Me 2

60. A nurse in the PACU is caring for a client . Which of the following assessment is the nurses priority ?

c ) respiratory status

23. A Nurse is completing an assessment of an older adult client and notes reddened areas over the bony prominences , but the client's skin is inct . Which of the following interventions should the nurse include the plan of care ?

c ) support bony prominences with pillows

82. A nurse is administering furosemide 80 mg PO twice - daily to a client who has pulmonary edema . Which of the following assessment findings indicates to the nurse that the medication is effective ?

c ) weight loss of 1.8 kg ( 4 lb ) in the past 24 hours

66. A nurse is caring for a client who has a new colostomy the nurse notes that the client appears withdrawn and looks away during ostomy care . Which of the following actions should the nurse take ?

Ask the client how they feel about the stoma

100. A nurse is assessing a client who has right - sided heart failure . Which of the following assessment findings should the nurse expect to find ?

pitting edema

70. A home health nurse is providing nutrition education for a client who has trigeminal neuralgia . Which of the following foods should the nurse recommend ?

vanilla pudding

71. A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake . Which of the following choices should the nurse recommend as containing the least potassium ?

) 1 Cup white rice

53. A nurse is caring for a client who has just undergone a total laryngectomy . Which of the following findings is the nurses priority for immediate intervention ?

) tachypnea

41. A nurse is planning care for a client who has status epilepticus . Which of the following interventions is the nurses priority to include ?

) turn the client to the lateral position during seizure activity

20.A nurse is planning care for a client who has a central venous access device for intermittent infusions . Which of the following actions should the nurse include in the plan of care ?

a ) Flush a catheter using a 10 ml syringe

94. A nurse is teaching a client who has asthma about the use of a peak flow meter . After setting the meter to the zero Base Line , what is the sequence of steps the nurse should instruct the client to take ? Rent the Seas move the steps into the box of the right placing them in the selected order of performance . Use all steps )

1. Stand upright 2. Fill your lungs with a deep breath 3. seal your lips around the mouth piece 4 . exhale forcefully and quickly 5 . record the highest of three consecutive readings

9 . A nurse is caring who is experiencing a hypertensive crisis . Which of the following actions should the nurse take ?

b ) Perform neurological assessments

54. A nurse is admitting a client to the emergency department after a gunshot wound to the abdomen . Which of the following actions should the nurse take to help prevent the onset of acute kidney failure ?

Administer IV fluids to the client

98. A nurse is preparing to administer piperacillin 3.375 grams by intermittent IV bolus every 6 hours . Available is piperacillin 3.375 grams in dextrose 5 % in water 100 ml to infuse over 30 minutes , the nurse should set the IV pump to deliver how many ml / hr ? ( round the answer to the nearest whole number . Use a leading zero if it applies . Do not use a trailing zero . )

Answer : 675 ml / hr

the RDA Protein is 0.8g / kg Of body weight , how daily ( Round the answer to the nearest whole 19. A nurse is caring for a client who weights 190 lb and is receiving Total parenteral Nutrition , if many grams of protein should the client receive number . Use a leading zero if it applies . Do not use a trailing zero )

Answer : 69 grams

90. A nurse is monitoring a client's heart rhythm following insertion of a permanent pacemaker . which of the following images should the nurse expect ?

Answer : D

89. A nurse in a provider's office is teaching a client about the self management of GERD which of the following instruction should the nurse include ?

b ) sleep with the head of your bed elevated 6 inches

A nurs is monitoring a client who is receiving two unitd of RBCS which manifestation indicates reaction

Back pain

84. A nurse on an oncology unit is canng for a client who is receiving internal radiation therapyWhich of the following actions should the nurse take ?

b ) wear a lead apron when providing client care

35. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia . Which of the following assessment findings supports this suspicion ?

Cool , clammy skin

3.A nurse is assessing a client who has pericarditis . In which of the following areas of the client's chest should the nurse place the stethoscope to best hear a pericardial friction rub ? ( select HOT spot )

D

2 . A nurse is assessing a client admitted with peripheral vascular disease Which of the following findings indicates a venous vascular disorder ?

Edema of the ankle

15. A nurse is caring for a client who is receiving a blood transfusion . The nurse observes that the client has bounding peripheral pulses , hypertension , and distended jugular veins . The nurse should anticipate administering which of the following prescribed medications ?

