Med surg 2 test practice questions (exam 2)

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer? A. "My pain resolves when I have something to eat." B. "The pain begins right after I eat." C. "I know that my father and my grandfather both had ulcers." D. "I seem to have bowel movements more often than I usually do."

"My pain resolves when I have something to eat."

A client has come to the clinic reporting pain just above her umbilicus. When assessing the client, the nurse notes Sister Mary Joseph nodules. The nurse should refer the client to the primary provider to be assessed for what health problem? A. A GI malignancy B. Dumping syndrome C. Peptic ulcer disease D. Esophageal/gastric obstruction

A GI malignancy

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as prescribed C. Vitamin B 12 injections as prescribed D. Administration of diuretics as prescribed

Administration of diuretics as prescribed

A nurse is providing care for a client whose pattern of laboratory testing reveals long-standing hypocalcemia. Which other laboratory result is most consistent with this finding? A. An elevated parathyroid hormone level B. An increased calcitonin level C. An elevated potassium level D. A decreased vitamin D level

An elevated parathyroid hormone level

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis? A. A middle-aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17-year-old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

An older adult client with an infected pressure ulcer in the sacral area

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication? A. Osteomyelitis B. Avascular necrosis C. Phantom pain D. Septicemia

Avascular necrosis

A client has symptoms of osteoporosis and is being assessed during an annual physical examination. The assessment shows that the client will require further testing related to a possible exacerbation of osteoporosis. The nurse should anticipate which diagnostic test? A. Bone densitometry B. Hip bone radiography C. Computed tomography (CT) D. Magnetic resonance imaging (MRI)

Bone densitometry

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture? A. Arthrography B. Bone scan C. Bone densitometry D. Arthroscopy

Bone densitometry

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis. Which of the following nursing diagnoses must be addressed in the plan of care? A. Risk for aspiration related to vertebral fracture B. Constipation related to vertebral fracture C. Impaired swallowing related to vertebral fracture D. Decreased cardiac output related to vertebral fracture

Constipation related to vertebral fracture

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? A. Use glycerin suppositories on a regular basis. B. Limit physical activity in order to promote bowel peristalsis. C. Consume high-residue, high-fiber foods. D. Resist the urge to defecate until the urge becomes intense.

Consume high-residue, high-fiber foods

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? A. Administer a Fleet enema as prescribed and remain with the client. B. Contact the primary care provider promptly and report these signs of perforation. C. Position the client supine and insert an NG tube. D. Page the primary provider and report that the client may be obstructed.

Contact the primary care provider promptly and report these signs of perforation

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a: A. sprain. B. strain. C. contusion. D. dislocation.

Contusion

A client has returned to the unit after undergoing limb-sparing surgery to remove a metastatic bone tumor. The nurse providing postoperative care in the days following surgery assesses for what complication from surgery? A. Deficient fluid volume B. Delayed wound healing C. Hypocalcemia D. Pathologic fractures

Delayed wound healing

A client's electronic health record notes that the client has hallux valgus. What signs and symptoms should the nurse expect this client to manifest? A. Deviation of a great toe laterally B. Abnormal flexion of the great toe C. An exaggerated arch of the foot D. Fusion of the toe joints

Deviation of a great toe laterally

A client is receiving education about an upcoming Billroth I procedure (gastroduodenostomy). This client should be informed that the client may experience which of the following adverse effects associated with this procedure? A. Persistent feelings of hunger and thirst B. Constipation or bowel incontinence C. Diarrhea and feelings of fullness D. Gastric reflux and belching

Diarrhea and feelings of fullness

A group of nurses have attended an in-service on the prevention of occupationally acquired diseases that affect health care providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for clients on airborne precautions

Disposing of sharps appropriately and not recapping needles

A nurse is assessing a client's stoma on postoperative day 3. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse best respond to this assessment finding? A. Irrigate the ostomy to clear a possible obstruction. B. Contact the primary care provider to report this finding. C. Document that the stoma appears healthy and well perfused. D. Document a nursing diagnosis of Impaired Skin Integrity

Document that the stoma appears healthy and well perfused

A client with a diagnosis of colon cancer is 2 days' postoperative following bowel resection and anastomosis. The nurse has planned the client's care in the knowledge of potential complications. What assessment should the nurse prioritize? A. Close monitoring of temperature B. Frequent abdominal auscultation C. Assessment of hemoglobin, hematocrit, and red blood cell levels D. Palpation of peripheral pulses and leg girth

Frequent abdominal auscultation

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy? A. Increased bone mass B. Resolution of infection C. Relief of bone pain D. Absence of tumor spread

Increased bone mass

The results of a nurse's musculoskeletal examination show an increase in the lumbar curvature of the spine. The nurse should recognize the presence of what health problem? A. Osteoporosis B. Kyphosis C. Lordosis D. Scoliosis

Lordosis

A nurse is caring for a client who has suffered an unstable thoracolumbar fracture. What goal should the nurse prioritize during nursing care? A. Preventing skin breakdown B. Maintaining spinal alignment C. Maximizing function D. Preventing increased intracranial pressure

Maintaining spinal alignment

A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. The nurse should perform interventions to prevent what complication? A. Muscle clonus B. Muscle atrophy C. Rheumatoid arthritis D. Muscle fasciculations

Muscle atrophy

A nurse is caring for a client with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition

Orange and foamy urine

An advanced practice nurse is assessing the size and density of a client's abdominal organs. If the results of palpation are unclear to the nurse, what assessment technique should be implemented? A. Percussion B. Auscultation C. Inspection D. Rectal examination

Percussion

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client? A. Place a pillow between the legs. B. Turn the client on the surgical side. C. Avoid flexion of the right hip. D. Keep the right hip adducted at all times

Place a pillow between the legs

The nurse is caring for a client with gastrointestinal symptoms who reports being under a significant amount of stress at home and at work. Which gastrointestinal effect of stress should the nurse anticipate is affecting this client? A. Increased gastric acid secretion B. Slowed peristalsis C. Increased enteric blood flow D. Relaxed sphincter muscles

Slowed peristalsis

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates. What of the following risk factors should the educator describe? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass index C. Small frame and female sex D. Male sex, diabetes, and high protein intake

Small frame and female sex

A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education? A. The client should drink at least 2 liters of fluid in the next 12 hours. B. The client can resume a normal routine immediately. C. The client should expect fecal urgency for several hours. D. The client can expect some scant rectal bleeding.

The client can resume a normal routine immediately

A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe? A. The entire peritoneal cavity can be visualized. B. The test allows for painless biopsy collection. C. The capsule is endoscopically placed in the intestine. D. The test is noninvasive.

The test is noninvasive

A client has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse perform following this procedure? A. Wrap the joint in a compression dressing. B. Perform passive range of motion exercises. C. Maintain the knee in flexion for up to 30 minutes. D. Apply heat to the knee.

Wrap the joint in a compression dressing

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly? A. "I clean my stoma twice a day with alcohol." B. "The only time I flush my tube is when I'm putting in medications." C. "I flush my tube with water before and after each of my medications." D. "I try to stay still most of the time to avoid dislodging my tube."

"I flush my tube with water before and after each of my medications."

The nurse is teaching the client on bed rest to perform quadriceps setting exercises. Which instruction should the nurse give the client? A. "Push the knees into the mattress." B. "Lie prone in bed." C. "Contract the buttock muscles." D. "Bend the knees."

"Push the knees into the mattress."

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction? A. "Skeletal traction temporarily stabilizes the fracture before surgery." B. "Weights are attached to the leg using a boot." C. "Traction involves passing a pin through the bone." D. "Light weights must be used with skeletal traction

"Traction involves passing a pin through the bone."

A nurse is caring for a client who has been scheduled for a bone scan. Which statement should the nurse include when educating the client about this diagnostic test? A. "The test is brief and requires that you drink a calcium solution 2 hours before the test." B. "You will not be allowed fluid for 2 hours before and 3 hours after the test." C. "You will be encouraged to drink water after the administration of the radioisotope injection." D. "This is a common test that can be safely performed on anyone."

"You will be encouraged to drink water after the administration of the radioisotope injection."

A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation? A. "You'll need to fast for at least 18 hours prior to your test." B. "Starting today, take over-the-counter (OTC) stool softeners twice daily." C. "You'll need to have enemas the day before the test." D. "For 24 hours before the test, insert a glycerin suppository every 4 hours."

"You'll need to have enemas the day before the test."

