urine for several months." 2. "My urinary output will increase in 1 to 3 weeks." 3. "I should keep a record of the headaches I experience over 3 months." 4. "I should notify my primary healthcare provider if my urinary output decreases."

3. "I should keep a record of the headaches I experience over 3 months."

The nurse is teaching a client who has been prescribed peritoneal dialysis. What statement by the client indicates to the nurse that teaching was successful? 1. "I need to decrease protein in my diet since my kidneys no longer work." 2. "Heating the dialysate in the microwave for 30 seconds will prevent abdominal cramping." 3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy." 4. "The automated peritoneal dialysis (APD) cycler is used every few hours during the day."

3. "I will notify my primary healthcare provider if the peritoneal drainage is cloudy."

The nurse is teaching a group of female clients how to perform a self-breast exam. One client reports no family history of breast cancer and indicates disinterest in learning the technique. What is the most appropriate response by the nurse? 1. "You can ask your healthcare provider to do this with your yearly physical." 2. "If you have no family history of cancer, you won't need to worry about this." 3. "Self-breast exams may detect changes early enough for successful treatment." 4. "You have the right to refuse anything related to health because of client rights."

3. "Self-breast exams may detect changes early enough for successful treatment."

A client, who received blunt chest trauma from an all-terrain vehicle accident, is admitted to the unit at 7 PM following insertion of a chest tube at 5 PM. The drainage collection chamber has 80 mL of drainage present upon arrival to the unit. Which assessment finding would be of concern to the nurse? Select all that apply. 1. Continuous bubbling is occurring in the suction control chamber. 2. Intermittent bubbling is noted in the water seal chamber. 3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 4. Slight fluctuations of water level in water seal chamber with respirations. 5. 190 mL of drainage noted in drainage collection chamber at 8 PM.

3. CDU is sitting upright on the bedside table with fluid levels as prescribed. 5. 190 ml of drainage noted in drainage collection chamber at 8 pm.

A client is diagnosed with a duodenal ulcer due to Helicobacter pylori (H Pylori). In addition to antibiotic therapy, the nurse anticipates that the client will also receive what class of pharmacologic agents? Select all that apply. 1. Miotic inhibitor 2. Serotonin antagonist 3. H2 antagonist 4. Acetylsalicyclic acid 5. Proton pump inhibitor

3. H2 antagonist 5. Proton pump inhibitor

What action by the nurse, who is administering platelets to a client, would require the charge nurse to intervene? 1. Verifies prescription for platelet transfusion. 2. Confirm client has provided informed consent. 3. Hangs platelets immediately upon arrival from blood bank refrigerator. 4. Infuse platelets with normal saline solution.

3. Hangs platelets immediately upon arrival from blood bank refrigerator.

Which intervention would the nurse include when planning care for a client who has increased intracranial pressure (IICP)? Select all that apply. 1. Place client supine. 2. Hyperextend head to maintain airway. 3. Maintain body temperature below 100.4 F (38 C). 4. Cluster nursing care. 5. Monitor vital signs for Cushing's Triad. 6. Limit suctioning.

3. Maintain body temperature below 100.4 F (38 C).. 5. Monitor vital signs for Cushing's Triad. 6. Limit suctioning.

A client is scheduled to be admitted to the surgical unit post total laryngectomy. What nursing intervention should the nurse include in the plan of care? Select all that apply. 1. Position left-side lying, supine. 2. Place on clear liquid diet after peristalsis returns. 3. Monitor tracheostomy for pulsations with heart beat. 4. Provide mouth care every 2 hours. 5. Maintain a humidified environment.

3. Monitor tracheostomy for pulsations with heart beat. 4. Provide mouth care every 2 hours. 5. Maintain a humidified environment.

The nurse is educating a group of college students about early signs and symptoms of cancer. When explaining the mnemonic "C-A-U-T-I-O-N", the nurse explains the 'N' stands for what sign/symptom? 1. Nausea 2. Nipple drainage 3. Nagging cough 4. Nose bleeds

3. Nagging cough

A client in the intensive care unit who is on the ventilator, suddenly exhibits signs of decreased cardiac output. A quick assessment reveals that the client has cyanosis, absence of breath sounds on the right side, neck vein distention, and the trachea is deviating to the left. What initial emergency measure should the nurse expect to be performed? 1. Insertion of a chest tube in the 7th intercostal space 2. Immediate removal of client from the ventilator 3. Needle decompression in the right 2nd intercostal space 4. Emergency thoracentesis of the left lung

3. Needle decompression in the right 2nd intercostal space.

While preparing chemotherapy, the nurse accidentily punctures the bag, spilling the solution on the floor. After activating the emergency spill protocol, what action should the nurse take first? 1. Place absorbent pads and absorbent powder over the spill. 2. Apply chemotherapy approved personal protective gown and gloves. 3. Obtain the proper spill kit for the specific chemotherapy drug used. 4. Post the "Caution-Chemo Spill" sign outside the room door.