Furosemide

10. A nurse is providing discharge teaching about blood sugar monitoring for a client who has a new diagnosis of type 2 diabetes mellitus . The nurse should instruct the client to obtain which of the following supplies ?

Hand mirror

28. A nurse is providing discharge teaching for a client who has asthma and a new prescription for a metered dose inhaler . Which of the following client statements indicates an understanding of the teaching ?

I should shake the inhaler before I use it

76. A nurse is caring for a client who has lower extremity fracture and a prescription for role change ? crutches . Which of the following client statements indicates that the client is adapting to their

I will need to have my partner take over shopping for groceries and cooking the meals for us

between the legs when in bed 43. A nurse is caring for a client who is receiving Total parenteral Nutrition ( TPN ) The crane infusion is almost complete and the new solution is not available which of the following actions should the nurse take ?

Infuse dextrose 10 % in wate

34. A nurse in an emergency department is preparing a client for emergency surgery . The client's blood alcohol level is 180 mg / DL which of the following action is the nurses priority ?

Insert an NG Tube

32. A nurse monitoring an older adult client who has an extrapolation of chronic lymphocytic leukemia . The nurse notes patikayy on the client's skin which of the following actions should the nurse take ?

Institute bleeding precautions

77. A nurse is assessing a client who is preoperative and reports an allergy to bananas . The nurse should recognize that the client is at risk for an allergic cross reactivity which of the following substances ?

Latex

62. Nurse is caring for a client who has pancreatitis and has been receiving Total parenteral Nutrition . Which of the following Laboratory test should the nurse monitor for overall nutritional status ?

Prealbumin

87. A nurse is preparing to administer two units of packed rbc's to a client . Which of the following actions should the nurse take ?

Prime the tubing with 0.9 % sodium chloride

59. A nurse is administering potassium chloride via IV infusion to a client who has severe hypokalemia Which of the following actions should the nurse take ?

Start the infusion at 30 meg hr

55. A nurse is caring for a client who has just returned from surgery with an external foxator to the left tibia which of the following requirred intervention

The clients capillary refil in the left toe is 6 seconds

97. A nurse is caring for a client who has a traumatic brain injury . and Cooperative , becomes agitated and Restless . Which of the following assessment should The client , who has been quiet the nurse perform first ?

a ) Blood pressure (

central catheter ( PICC 11. A nurse is completing discharge teaching who has a peripherally inserted ) line in the left arm . Which of the following instructions should the nurse include in the teaching ?

a ) Do not elevate the arm above the level of the heart

85. A nurse is caring for a client who has plan for 3 months which of the following results should the nurse monitor to determine long - term diabetes mellitus and has been following a treatment glycemic control ?

a ) Glycosylated hemoglobin level

burn injury to the lower 45. A nurse is caring for a client in the emergency department who experienced a full thickness torso 1 hour ago . Which of the following findings should the nurse expect ? a ) Hypotension

a ) Hypotension

17. A nurse is caring for a client who has bladder cancer and a WBC count of 900 / mm3 . which of the following actions should the nurse take ?

a ) Instruct client to avoid eating raw fruit

31. A nurse is teaching a client who has a new prescription for Warfarin about foods that affect the INR . The nurse should include in the teaching that which of the following Foods interact with this medication ?

a ) Kale

27. A nurse is providing teaching to a client who is receiving opioids for pain management . Which of the following information should the nurse include in the teaching ?

a ) Monitor urinary output for retention

58. A nurse is planning care for a client who has left - sided hemiplegia following a stroke which of the following actions should the nurse include in the plan of care ?

a ) Place a plate guard on the clients meal tray

93. A nurse is discussing nutrition options with a client who has a new diagnosis of COPD Which of the following statements should the nurse take ?

a ) Plan to include high protein foods in each of your meals

18. A nurse is caring for a patient who has hypotension , cool and clammy skin , tachycardia and tachypnea . Which of the following positions should the nurse place the client ?

a ) Reverse Trendelenburg elevated

22. A nurse is caring for an older adult client who has dementia . Which of the following question should the nurse ask to assess the client's abstract thinking ?

a ) What is meant by saying " don't beat around the bush ?