A nurse is caring for a client whose cancer metastasis has resulted in bone pain. What should the nurse expect the client to describe? A. A dull, deep ache that is "boring" in nature B. Soreness or aching that may include cramping C. Sharp, piercing pain that is relieved by immobilization D. Spastic or sharp pain that radiates

A dull, deep ache that is "boring" in nature

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. Which assessment findings are most consistent with this diagnosis? A. Hot skin and a capillary refill of 1 to 2 seconds B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin C. Pain, diaphoresis, and erythema D. Jaundiced skin, weakness, and capillary refill of 3 seconds

Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin

The nurse is administering medications to a client through a feeding tube. Which action should the nurse take? A. Flush the tube with 5 mL of water before administering medication. B. Turn the tube feeding off for 1 hour before administering the medication. C. Administer each medication separately. D. Flush with 50 mL of water between each medication.

Administer each medication separately

A client with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the client's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing client positioning

Administering diuretics Implementing fluid restrictions Enhancing client positioning

A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention? A. Positioning the client supine B. Administering diuretics C. Oxygen by nasal cannula D. Administering volume expanders

Administering volume expanders

A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

Alanine aminotransferase (ALT) Gamma-glutamyl transferase (GGT) Aspartate aminotransferase (AST)

A nurse is caring for a client with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client? A. Insert a nasogastric tube. B. Administer a micro Fleet enema at least 3 hours before the procedure. C. Have the client lie in a supine position for the procedure. D. Apply local anesthetic to the back of the client's throat.

Apply local anesthetic to the back of the client's throat

A client has suffered a muscle strain and is reporting pain at 6 on a 10-point scale. The nurse should recommend what action? A. Taking an opioid analgesic as prescribed B. Applying a cold pack to the injured site C. Performing passive ROM exercises D. Applying a heating pad to the affected muscle

Applying a cold pack to the injured site

A public health nurse is organizing a campaign that will address the leading cause of musculoskeletal-related disability. The nurse should focus on what health problem? A. Osteoporosis B. Arthritis C. Hip fractures D. Lower back pain

Arthritis

The nurse is preparing to check for tube placement in the client's stomach as well as measure the residual volume. What are these nursing actions attempting to prevent? A. Gastric ulcers B. Aspiration C. Abdominal distention D. Diarrhea

Aspiration

The nurse is caring for a client who had a low-profile gastrostomy device placed. Which instruction should the nurse give the client and family? A. Wear the tubing outside of clothing. B. Use tape to secure the device. C. Bring the connection tubing if going to the hospital. D. Change the wet-to-dry dressing daily.

Bring the connection tubing if going to the hospital

A nurse is providing care for a client who has osteomalacia. What major goal should guide the choice of medical and nursing interventions? A. Maintenance of skin integrity B. Prevention of bone metastasis C. Maintenance of adequate levels of activated vitamin D D. Maintenance of adequate parathyroid hormone function

Maintenance of adequate levels of activated vitamin D

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

Peritonitis

A client is being assessed for a suspected deficit in intrinsic factor synthesis. What diagnostic or assessment finding is the most likely rationale for this examination of intrinsic factor production? A. Muscle wasting B. Chronic jaundice in the absence of liver disease C. The presence of fat in the client's stool D. Persistently low hemoglobin and hematocrit

Persistently low hemoglobin and hematocrit

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? A. Administer analgesics as required. B. Place a pillow between the client's legs when turning. C. Maintain prone positioning at all times. D. Encourage internal and external rotation of the affected leg.

Place a pillow between the client's legs when turning

A nurse is preparing to discharge a client home on parenteral nutrition. What should an effective home care teaching program address? Select all that apply. A. Preparing the client to troubleshoot for problems B. Teaching the client and family strict aseptic technique C. Teaching the client and family how to set up the infusion D. Teaching the client to flush the line with sterile water E. Teaching the client when it is safe to leave the access site open to air

Preparing the client to troubleshoot for problems Teaching the client and family strict aseptic technique Teaching the client and family how to set up the infusion

A nurse on the orthopedic unit is assessing a client's peroneal nerve. The nurse should perform this assessment by doing what action? A. Pricking the skin between the great and second toe B. Stroking the skin on the sole of the client's foot C. Pinching the skin between the thumb and index finger D. Stroking the distal fat pad of the small finger

Pricking the skin between the great and second toe

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? A. Maximize the efficiency of care. B. Ensure that the client's health care is holistic. C. Facilitate the client's adjustment to a new body image. D. Promote the client's highest possible level of function.

Promote the client's highest possible level of function

A client who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What should the goals of physical therapy for this client include? A. Muscle training to relieve dysphagia B. Relieving nerve paralysis in the cervical plexus C. Promoting maximum shoulder function D. Alleviating achalasia by decreasing esophageal peristalsis

Promoting maximum shoulder function

A client has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this client's discharge education? A. Resumption of activities of daily living B. Pain control C. Promotion of adequate nutrition D. Strategies for promoting communication

Promotion of adequate nutrition

A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? A. Bursitis B. Radiculopathy C. Sciatica D. Tendonitis

Sciatica

A nurse is caring for an 83-year-old client who is being assessed for recurrent and intractable nausea. What age-related change to the GI system may be a contributor to the client's health issues? A. Stomach emptying takes place more slowly. B. The villi and epithelium of the small intestine become thinner. C. The esophageal sphincter becomes incompetent. D. Saliva production decreases.

Stomach emptying takes place more slowly

A client has returned to the medical unit after a barium enema. When assessing the client's subsequent bowel patterns and stools, what finding would warrant reporting to the health care provider? A. Large, wide stools B. Milky white stools C. Three stools during an 8-hour period of time D. Streaks of blood present in the stool

Streaks of blood present in the stool

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? A. Tachycardia, hypotension, and tachypnea B. Tarry, foul-smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst, unrelieved by oral fluid administration

Tachycardia, hypotension, and tachypnea

A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client? A. The cast will feel cool to touch for the first 30 minutes. B. The cast should be wrapped snuggly with a towel until the client gets home. C. The cast should be supported on a board while drying. D. The cast will only have full strength when dry.

The cast will only have full strength when dry

A nurse is providing a class on osteoporosis at the local center for older adults. Which statement related to osteoporosis is most accurate? A. High levels of vitamin D can cause osteoporosis. B. A nonmodifiable risk factor for osteoporosis is a person's level of activity. C. Secondary osteoporosis occurs in women after menopause. D. The use of corticosteroids increases the risk of osteoporosis.

The use of corticosteroids increases the risk of osteoporosis

When assessing a client's peripheral nerve function, the nurse uses an instrument to prick the fat pad at the top of the client's small finger. This action will assess what nerve? A. Radial B. Ulnar C. Median D. Tibial

Ulnar

A client asks the nursing assistant for a bedpan. When the client is finished, the nursing assistant notifies the nurse that the client has bright red streaking of blood in the stool. The nurse's assessment should focus on what potential cause? A. Diet high in red meat B. Upper GI bleed C. Hemorrhoids D. Use of iron supplements

Upper GI bleed

A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location? A. Sigmoid colon B. Upper GI tract C. Large intestine D. Anus or rectum

Upper GI tract

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include? A. Check the gastric residual volume every 4 hours. B. Hold the tube feeding if the gastric residual volume is greater than 200 mL. C. Position client flat in bed during feedings. D. Use client assessment findings to determine tolerance of feedings.

Use client assessment findings to determine tolerance of feedings

A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client? A. Administration of prophylactic antibiotics B. Total parenteral nutrition (TPN) C. Use of a pressure-relieving mattress D. Use of a Foley catheter until discharge

Use of a pressure-relieving mattress

A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take? A. Place the client in a prone position. B. Administer bolus feedings. C. Place a mask over the client's nose. D. Wear personal protective equipment.

Wear personal protective equipment

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). Which statement(s) by the client indicates effective knowledge of the procedure? Select all that apply. A. "I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." B. "It is likely that I will need to receive nutrition directly into my veins." C. "One of my nerves, the vagus nerve, may be cut during the surgery." D. "I can eat a normal diet again after 3 to 5 weeks." E. "This surgery will remove part of my stomach and colon."

"I will be at risk of developing diarrhea, nausea, and feeling light-headed after eating." "One of my nerves, the vagus nerve, may be cut during the surgery."

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education? A. "Drinking beverages after your meal, rather than with your meal, may bring some relief." B. "It's best to avoid dry foods, such as rice and chicken, because they're harder to swallow." C. "Many clients obtain relief by taking over-the-counter antacids 30 minutes before eating." D. "Instead of eating three meals a day, try eating smaller amounts more often."

"Instead of eating three meals a day, try eating smaller amounts more often."

A client who suffered a stroke had an NG tube inserted to facilitate feeding shortly after admission. The client has since become comatose and the client's family asks the nurse why the health care provider is recommending the removal of the client's NG tube and the insertion of a gastrostomy tube. What is the nurse's best response? A. "It eliminates the risk for infection." B. "Feeds can be infused at a faster rate." C. "Regurgitation and aspiration are less likely." D. "It allows caregivers to provide personal hygiene more easily."