3. Obtain the proper spill kit for the specific chemotherapy drug used.

3. "A compression sock is applied to shape the stump smaller and rounder on the bottom." Select all that apply. 1. Remove the abductor pillow. 2. Place a pillow under both knees. 3. Position the feet with the toes pointed upward. 4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses. 5. Report to the healthcare provider the 15g/dL (9.31mmol/L) Hemoglobin.

3. Position the feet with the toes pointed upward. 4. Assess client's popliteal, dorsalis pedis, and posterior tibial pulses.

Which laboratory test should be assessed by the nurse prior to administering radioactive iodine (RAI) to a female client? 1. Thyroid Scan 2. Serum calcium 3. Pregnancy test 4. Metanephrine test

3. Pregnancy test

An elderly client with partial and full-thickness burns has begun receiving fluids at 600 ml/hour, as determined by the Parkland (Consensus) Formula. Based on the assessment data for the first four hours, what should the nurse report to the primary healthcare provider? 1. The cardiovascular system is becoming seriously overloaded 2. The speed of the IV should be reduced since CVP is now normal 3. The changes in vital signs indicate an expected response to fluids 4. The client is deteriorating because of age and extent of the burns

3. The changes in vital signs indicate and expected response to fluids

An elderly client arrives at the emergency room reporting a severe headache and blurred vision. The client indicates having awakened this morning with flu-like symptoms including nausea, vomiting and dizziness. The nurse notes the client appears very weak with shortness of breath and dark cherry red lips. Based on assessment findings, what life-threatening problem does the nurse expect? 1. Guillian Barre 2. Severe dehydration 3. Advanced influenza 4. Carbon monoxide poisoning

4. Carbon monoxide poisoning

A client is admitted to the ICU with diabetes insipidus following a head injury. Which finding would the nurse anticipate in this client? 1. Low serum hematocrit 2. High serum glucose 3. High urine protein 4. Low urine specific gravity

4. Low urine specific gravity

A client arrives at the clinic with reports of persistent vomiting, weakness and leg cramps. The nurse notes that the client is irritable. BP 102/58, HR 108, RR 14. Based on this data, what acid/base imbalance does the nurse expect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis

4. Metabolic alkalosis

A nurse is caring for a client with fat embolus syndrome (FES). Which data would support the nurse's assessment that the FES has resolved? 1. Respirations - 24. 2. Oxygen saturation - 94%. 3. Arterial blood gas - pH 7.34. 4. No infiltrates noted on chest x-ray.

4. No infiltrates noted on chest x-ray.

The nurse notes continuous bubbling in the water seal chamber of the chest tube system. What should be the nurse's initial action? 1. Clamp the chest tube closest to the chest wall. 2. Increase the water level in the water seal chamber. 3. Have the client take a deep breath and do valsalva maneuver. 4. Notify the healthcare provider.

4. Notify the healthcare provider.

A client is admitted with a diagnosis of bacterial meningitis. Which action should the nurse initiate first? 1. Darken room. 2. Provide sponge bath for fever of 102 F (38.8 C). 3. Pad side rails. 4. Place on Droplet precautions

4. Place on droplet precautions

A client, who receives hemodialysis three times a week, has been placed on a fluid restriction of 1000 mL/day. What is the nurse's best action when the client is seen drinking a 12 ounce (360 mL) soft drink? 1. Take the soft drink away from the client. 2. Document the client is noncompliant. 3. Notify dietary to no longer send beverages with food trays. 4. Reinforce the importance of the fluid restriction with the client.

4. Reinforce the importance of the fluid restriction with the client.

What does the nurse need to remember when caring for clients on the oncology unit who have a radiation implant? Select all that apply. 1. Nursing assignments should be rotated weekly. 2. The nurse should care for no more than 3 clients with a radiation implant per shift. 3. Limit visitors to 60 minutes per day. 4. Wear film badge throughout assigned shift. 5. Educate visitors to stay at least 6 feet from the client.

4. Wear film badge throughout assigned shift. 5. Educate visitors to stay at least 6 feet from the client.

Which initial arterial blood gas (ABG) results would the nurse likely see in a client who has overdosed on acetylsalicylic acid (ASA)? 1. pH 7.50, PaCO2 42, PaO2 63, SaO2 91, HCO3 28 2. pH 7.32, PaCO2 36, PaO2 83, SaO2 95, HCO3 19 3. pH 7.28, PaCO2 28, PaO2 72, SaO2 90, HCO3 16 4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

4. pH 7.48, PaCO2 30, PaO2 88, SaO2 92, HCO3 24

The nurse performs an initial assessment on a client admitted following a motor vehicle crash. Based on this assessment, what Glasgow Coma Scale (GSC) score would the nurse assign to the client? Client obtunded, with occassional moaning noted. Opened eyes and extended arm during IV start.

6 Eye opening-2 Motor response-2 Verbal response-2