26. A nurse is assessing a client following the insertion of a central venous catheter . Which of the following findings indicates a pneumothorax ?

a ) diminished breath sounds

96. A nurse in a clinic is providing for preventive teaching to an older client during a Well Visit . The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after age 60 ( select all that apply )

a ) human papillomavirus d ) Influenza e ) herpes zoster

99. Nurse in the emergency department is caring for a client who was involved in an explosion . Which of the following actions should the nurse plan to take first question ( click on the exhibit button for additional information about the client )

a ) initiate peripheral IV access

7 . A nurse is providing teaching to a client who is postoperative following a total hip arthroplasty . Which of the following statements should the nurse make ?

a ) use raised toilet seat to maintain your hips above the knees

78. A nurse on a medical unit is planning care for a group of clients . Which of the following clients should the nurse attend to First ?

a client who has thrombocytopenia and reports a nosebleed

25. A nurse is caring for a client who is scheduled for an abdominal paracentesis . The nurse should plan to take which of the following actions ?

ask the client to empty his bladder prior to the procedure

86. A nurse is reviewing the plan of care for a client following interventions should the nurse anticipate button for additional information about the client ) who has a seizure disorder . Which of the including in the plan ? ( click on the exhibit

b ) Hold the client's phenytoin

91. A nurse is assessing a client who has heart failure which of the following client statements should indicate to the nurse that the client needs a referral for cardiac rehabilitation ?

b ) I am too - tired to brush my teeth

33. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes . Which of the following statements by the client indicates effectiveness of the teaching

b ) I should apply antibiotic ointment to the lesions

68. A nurse is teaching a client who has AIDS and wishes to continue self care at home despite living alone . Which of the following actions by the nurse demonstrates client advocacy ?

b ) Initiate a referral for the client to a home health agency

74. a nurse is planning nurse should plan to instruct to teach a client whose provider has prescribed the client that he can include which of the following Foods in his a low purine diet . The diet ( select all that apply )

b ) Nuts c ) Apricots

63. A nurse is teaching a client who has endometriosis about the adverse effects of leuprolide Which the following manifestations should the nurse include in the teaching ?

bone loss

5 . A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure . Which of the following is the priority topic for the nurse to review with the client ?

c ) Changes in weight

1. A nurse is assessing a client who has a diagnosis on colon cancer which of the following should the nurse expect ?

c ) Hematochezia

16. A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer . Which of the following actions should the nurse plan to take ?

c ) Insert a large bore nasogastric tube

61. A nurse is reviewing the medical record of a client who is scheduled for a CT scan with contrast media . Which of the following medication should the nurs instruct the client to withhold for 48 hours following the procedure ?

c ) Metformin

8 . A nurse finds a client in bed , unresponsive and breathing . Which of the following action should the nurse take first ?

c ) Palpate for the client's carotid pulse

65. A nurse is planning the discharge of a client who had an ensure that the client is discharged with which of the following ischemic stroke . The nurse should types of pharmacologic therapy ?

c ) anti thrombotic

75. Nurse is caring for a client following a total knee of 6 on a paint scale of 0 to 10. Which of the following interventions should the nurse take ? arthroplasty . The client reports a pain level

c ) apply an ice pack to the clients knee

67. A nurse is preparing to perform ocular irrigation for a client following a chemical Splash to the eye . Which of the following actions should the nurse plan to take first ?

c ) collect information about the iritant that caused an Injury

14. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home When discussing peritonitis , which of the following manifestations should the nurse identify as the earliest indication of this complication ?

c ) d ) Fever

21. A nurse is reviewing the medical record of a client who is to undergo open heart surgery . Which of the following findings should the nurse report to the provider as a contradiction to receiving heparin ?

c ) d ) Thrombocytopenia

92. A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate . The client reports bladder spasms and the nurse observes decreased urinary output . Which of the following actions should the nurse take ?

c ) flush the catheter manually with 0.9 % sodium chloride

81. A nurse is providing teaching to a client who has a deep vein thrombosis ( DVT ) . Which of the following findings should the nurse identify as a risk factor for the development of the DVTS ?

c ) oral contraceptive use

69. A nurse is assessing a client who has cirrhosis . Which of the following findings is the priority for the nurse to report ?

c ) platelets 70.000 / mm3

83 , A nurse is preparing to administer furosemide to a client who has acute heart failure . Which of the following laboratory results should the nurse identify as a contradiction for receiving the medication ?