"Regurgitation and aspiration are less likely."

A client has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the client's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises. 2. Hematemesis. 3. Clotting abnormalities. 4. Vascular collapse. 5. Coma. A. 1, 2, 5, 4, 3 B. 1, 2, 3, 4, 5 C. 2, 3, 1, 4, 5 D. 3, 1, 2, 5, 4

1, 2, 3, 4, 5

A client returns to the unit after a neck dissection. The surgeon placed a Jackson-Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the health care provider immediately for what finding? A. Presence of small blood clots in the drainage B. 60 mL of milky or cloudy drainage C. Spots of drainage on the dressings surrounding the drain D. 120 mL of serosanguinous drainage

60 mL of milky or cloudy drainage

A nurse is conducting health screening with a diverse group of clients. Which client likely has the most risk factors for developing hemorrhoids? A. A 45-year-old teacher who stands for 6 hours per day B. A pregnant woman at 28 weeks' gestation C. A 37-year-old construction worker who does heavy lifting D. A 60-year-old professional who is under stress

A pregnant woman at 28 weeks' gestation

A nurse is performing a nursing assessment of a client suspected of having a musculoskeletal disorder. Which assessment should the nurse prioritize for a client who has a musculoskeletal disorder? A. Range of motion B. Activities of daily living C. Gait D. Strength

Activities of daily living

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition. What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN. B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN. C. Administer 3 ampules of dextrose 50% immediately prior to discontinuing the PN. D. Administer 3 ampules of dextrose 50% 1 hour after discontinuing the PN.

Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN

A client is undergoing diagnostic testing for suspected Paget disease. What assessment finding is most consistent with this diagnosis? A. Altered serum magnesium levels B. Altered serum calcium levels C. Altered serum potassium levels D. Altered serum sodium levels

Altered serum calcium levels

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms? A. A pattern of distinct exacerbations and remissions B. Severe diarrhea C. An absence of blood in stool D. Involvement of the rectal mucosa

An absence of blood in stool

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? A. Antidiarrheal medications 30 minutes before a meal B. Antiemetics on a PRN basis C. Vitamin B 12 injections to prevent pernicious anemia D. Beta adrenergic blockers to reduce bowel motility

Antidiarrheal medications 30 minutes before a meal

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. A. Massage B. Applying ice C. Compression dressings D. Resting the affected extremity E. Corticosteroids F. Elevating the injured limb

Applying ice Compression dressings Resting the affected extremity Elevating the injured limb

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? A. Encourage the client to take stool softener daily. B. Assess the client's food and fluid intake. C. Assess the client's surgical history. D. Encourage the client to take fiber supplements.

Assess the client's food and fluid intake

A client with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the client's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringe B. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheter D. Assessing the patency of the drainage catheter

Assessing the patency of the drainage catheter

The nurse determines that a client who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the nurse's priority when suctioning this client? A. Avoid applying suction on or near the suture line. B. Position client on the non-operative side with the head of the bed down. C. Assess the client's ability to perform self-suctioning. D. Evaluate the client's ability to swallow saliva and clear fluids.

Avoid applying suction on or near the suture line

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager hump

Bone fracture

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation? A. Estrogen B. Parathyroid hormone (PTH) C. Calcitonin D. Progesterone

Calcitonin

During assessment, a client reports experiencing rhythmic muscle contractions when the nurse performs passive extension of the wrist. The nurse should recognize the presence of which condition? A. Fasciculations B. Contractures C. Effusion D. Clonus

Clonus

A nurse is creating a care plan for a client who is receiving parenteral nutrition. The client's care plan should include nursing action(s) relevant to what potential complications? Select all that apply. A. Dumping syndrome B. Clotted or displaced catheter C. Pneumothorax D. Hyperglycemia E. Line sepsis

Clotted or displaced catheter Pneumothorax Hyperglycemia Line sepsis

A client injured in a motor vehicle accident has sustained a fracture to the diaphysis of the right femur. Of which tissue is the diaphysis of the femur mainly constructed? A. Epiphyses B. Cartilage C. Cortical bone D. Cancellous bone

Cortical bone

A client has been prescribed cimetidine for the treatment of peptic ulcer disease. When providing relevant health education for this client, the nurse should ensure the client is aware of what potential outcome? A. Bowel incontinence B. Drug-drug interactions C. Abdominal pain D. Heat intolerance

Drug-drug interactions

A nurse is caring for a client who is 12 hours' postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? A. Elevate the foot on several pillows. B. Apply warm compresses intermittently to the surgical area. C. Administer a loop diuretic as prescribed. D. Increase circulation through frequent ambulation.

Elevate the foot on several pillows

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis? A. Ensuring adequate exposure to sunlight B. Eating a low-purine diet C. Performing cardiovascular exercise while avoiding weight-bearing exercises D. Taking thyroid supplements as prescribed

Ensuring adequate exposure to sunlight

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action? A. Inform the surgeon of this finding. B. Explain the risks of flexion contracture to the client. C. Transfer the client to a sitting position. D. Encourage the client to perform active ROM exercises with the residual limb.

Explain the risks of flexion contracture to the client

The nurse's musculoskeletal assessment of a client reveals involuntary twitching of muscle groups. How would the nurse document this observation in the client's chart? A. Tetany B. Atony C. Clonus D. Fasciculations

Fasciculations

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake

Following proper hand-washing techniques

An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body? A. Haloperidol B. Prostigmine C. Epinephrine D. Glucagon

Glucagon

A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? A. Gastroesophageal reflux disease (GERD) B. Peptic ulcers C. Hemorrhoids D. Recurrent nausea and vomiting

Hemorrhoids

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow? A. Inspection, auscultation, percussion, and palpation B. Inspection, palpation, auscultation, and percussion C. Inspection, percussion, palpation, and auscultation D. Inspection, palpation, percussion, and auscultation

Inspection, auscultation, percussion, and palpation

A nurse is assessing a client who reports a throbbing, burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem? A. Morton neuroma B. Pes cavus C. Hallux valgus D. Onychocryptosis

Morton neuroma

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take? A. Administer pain medication. B. Massage the client's calf. C. Apply antiembolic stockings. D. Notify the health care provider.

Notify the health care provider

A 10-year-old client is growing at a rate appropriate for the client's age. Which cells are responsible for the secretion of bone matrix, which eventually results in bone growth? A. Osteoblasts B. Osteocytes C. Osteoclasts D. Lamellae

Osteoblasts

A client is involved in a motorcycle accident and injures an arm. The health care provider diagnoses the man with an intra-articular fracture and splints the injury. The nurse implements the teaching plan developed for this client. What sequela of intra-articular fractures should the nurse describe regarding this client? A. Posttraumatic arthritis B. Fat embolism syndrome (FES) C. Osteomyelitis D. Compartment syndrome

Posttraumatic arthritis

A nurse is caring for an older adult who has been experiencing severe Clostridium difficile-related diarrhea. When reviewing the client's most recent laboratory tests, the nurse should prioritize what finding? A. White blood cell level B. Creatinine level C. Hemoglobin level D. Potassium level

Potassium level

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan? A. Increased potassium intake B. Fluid restriction to 2 L per day C. Reduction in sodium intake D. High-protein, low-fat diet

Reduction in sodium intake

While performing an assessment, the nurse notes that a client has soft subcutaneous nodules along the extensor tendons of the fingers. Which disorder does this client most likely have? A. Osteoarthritis B. Rheumatoid arthritis C. Gout D. Paget disease

Rheumatoid arthritis

A client is receiving ongoing nursing care for the treatment of Parkinson disease. When assessing this client's gait, which finding is most closely associated with this health problem? A. Spastic hemiparesis gait B. Shuffling gait C. Rapid gait D. Steppage gait

Shuffling gait

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer? A. The client has abdominal bloating that developed rapidly. B. The client has a rigid, "board-like" abdomen that is tender. C. The client is experiencing intense lower right quadrant pain. D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes.

The client has a rigid, "board-like" abdomen that is tender

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize? A. The client will express satisfaction with the ability to perform ADLs. B. The client will recover from OA within 6 months. C. The client will adhere to the prescribed plan of care. D. The client will deny signs or symptoms of OA.

The client will express satisfaction with the ability to perform ADLs

A nurse is preparing to discharge a client after recovery from gastric surgery. What is an appropriate discharge outcome for this client? A. Bowel movements maintain a loose consistency. B. Three large meals per day are tolerated. C. Weight is maintained or gained. D. High calcium diet is consumed.