c ) potassium 3.2 meq / L

48. A nurse is caring for a client admitted with a skull fracture , which of the following assessment findings should be of greatest concern to the nurse ?

d ) Glasgow Coma Scale score changes from 14 to 9

13. A nurse is caring for a client who has a sealed radiation implant . Which of the following actions should the nurse take ?

d ) Limit family member visits to 30 min per day

24. A nurse is reviewing a cardiac Rhythm strip of a client who has atrial flutter . Which of the following findings should the nurse expect ?

d ) Sawtooth pattern with atrial rate of 252 400 / minutes

40. A nurse is caring for a client who has advanced liver disease . Which of the following laboratory results should the nurse monitor when assessing this client ?

d ) Serum ammonia

4. A nurse is caring for a client who has a chest tube . The client asks why the fluid in the water -seal chamber rises and falls . Which of the following statements should the nurse make ?

d ) Your breathing pattern causes this "

6 . A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation ( TENS ) unit . Which of the following statements should the nurse include ?

d ) adjust the dial until you feel a ' pins and needles ' sensation "

72. A nurse is planning care for a client who has a full - thickness burns on the lower extremities . Which of the following interventions should the nurse include ?

d ) apply new - gloves when alternating between wound care sites

46. A nurse is planning care for an older adult client who has Meniere's disease . Which of the following interventions should the nurse include in the plan ?

d ) encourage the client to change position slowly

95. A nurse is caring for a client who has bounding pulses , crackles on auscultation , and pink frothy secretions when receiving suction . The nurse should recognize these assessment findings us indicating which of the following ?

d ) fluid volume excess

30. A nurse is caring for a client who has anemia . Which of the following assessment findings should the nurse anticipate with the client's condition ?

d ) flushed skin color

49. A nurse is caring for a client who has an indwelling urinary catheter . Which of the following actions should the nurse take when performing a close intermittent irrigation ?

d ) inject the irrigation solution slowly into the catheter

2 and 02 saturation 95 % The nurse 88. A nurse is caring for a client who has chronic renal failure . The client displays the following ABG results : pH : 7.24 paCO2 : 44 mm Hg . pa02 : 84 mmHg . HCO3 : 18 meq / L base excess should include that the client has which of the following acid - base balances ? a )

d ) metabolic acidosis

52. Nurse is caring for an older adult client who is suspected of having septicemia . Which of the following actions is the nurses priority ?

d ) obtain a blood specimen for culture and sensitivity testing

73. A nurse is caring for a client who has cancer . The client tells the vitamins and minerals instead of chemotherapy " which of the following responses should the nurse , " I would prefer to try nurse make

d ) tell me what you know about chemotherapy

44. A nurse is caring for a client who is 6 hours postoperative following application of an external fixator for a tibial fracture . Which of the following actions should the nurse take ?

dependent palpate the dorsalis pedis pulse

51. A nurse is caring for a client who is post - operative conscious ) Sedation . Which of the following assessment findings is the nurse's priority ?

gag reflex

57. A nurse is reviewing the medication list of a client who is being admitted with diabetes insipidus . Which of the following medication places the client at an increased risk for developing diabetes insipidus ?

lithium

increased 36. A nurse is caring for a client who is receiving radiation . The client reports nausea since the therapy was initiated . Which of the following considerations should the nurse include when finding the clients meals

offer frequent High carbohydrate meals

42. A nurse is caring for a client who had a total hip arthroplasty . Which of the following actions should the nurse take to prevent hip dislocation ?

place two bed pillows between the legs when in bed

56. A nurse is an emergency department is reviewing a client's ECG reading . Which of the following findings should the nurse identify as an indication that the client has a first degree heart block ?

prolonged PR intervals

64. A nurse is caring for a client who had an arterial revascularization of the right lower extremity which of the following is the priority action the nurse should plan to take after contacting the provider ? ( Click on the exhibit " button for additional information about the client )

start an IV fluid bolus of 0.9 % sodium chloride 500 ml to infuse over 1 hour

80. A nurse is teaching a client who has diabetes mellitus about foot care . Which of the following instruction should the nurse include ?

where cotton rather than nylon socks

29. A nurse is providing preoperative teaching for a client who is having left - sided cardiac catheterization . Which of the following information should the nurse include in the teaching ?

you should expect warm sensation after the injection of the contrast dye during the procedure