Weight is maintained or gained

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for: A. jaundice. B. bleeding. C. malnutrition. D. hypokalemia.

jaundice

A client has come to the clinic for a routine annual physical. The nurse practitioner notes a palpable, painless projection of bone at the client's shoulder. The projection appears to be at the distal end of the humerus. The nurse should suspect the presence of: A. osteomyelitis. B. osteochondroma. C. osteomalacia. D. Paget disease.

osteochondroma

A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of: A. tonus. B. flaccidity. C. atony. D. spasticity.

spasticity

A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond? A. "Abdominal ultrasound is very safe, but it can't be performed if you're pregnant." B. "Abdominal ultrasound poses no known safety risks of any kind." C. "Current guidelines state that a person can have up to 3 ultrasounds per year." D. "Current guidelines state that a person can have up to 6 ultrasounds per year

"Abdominal ultrasound poses no known safety risks of any kind."

A client with gastritis required hospital treatment for an exacerbation of symptoms and receives a subsequent diagnosis of pernicious anemia due to malabsorption. When planning the client's continuing care in the home setting, what assessment question is most relevant? A. "Does anyone in your family have experience at giving injections?" B. "Are you going to be anywhere with strong sunlight in the next few months?" C. "Are you aware of your blood type?" D. "Do any of your family members have training in first aid?"

"Does anyone in your family have experience at giving injections?"

Diagnostic tests show that a client's bone density has decreased over the past several years. The client asks the nurse which factors contribute to bone density decreasing. Which response by the nurse would be best? A. "For many people, a lack of proper nutrition can cause a loss of bone density." B. "Progressive loss of bone density is mostly related to your genes." C. "Stress is known to have many unhealthy effects, including reduced bone density." D. "Bone density decreases with age, but scientists are not exactly sure why this is the case."

"For many people, a lack of proper nutrition can cause a loss of bone density."

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation? A. "How many alcoholic drinks do you typically consume in a week?" B. "To the best of your knowledge, are your immunizations up to date?" C. "Have you ever worked in an occupation where you might have been exposed to toxins?" D. "Has anyone in your family ever experienced symptoms similar to yours?"

"How many alcoholic drinks do you typically consume in a week?"

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client? A. "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." B. "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." C. "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." D. "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."

"Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food."

A nurse is caring for a client who has had a total hip replacement. The nurse is reviewing health education prior to discharge. Which of the client's statements would indicate to the nurse that the client requires further teaching? A. "I'll need to keep several pillows between my legs at night." B. "I need to remember not to cross my legs. It's such a habit." C. "The occupational therapist is showing me how to use a 'sock puller' to help me get dressed." D. "I will need my husband to assist me in getting off the low toilet seat at home."

"I will need my husband to assist me in getting off the low toilet seat at home."

A client with a right tibial fracture is being discharged home after having a cast applied. What instruction should the nurse provide in relationship to the client's cast care? A. "Cover the cast with a blanket until the cast dries." B. "Keep your right leg elevated above heart level." C. "Use a clean object to scratch itches inside the cast." D. "A foul smell from the cast is normal after the first few days."

"Keep your right leg elevated above heart level."

The nurse is providing a client with the supplies necessary to perform two hemoccult tests on the client's stool. What instruction should the nurse give this client? A. "If possible, fast for 12 hours before collecting a sample." B. "Take all your medications except the antihypertensive ones." C. "Don't eat highly acidic foods 72 hours before you start the test." D. "Mail the paper slides to the clinic once you've collected the samples."

"Mail the paper slides to the clinic once you've collected the samples."

A client was brought to the emergency department after a fall. The client is taken to the operating room to receive a right hip prosthesis. In the immediate postoperative period, what health education should the nurse emphasize? A. "Make sure you don't bring your knees close together." B. "Try to lie as still as possible for the first few days." C. "Try to avoid bending your knees until next week." D. "Keep your legs higher than your chest whenever you can."

"Make sure you don't bring your knees close together."

A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client? A. "Take no NSAIDs within 72 hours of the test." B. "Take prescribed medications as usual." C. "Avoid over-the-counter (OTC) vitamin C supplements." D. "Do not use fiber supplements before the test."

"Take no NSAIDs within 72 hours of the test."

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond? A. "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." B. "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery, but your body will then begin to compensate." C. "Your body will absorb slightly fewer nutrients from the food you eat, but you won't be aware of this." D. "Your small intestine will adapt over time to the absence of your appendix."

"Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery."

A client has come to the clinic reporting blood in the stool. A fecal occult blood test is performed but is negative. Based on the client's history, the health care provider suggests a colonoscopy, but the client refuses, citing a strong aversion to the invasive nature of the test. What other test might the provider order to check for blood in the stool? A. A laparoscopic intestinal mucosa biopsy B. A fecal immunochemical test (FIT) C. Computed tomography (CT) D. Magnetic resonance imagery (MRI)

A fecal immunochemical test (FIT)

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)

A regimen of antiviral medications

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury? A. A first-degree strain B. A second-degree strain C. A first-degree sprain D. A second-degree sprain

A second-degree strain

A nurse is performing an admission assessment for an 81-year-old client who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver

A slightly decreased size of the liver

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? A. A tourniquet B. A syringe preloaded with vitamin K C. A unit of packed red blood cells, placed on ice D. A dose of protamine sulfate

A tourniquet

A client's colorectal cancer has necessitated a hemicolectomy with the creation of a colostomy. In the 4 days since the surgery, the client has been unwilling to look at the ostomy or participate in any aspects of ostomy care. What is the nurse's most appropriate response to this observation? A. Ensure that the client knows that he or she will be responsible for care after discharge. B. Reassure the client that many people are fearful after the creation of an ostomy. C. Acknowledge the client's reluctance and initiate discussion of the factors underlying it. D. Arrange for the client to be seen by a social worker or spiritual advisor.

Acknowledge the client's reluctance and initiate discussion of the factors underlying it

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptom resolution. B. Adhere to dosing recommendations of over-the-counter analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.

Adhere to dosing recommendations of over-the-counter analgesics

A nurse is caring for a client with Paget disease and is reviewing the client's most recent laboratory values. Which of the following values are most characteristic of Paget disease? A. An elevated level of parathyroid hormone and low calcitonin levels B. A low serum alkaline phosphatase level and a low serum calcium level C. An elevated serum alkaline phosphatase level and a normal serum calcium level D. An elevated calcitonin level and low levels of parathyroid hormone

An elevated serum alkaline phosphatase level and a normal serum calcium level

A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection

An immune globulin injection

A client has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule. The nurse should anticipate what diagnostic procedure? A. Arthrography B. Knee biopsy C. Arthrocentesis D. Electromyography

Arthrocentesis

A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The nurse assesses that the indwelling urinary catheter was removed one hour ago in the post-anesthesia care unit and that the client has not yet voided. Which action should the nurse take? A. Inform the primary provider promptly. B. Ask if the client needs to void. C. Perform intermittent catheterization. D. Obtain an order to reinsert the indwelling urinary catheter

Ask if the client needs to void

A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

Assessment for variceal bleeding

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fetor hepaticus D. Palmar erythema

Asterixis

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed. The nurse has attempted to aspirate with a large-bore syringe, with no success. What should the nurse do next? A. Withdraw the NG tube 2 inches (5 cm) and reattempt aspiration. B. Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating. C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers. D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider.

Attach a syringe filled with warm water and attempt an in-and-out motion of instilling and aspirating

An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. A. Avoid drinking alcohol B. Adopt a low-residue diet C. Avoid nonsteroidal anti-inflammatories D. Take calcium gluconate as prescribed E. Prepare for the possibility of surgery

Avoid drinking alcohol Avoid nonsteroidal anti-inflammatories

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide? A. Take the medication on an empty stomach. B. Take up to one extra dose per day if stomach pain persists. C. Take at bedtime to mitigate the effects of drowsiness. D. Avoid drinking alcohol while taking the drug.

Avoid drinking alcohol while taking the drug

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client? A. Avoid lifting more than one-third of body weight without assistance. B. Focus on using back muscles efficiently when lifting heavy objects. C. Lift objects while holding the object a safe distance from the body. D. Tighten the abdominal muscles and lock the knees when lifting an object.

Avoid lifting more than one-third of body weight without assistance

A client will be undergoing a urea breath test for the detection of Helicobacter pylori. Which instruction should the nurse give to the client to prepare for this test? A. Ingest a capsule of carbon-labeled urea ingested three days before the test. B. Take prescribed antibiotics one month before the test. C. Fast for 12 hours before the test. D. Avoid taking cimetidine 24 hours before the test.

Avoid taking cimetidine 24 hours before the test

A nurse is caring for a client who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this client, what would the nurse be sure to include? A. Increasing calcium intake to promote bone healing B. Avoiding chewing food for the specified number of weeks after surgery C. Techniques for managing parenteral nutrition in the home setting D. Techniques for managing a gastrostomy

Avoiding chewing food for the specified number of weeks after surgery

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

Avoiding taking aspirin to treat pain or fever

A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist? A. Nerve damage is associated with third-degree strains. B. Compartment syndrome is associated with third-degree strains. C. Avulsion fractures are associated with third-degree strains. D. Greenstick fractures are associated with third-degree strains.

Avulsion fractures are associated with third-degree strains

A client with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the client's prioritization for receiving a donor liver be determined? A. By considering the client's age and prognosis B. By objectively determining the client's medical need C. By objectively assessing the client's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options

By objectively determining the client's medical need

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

Calcium Vitamin D

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem? A. Carpel tunnel syndrome B. Tendonitis C. Impingement syndrome D. Dupuytren contracture

Carpel tunnel syndrome

A nurse is caring for a client with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL (408 mmol/L). For what complication is this client at risk? A. Chronic jaundice B. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly

Central nervous system damage

A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? A. Cereal with milk, a scrambled egg, and grapefruit B. Poached eggs with sausage and toast C. Waffles with fresh strawberries and powdered sugar D. A bagel topped with butter and jam with a side dish of grapes

Cereal with milk, a scrambled egg, and grapefruit

A nurse is aware of the high incidence of catheter-related bloodstream infections in clients receiving parenteral nutrition. What nursing action has the greatest potential to reduce catheter-related bloodstream infections? A. Use clean technique and wear a mask during dressing changes. B. Change the dressing no more than weekly. C. Apply antibiotic ointment around the site with each dressing change. D. Irrigate the insertion site with sterile water during each dressing change.

Change the dressing no more than weekly

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10-point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

Checking the client's capillary blood glucose levels regularly

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement. What outcome must be met prior to discharge? A. Client is able to perform ADLs independently. B. Client is able to perform transfers safely. C. Client is able to weight-bear equally on both legs. D. Client is able to demonstrate full ROM of the affected hip.

Client is able to perform transfers safely

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal? A. Client will accurately identify foods that trigger symptoms. B. Client will demonstrate appropriate care of his ileostomy. C. Client will demonstrate appropriate use of standard infection control precautions. D. Client will adhere to recommended guidelines for mobility and activity.

Client will accurately identify foods that trigger symptoms

A nurse is providing discharge teaching for a client who underwent foot surgery. The nurse is collaborating with the occupational therapist and discussing the use of assistive devices. On what variables does the choice of assistive devices primarily depend? A. Client's general condition, balance, and weight-bearing prescription B. Client's general condition, strength, and gender C. Client's motivation, age, and weight-bearing prescription D. Client's occupation, motivation, and age

Client's general condition, balance, and weight-bearing prescription

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure? A. Colonoscopy B. Barium enema C. ERCP D. Upper gastrointestinal fibroscopy

Colonoscopy

Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture? A. Open B. Comminuted C. Intra-articular D. Greenstick

Comminuted

The nurse is performing an assessment of a client's musculoskeletal system and is appraising the client's bone integrity. Which action should the nurse perform during this phase of assessment? A. Compare parts of the body symmetrically. B. Assess extremities when in motion rather than at rest. C. Percuss as many joints as are accessible. D. Administer analgesia 30 to 60 minutes before assessment.

Compare parts of the body symmetrically

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture? A. Compression B. Compound C. Impacted D. Transverse

Compound

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply. A. Computed tomography (CT) B. Angiography C. Magnetic resonance imaging (MRI) D. Ultrasound E. X-ray

Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasound X-ray

A client has had a cast placed for the treatment of a humeral fracture. The nurse's most recent assessment shows signs and symptoms of compartment syndrome. What is the nurse's most appropriate action? A. Arrange for a STAT assessment of the client's serum calcium levels. B. Perform active range of motion exercises. C. Assess the client's joint function symmetrically. D. Contact the primary provider immediately.

Contact the primary provider immediately

A nurse is performing a musculoskeletal assessment of a client with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of what assessment finding? A. Fasciculations B. Clonus C. Effusion D. Crepitus

Crepitus

A nurse is reviewing the care of a client who has a long history of lower back pain that has not responded to conservative treatment measures. The nurse should anticipate the administration of what drug? A. Calcitonin B. Prednisone C. Aspirin D. Cyclobenzaprine

Cyclobenzaprine

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? A. Assessment of blood pressure and assessment for headaches and visual changes B. Assessments for signs and symptoms of venous thromboembolism C. Daily weights and abdominal girth measurement D. Blood glucose monitoring q4h

Daily weights and abdominal girth measurement

A client with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the client's treatment? A. Decisional conflict B. Deficient knowledge C. Death anxiety D. Disturbed thought processes

Death anxiety

A client has been experiencing significant psychosocial stress in recent weeks. The nurse is aware of the hormonal effects of stress, including norepinephrine release. Release of this substance would have what effect on the client's gastrointestinal function? Select all that apply. A. Decreased motility B. Increased sphincter tone C. Increased enzyme release D. Inhibition of secretions E. Increased peristalsis

Decreased motility Increased sphincter tone Inhibition of secretions

A nurse is performing an abdominal assessment of an older adult client. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function? A. Increased gastric motility B. Decreased gastric pH C. Increased gag reflex D. Decreased mucus secretion

Decreased mucus secretion

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. A. Systemic infection B. Complex regional pain syndrome C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism

Deep vein thrombosis Compartment syndrome Fat embolism

A client with gastric cancer has been scheduled for a total gastrectomy. During the preoperative assessment, the client confides in the nurse feeling the surgery will "mutilate" the client's body. The nurse should plan interventions that address what nursing diagnosis? A. Disturbed body image B. Deficient knowledge related to the risks of surgery C. Anxiety about the surgery D. Low self-esteem

Disturbed body image

The nurse is assessing a client who had an ileostomy created three days ago for the treatment of irritable bowel disease. The nurse observes that the client's stoma is bright red and there are scant amounts of blood on the stoma. What is the nurse's best action? A. Contact the care provider to have the client's hemoglobin and hematocrit measured. B. Document these expected assessment findings. C. Apply barrier ointment to the stoma as prescribed. D. Cleanse the stoma with alcohol or chlorhexidine.

Document these expected assessment findings

A client presents at the clinic with a report of morning numbness, cramping, and stiffness in the fourth and fifth fingers of the right hand. What disease process should the nurse suspect? A. Tendonitis B. A ganglion C. Carpal tunnel syndrome D. Dupuytren disease

Dupuytren disease

A client is scheduled for a bone scan to rule out osteosarcoma of the pelvic bones. Which client status would be most important for the nurse to verify before the client's scan? A. Completion of the bowel cleansing regimen B. Empty bladder C. No allergy to penicillins D. Fast for at least 8 hours

Empty bladder

A nurse is caring for a client who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the client's appetite? A. Encourage the family to bring in the client's favorite foods. B. Limit visitors at mealtimes so that the client is not distracted. C. Avoid offering food unless the client initiates. D. Provide thorough oral care immediately after the client eats

Encourage the family to bring in the client's favorite food

A client with a total hip replacement has developed decreased breath sounds What is the nurse's best action? A. Place the client on bed rest. B. Request an antitussive medication from the health care provider. C. Encourage use of the incentive spirometer. D. Assess for signs and symptoms of systemic infection

Encourage use of the incentive spirometer

A nurse is caring for a client who had a right below-the-knee amputation (BKA). The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning. What nursing action will best achieve these goals? A. Encouraging the client to turn from side to side and to assume a prone position B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C. Minimizing movement of the flexor muscles of the hip D. Encouraging the client to sit in a chair for at least 8 hours a day

Encouraging the client to turn from side to side and to assume a prone position

A client with a simple arm fracture is receiving discharge education from the nurse. What would the nurse instruct the client to do? A. Elevate the affected extremity to shoulder level when at rest. B. Engage in exercises that strengthen the unaffected muscles. C. Apply topical anesthetics to accessible skin surfaces as needed. D. Avoid using analgesics so that further damage is not masked.

Engage in exercises that strengthen the unaffected muscles

A nurse is providing care for a client whose recent colostomy has contributed to a nursing diagnosis of Disturbed Body Image Related to Colostomy. What intervention best addresses this diagnosis? A. Encourage the client to conduct online research into colostomies. B. Engage the client in dialogue about the implications of having the colostomy. C. Emphasize the fact that the colostomy was needed to alleviate a much more serious health problem. D. Emphasize the fact that the colostomy is temporary measure and is not permanent.

Engage the client in dialogue about the implications of having the colostomy

A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure? A. Assessing the client for signs and symptoms of active infection B. Ensuring that the client can remain immobile for up to 3 hours C. Assessing the client for a history of nut allergies D. Ensuring that there are no metal objects on or in the client

Ensuring that there are no metal objects on or in the client

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

Erosion of the lining of the stomach or intestine

A client was treated in the emergency department and critical care unit after ingesting bleach. What possible complication of the resulting gastritis should the nurse recognize? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

Esophageal or pyloric obstruction related to scarring

A nurse is taking a health history on a client with musculoskeletal dysfunction. What should the nurse prioritize during this phase of the assessment? A. Evaluating the effects of the musculoskeletal disorder on the client's function B. Evaluating the client's adherence to the existing treatment regimen C. Evaluating the presence of genetic risk factors for further musculoskeletal disorders D. Evaluating the client's active and passive range of motion

Evaluating the effects of the musculoskeletal disorder on the client's function

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic. How does this change in muscle tone affect the client's traction prescription? A. Traction must temporarily be aligned in a slightly different direction. B. Extra weight is needed initially to keep the limb in proper alignment. C. A lighter weight should be initially used. D. Weight will temporarily alternate between heavier and lighter weights

Extra weight is needed initially to keep the limb in proper alignment

A nurse is providing anticipatory guidance to a client who is preparing for a total gastrectomy. The nurse learns that the client is anxious about numerous aspects of the surgery. What intervention is most appropriate to alleviate the client's anxiety? A. Emphasize the fact that gastric surgery has a low risk of complications. B. Encourage the client to focus on the benefits of the surgery. C. Facilitate the client's contact with support services. D. Obtain an order for a PRN benzodiazepine

Facilitate the client's contact with support services

A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the client to monitor closely for what postprocedure complication? A. Fever B. Crepitus C. Fasciculations D. Synovial fluid leakage

Fever

A client has sustained traumatic injuries that involve several bone fractures. A fracture of what type of bone may interfere with the protection of the client's vital organs? A. Long bones B. Short bones C. Flat bones D. Irregular bones

Flat bones

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test? A. Stool will be yellow for the first 24 hours' postprocedure. B. The barium may cause diarrhea for the next 24 hours. C. Fluids must be increased to facilitate the evacuation of the stool. D. Slight anal bleeding may be noted as the barium is passed.

Fluids must be increased to facilitate the evacuation of the stool

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? A. Recurrent constipation coupled with weight loss B. Foul-smelling diarrhea that contains fat C. Fever accompanied by a rigid, tender abdomen D. Bloody bowel movements accompanied by fecal incontinence

Foul-smelling diarrhea that contains fat

A client has been experiencing disconcerting GI symptoms that have been worsening in severity. Following medical assessment, the client has been diagnosed with lactose intolerance. The nurse should recognize an increased need for what form of health promotion? A. Annual screening colonoscopies B. Adherence to recommended immunization schedules C. Regular blood pressure monitoring D. Frequent screening for osteoporosis

Frequent screening for osteoporosis

A nurse is assessing the abdomen of a client just admitted to the unit with suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? A. Abdominal lesions are usually due to age-related skin changes. B. Integumentary diseases often cause GI disorders. C. GI diseases often produce skin changes. D. The client needs to be assessed for self-harm.

GI diseases often produce skin changes

A client presents at a clinic reports heel pain that impairs walking ability. The client is subsequently diagnosed with plantar fasciitis. This client's plan of care should include what intervention? A. Wrapping the affected area in lamb's wool or gauze to relieve pressure B. Gently stretching the foot and the Achilles tendon C. Wearing open-toed shoes at all times D. Applying topical analgesic ointment to plantar surface each morning

Gently stretching the foot and the Achilles tendon

A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the client's commode and supply a bedpan. B. Complete an incident report and submit it to the unit supervisor. C. Have the client assessed by the primary provider due to the risk of internal bleeding. D. Perform a focused abdominal assessment in order to rule out injury.

Have the client assessed by the primary provider due to the risk of internal bleeding

A client is scheduled for the creation of a continent ileostomy. What dietary guidelines should the nurse encourage during the weeks following surgery? A. A minimum of 30 g of soluble fiber daily B. Increased intake of free water and clear juices C. High intake of strained fruits and vegetables D. A high-calorie, high-residue diet

High intake of strained fruits and vegetables

A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations? A. How does the strength in the affected extremity compare to the strength in the unaffected extremity? B. Does the color in the affected extremity match the color in the unaffected extremity? C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? D. Does the client have a family history of paresthesia or other forms of altered sensation?

How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?

The orthopedic nurse should assess for signs and symptoms of Volkmann contracture if a client has fractured which of the following bones? A. Femur B. Humerus C. Radial head D. Clavicle

Humerus

A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds? A. Normal B. Hypoactive C. Hyperactive D. Paralytic ileus

Hypoactive

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide

IV administration of octreotide

A nurse educator is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunization B. Use of standard precautions C. Consumption of a vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B 12 injections

Immunization Use of standard precautions

A nurse is providing care for a client who has a recent diagnosis of Paget disease. When planning this client's nursing care, what should interventions address? Select all that apply. A. Impaired physical mobility B. Acute pain C. Disturbed auditory sensory perception D. Risk for injury E. Risk for unstable blood glucose

Impaired physical mobility Acute pain Disturbed auditory sensory perception Risk for injury

A nurse on a solid organ transplant unit is planning the care of a client who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the client's psychosocial status D. Administration of antiretroviral medications

Implementation of infection-control measures

A nurse is caring for a client with liver failure and is performing an assessment of the client's increased risk of bleeding. The nurse recognizes that this risk is related to the client's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K

Inability of the liver to use vitamin K

A critical care nurse is caring for a client diagnosed with acute pancreatitis. The nurse knows this client should be started on parenteral nutrition (PN) after what indications? A. 5% deficit in body weight compared to pre-illness weight and increased caloric need B. Calorie deficit and muscle wasting combined with low electrolyte levels C. Inability to take in adequate oral food or fluids within 7 days D. Significant risk of aspiration coupled with decreased level of consciousness

Inability to take in adequate oral food or fluids within 7 days

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care. What factor increases this client's risk for dental caries? A. Hormonal changes brought on by the stress response cause an acidic oral environment B. Systemic infections frequently migrate to the teeth C. Hydration that is received intravenously lacks fluoride D. Inadequate nutrition and decreased saliva production can cause cavities

Inadequate nutrition and decreased saliva production can cause cavities

A client who has been experiencing changes in his bowel function is scheduled for a barium enema. What instruction should the nurse provide for postprocedure recovery? A. Remain NPO for 6 hours postprocedure. B. Administer a Fleet enema to cleanse the bowel of the barium. C. Increase fluid intake to evacuate the barium. D. Avoid dairy products for 24 hours' postprocedure

Increase fluid intake to evacuate the barium

An adult client has been diagnosed with diverticular disease after ongoing challenges with constipation. The client will be treated on an outpatient basis. What components of treatment should the nurse anticipate? Select all that apply. A. Anticholinergic medications B. Increased fiber intake C. Enemas on alternating days D. Reduced fat intake E. Fluid reduction

Increased fiber intake Reduced fat intake

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following? A. Regular application of an OTC antibiotic ointment B. Increased fluid and fiber intake C. Daily use of OTC glycerin suppositories D. Use of an NSAID to reduce inflammation

Increased fluid and fiber intake

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale-appearing calf

Increased warmth of the calf

A medical nurse who is caring for a client being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this client. What is a priority psychosocial outcome for this client? A. Indicates acceptance of altered appearance and demonstrates positive self-image B. Freely expresses needs and concerns related to postoperative pain management C. Compensates effectively for alteration in ability to communicate related to dysarthria D. Demonstrates effective stress management techniques to promote muscle relaxation

Indicates acceptance of altered appearance and demonstrates positive self-image

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included? A. Risk for peripheral neurovascular dysfunction related to catheter placement B. Ineffective role performance related to parenteral nutrition C. Bowel incontinence related to parenteral nutrition D. Chronic pain related to catheter placement

Ineffective role performance related to parenteral nutrition

A nurse is providing care for a client whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis? A. Risk for disuse syndrome B. Unilateral neglect C. Risk for trauma D. Ineffective tissue perfusion

Ineffective tissue perfusion

A client is admitted to the medical unit with a diagnosis of intestinal obstruction. When planning this client's care, which of the following nursing diagnoses should the nurse prioritize? A. Ineffective tissue perfusion related to bowel ischemia B. Imbalanced nutrition: Less than body requirements related to impaired absorption C. Anxiety related to bowel obstruction and subsequent hospitalization D. Impaired skin integrity related to bowel obstruction

Ineffective tissue perfusion related to bowel ischemia

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client? A. Most affected clients acquired the infection during international travel. B. Infection typically occurs due to ingestion of contaminated food and water. C. Many people possess genetic factors causing a predisposition to H. pylori infection. D. The H. pylori microorganism is endemic in warm, moist climates.

Infection typically occurs due to ingestion of contaminated food and water

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what? A. Infection with Helicobacter pain B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid-base imbalance

Infection with Helicobacter pain

A nurse is caring for a client who is scheduled for a colonoscopy and whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation? A. Inflammatory bowel disease B. Intestinal polyps C. Diverticulitis D. Colon cancer

Inflammatory bowel disease

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and C C. Reflux of bile into the distal esophagus D. Influx of extracellular fluid into the small intestine

Influx of extracellular fluid into the small intestine

The nurse is caring for a client who has a diagnosis of AIDS. Inspection of the client's mouth reveals the new presence of white lesions on the client's oral mucosa. What is the nurse's most appropriate response? A. Encourage the client to gargle with salt water twice daily. B. Attempt to remove the lesions with a tongue depressor. C. Make a referral to the unit's dietitian. D. Inform the primary provider of this finding.

Inform the primary provider of this finding

A nurse is initiating parenteral nutrition (PN) to a postoperative client who has developed complications. The nurse should initiate therapy by performing which of the following actions? A. Starting with a rapid infusion rate to meet the client's nutritional needs as quickly as possible B. Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance C. Changing the rate of administration every 2 hours based on serum electrolyte values D. Increasing the rate of infusion at mealtimes to mimic the circadian rhythm of the body

Initiating the infusion slowly and monitoring the client's fluid and glucose tolerance

A client has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography. The nurse should teach the client about what process? A. Injection of a contrast agent into the knee joint prior to ROM exercises B. Aspiration of synovial fluid for serologic testing C. Injection of corticosteroids into the client's knee joint to facilitate ROM D. Replacement of the client's synovial fluid with a synthetic substitute

Injection of a contrast agent into the knee joint prior to ROM exercises

A nurse is preparing to place a client's prescribed nasogastric tube. What anticipatory guidance should the nurse provide to the client? A. Insertion is likely to cause some gagging. B. Insertion will cause some short-term pain. C. A narrow-gauge tube will be inserted before being replaced with a larger-gauge tube. D. Topical anesthetics will be used to reduce discomfort during insertion

Insertion is likely to cause some gagging

A 35-year-old client presents at the emergency department with symptoms of a small bowel obstruction. In collaboration with the primary care provider, what intervention should the nurse prioritize? A. Insertion of a nasogastric tube B. Insertion of a central venous catheter C. Administration of a mineral oil enema D. Administration of a glycerin suppository and an oral laxative

Insertion of a nasogastric tube

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction (GOO). What is the nurse's priority intervention? A. Administration of antiemetics B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed

Insertion of an NG tube for decompression

The nurse's comprehensive assessment of an older adult involves the assessment of the client's gait. How should the nurse best perform this assessment? A. Instruct the client to walk heel-to-toe for 15 to 20 steps. B. Instruct the client to walk in a straight line while not looking at the floor. C. Instruct the client to walk away from the nurse for a short distance and then toward the nurse. D. Instruct the client to balance on one foot for as long as possible and then walk in a circle around the room.

Instruct the client to walk away from the nurse for a short distance and then toward the nurse

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention? A. Maintenance of high Fowler positioning whenever possible B. Intermittent application of heat to the client's back C. Use of a pressure-reducing mattress D. Passive range of motion exercises

Intermittent application of heat to the client's back

A nurse is discussing conservative management of tendonitis with a client. What is the nurse's best recommendation? A. Weight reduction B. Use of oral opioid analgesics C. Intermittent application of ice and heat D. Passive range of motion exercises

Intermittent application of ice and heat

A client is undergoing diagnostic testing for a tumor of the small intestine. What are the most likely symptoms that prompted the client to first seek care? A. Hematemesis and persistent sensation of fullness B. Abdominal bloating and recurrent constipation C. Intermittent pain and bloody stool D. Unexplained bowel incontinence and fatty stools

Intermittent pain and bloody stool

An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care? A. Administration of oral and IV corticosteroids as prescribed B. Prevention of falls and pathologic fractures C. Maintenance of adequate serum levels of vitamin D D. Intravenous administration of antibiotics

Intravenous administration of antibiotics

A nurse is preparing to administer a client's intravenous fat emulsion simultaneously with parenteral nutrition (PN). What principle should guide the nurse's action? A. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered. B. The nurse should prepare for placement of another intravenous line, as intravenous fat emulsions may not be infused simultaneously through the line used for PN. C. Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site after running the emulsion through a filter. D. The intravenous fat emulsions can be piggy-backed into any existing IV solution that is infusing.

Intravenous fat emulsions may be infused simultaneously with PN through a Y-connector close to the infusion site and should not be filtered

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug? A. It reduces the stomach's volume of hydrochloric acid B. It increases the speed of gastric emptying C. It protects the stomach's lining D. It increases lower esophageal sphincter pressure

It protects the stomach's lining

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep client NPO until the results of test are known. B. Keep client NPO until the client's gag reflex returns. C. Administer analgesia until post-procedure tenderness is relieved. D. Give the client a cold beverage to promote swallowing ability.

Keep client NPO until the client's gag reflex returns

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote? A. Knots in the rope should not be resting against pulleys. B. Weights should rest against the bed rails. C. The end of the limb in traction should be braced by the footboard of the bed D. Skeletal traction may be removed for brief periods to facilitate the client's independence.

Knots in the rope should not be resting against pulleys

A client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of which condition? A. Scoliosis B. Epiphyses C. Lordosis D. Kyphosis

Kyphosis

A nurse is caring for a client admitted with a suspected malabsorption disorder. The nurse knows that one of the accessory organs of the digestive system is the pancreas. What digestive enzymes does the pancreas secrete? Select all that apply. A. Pepsin B. Lipase C. Amylase D. Trypsin E. Ptyalin

Lipase Amylase Trypsin

A client is undergoing diagnostic testing for osteomalacia. Which of the following laboratory results are most suggestive of this diagnosis? A. High chloride, calcium, and magnesium levels B. High parathyroid and calcitonin levels C. Low serum calcium and magnesium levels D. Low serum calcium and low phosphorus level

Low serum calcium and low phosphorus level

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? A. In a knee-chest position (lithotomy position) B. Lying prone with legs drawn toward the chest C. Lying on the left side with legs drawn toward the chest D. In a prone position with two pillows elevating the buttocks

Lying on the left side with legs drawn toward the chest

A nurse is talking with a client who is scheduled to have a hemicolectomy with the creation of a colostomy. The client admits to being anxious, and has many questions concerning the surgery, the care of a stoma, and necessary lifestyle changes. What nursing action is most appropriate? A. Reassure the client that the procedure is relatively low risk and that clients are usually successful in adjusting to an ostomy. B. Provide the client with educational materials that match the client's learning style. C. Encourage the client to write down these concerns and questions to bring forward to the surgeon. D. Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse.

Maintain an open dialogue with the client and facilitate a referral to the wound-ostomy-continence (WOC) nurse

A client has been diagnosed with a small bowel obstruction and has been admitted to the medical unit. The nurse's care should prioritize which of the following outcomes? A. Preventing infection B. Maintaining skin and tissue integrity C. Preventing nausea and vomiting D. Maintaining fluid and electrolyte balance

Maintaining fluid and electrolyte balance

A client is recovering in the hospital following gastrectomy. The nurse notes that the client has become increasingly difficult to engage and has had several angry outbursts at staff members in recent days. The nurse's attempts at therapeutic dialogue have been rebuffed. What is the nurse's most appropriate action? A. Ask the client's primary provider to liaise between the nurse and the client. B. Delegate care of the client to a colleague. C. Limit contact with the client in order to provide privacy. D. Make appropriate referrals to services that provide psychosocial support.

Make appropriate referrals to services that provide psychosocial support

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care? A. Measure and record drainage. B. Monitor drainage for change in color. C. Titrate the suction every hour. D. Feed the client via the G tube as prescribed

Measure and record drainage

A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow? A. Temporal lobe B. Medulla oblongata C. Cerebellum D. Pons

Medulla oblongata

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

Metoclopramide

A client with diabetes is attending a class on the prevention of associated diseases. What action should the nurse teach the client to reduce the risk of osteomyelitis? A. Increase calcium and vitamin intake. B. Monitor and control blood glucose levels. C. Exercise 3 to 4 times weekly for at least 30 minutes. D. Take corticosteroids as prescribed.

Monitor and control blood glucose levels

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action? A. Insert a nasogastric tube promptly. B. Reposition the client supine. C. Monitor the client closely for further signs of dumping syndrome. D. Assess the client for signs and symptoms of aspiration.

Monitor the client closely for further signs of dumping syndrome

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client? A. Place the client in a prone position. B. Provide the client with ice water to slow any GI bleeding. C. Prepare for the insertion of an NG tube. D. Notify the health care provider.

Notify the health care provider

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

Osteomyelitis

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? A. Hematogenous osteomyelitis B. Osteomyelitis with vascular insufficiency C. Contiguous focus osteomyelitis D. Osteomyelitis with muscular deterioration

Osteomyelitis with vascular insufficiency

A bone biopsy has just been completed on a client with suspected bone metastases. The nurse should prioritize assessments for which common complication of bone biopsy? A. Dehiscence at the biopsy site B. Pain C. Hematoma formation D. Infection

Pain

A nurse is promoting increased protein intake to enhance a client's wound healing. What is the enzyme that will initiate the digestion of the protein that the client consumes? A. Pepsin B. Intrinsic factor C. Lipase D. Amylase

Pepsin

A nurse is performing an admission assessment of a client with a diagnosis of cirrhosis. What technique should the nurse use to palpate the client's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degrees to right side of the abdomen and push down firmly.

Place hand under right lower rib cage and press down lightly with the other hand

A client was fitted with an arm cast after fracturing the humerus. Twelve hours after the application of the cast, the client tells the nurse that the injured arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? A. Prepare the client for opening or bivalving of the cast. B. Obtain a prescription for a different analgesic. C. Encourage the client to wiggle and move the fingers. D. Petal the edges of the client's cast.

Prepare the client for opening or bivalving of the cast

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action? A. Warm the client's foot and determine whether circulation improves. B. Reposition the client with the affected foot dependent. C. Reassess the client's neurovascular status in 15 minutes. D. Promptly inform the primary care provider.

Promptly inform the primary care provider

A nurse is caring for a client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action? A. Document the findings as being consistent with a viable graft. B. Promptly report these indications of venous congestion. C. Closely monitor the client and reassess in 30 minutes. D. Reposition the client to promote peripheral circulation

Promptly report these indications of venous congestion

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation? A. Allow the client to gently scratch inside the cast with a pencil. B. Give the client a sterile tongue depressor to use for scratching instead of the pencil. C. Provide a fan to blow cool air into the cast to relieve itching. D. Obtain a prescription for a sedative, such as lorazepam, to prevent the client from scratching.

Provide a fan to blow cool air into the cast to relieve itching

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. What would be the nursing care most needed by the client at this time? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

Providing the client with physical and emotional support

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms. Which of the following actions should the nurse prioritize? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

Providing the client with physical and emotional support

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? A. Burning pain on swallowing B. Regurgitation of undigested food C. Symptoms mimicking a myocardial infarction D. Chronic parotid abscesses

Regurgitation of undigested food

A client's fracture is healing and compact bone is replacing spongy bone around the periphery of the fracture. This process characterizes what phase of the bone healing process? A. Hematoma formation B. Fibrocartilaginous callus formation C. Remodeling D. Bony callus formation

Remodeling

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action? A. Facilitate a referral to the wound-ostomy-continence (WOC) nurse. B. Report signs and symptoms of obstruction to the health care provider. C. Encourage the client to mobilize in order to enhance motility. D. Contact the health care provider and obtain a swab of the stoma for culture.

Report signs and symptoms of obstruction to the health care provider

A nurse is caring for a client who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the client and notes the presence of high-pitched adventitious sounds over the client's trachea on auscultation. The client's oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurse's most appropriate action? A. Encourage the client to perform deep breathing and coughing exercises hourly. B. Reposition the client into a prone or semi-Fowler position and apply supplementary oxygen by nasal cannula. C. Activate the emergency response system. D. Report this finding promptly to the health care provider and remain with the client.

Report this finding promptly to the health care provider and remain with the client

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the client's sodium intake does not exceed recommended levels. B. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. C. Inform the primary provider that the client should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

Report this finding to the primary provider due to the possibility of hepatic encephalopathy

A client has been scheduled for a urea breath test in one month's time. What nursing diagnosis most likely prompted this diagnostic test? A. Impaired dentition related to gingivitis B. Risk for impaired skin integrity related to peptic ulcers C. Imbalanced nutrition: Less than body requirements related to enzyme deficiency D. Diarrhea related to Clostridium difficile infection

Risk for impaired skin integrity related to peptic ulcers

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius? A. Risk for infection B. Risk for ineffective role performance C. Risk for perioperative positioning injury D. Risk for powerlessness

Risk for infection

A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogenesis D. Risk for contamination related to accumulation of ammonia

Risk for infection related to immunosuppressant use

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? A. Imbalanced nutrition: Less than body requirements related to decreased oral intake B. Risk for infection related to possible rupture of appendix C. Constipation related to decreased bowel motility and decreased fluid intake D. Chronic pain related to appendicitis

Risk for infection related to possible rupture of appendix

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize? A. Risk for activity intolerance related to the presence of a subclavian catheter B. Risk for infection related to the presence of a subclavian catheter C. Risk for functional urinary incontinence related to the presence of a subclavian catheter D. Risk for sleep deprivation related to the presence of a subclavian catheter

Risk for infection related to the presence of a subclavian catheter

A nurse's assessment reveals that a client has shoulders that are not level and one prominent scapula that is accentuated by bending forward. The nurse should expect to read about which health problem in the client's electronic health record? A. Lordosis B. Kyphosis C. Scoliosis D. Muscular dystrophy

Scoliosis

The nurse is caring for a client with a duodenal ulcer and is relating the client's symptoms to the physiologic functions of the small intestine. What do these functions include? Select all that apply. A. Secretion of hydrochloric acid (HCl) B. Reabsorption of water C. Secretion of mucus D. Absorption of nutrients E. Movement of nutrients into the bloodstream

Secretion of mucus Absorption of nutrients Movement of nutrients into the bloodstream

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem? A. Consumes one or more protein drinks daily. B. Takes over-the-counter antacids frequently throughout the day. C. Smokes one pack of cigarettes daily. D. Reports a history of social drinking on a weekly basis.

Smokes one pack of cigarettes daily

The nurse educator is reviewing the blood supply of the GI tract with a group of medical nurses. The nurse is explaining the fact that the veins that return blood from the digestive organs and the spleen form the portal venous system. What large veins will the nurse list when describing this system? Select all that apply. A. Splenic vein B. Inferior mesenteric vein C. Gastric vein D. Inferior vena cava E. Saphenous vein

Splenic vein Inferior mesenteric vein Gastric vein

A nurse is caring for a client with hepatic encephalopathy. The nurse's assessment reveals that the client exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

Stage 3

A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is: A. Staphylococcus aureus. B. Proteus. C. Pseudomonas. D. Escherichia coli.

Staphylococcus aureus

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self-suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

Strategies for avoiding irritating foods and beverages

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis. What principle should guide the management of activity and mobility in this client? A. Stress on the weakened bone must be avoided. B. Increased heart rate enhances perfusion and bone healing. C. Bed rest results in improved outcomes in clients with osteomyelitis. D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment.

Stress on the weakened bone must be avoided

A 32-year-old client comes to the clinic reporting shoulder tenderness, pain, and limited movement. Upon assessment the nurse finds edema. An MRI shows hemorrhage of the rotator cuff tendons and the client is diagnosed with impingement syndrome. What action should the nurse recommend in order to promote healing? A. Support the affected arm on pillows at night. B. Take prescribed corticosteroids as prescribed. C. Put the shoulder through its full range of motion three times daily. D. Keep the affected arm in a sling for 2 to 4 weeks.

Support the affected arm on pillows at night

A nurse is caring for a client with a bone tumor. The nurse is providing education to help the client reduce the risk for pathologic fractures. What should the nurse teach the client? A. Strive to achieve maximum weight-bearing capabilities. B. Gradually strengthen the affected muscles through weight training. C. Support the affected extremity with external supports such as splints. D. Limit reliance on assistive devices in order to build strength.

Support the affected extremity with external supports such as splints

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications? A. Perform chest physiotherapy once per shift and as needed. B. Teach the client to perform deep breathing and coughing exercises. C. Administer prophylactic antibiotics as prescribed. D. Administer nebulized bronchodilators and corticosteroids as prescribed

Teach the client to perform deep breathing and coughing exercises

The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? A. The breakdown of food particles into cell form for digestion B. The maintenance of fluid and acid-base balance C. The absorption into the bloodstream of nutrient molecules produced by digestion D. The control of absorption and elimination of electrolytes

The absorption into the bloodstream of nutrient molecules produced by digestion

A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? A. The client will be monitored closely to detect malignant changes. B. Liver enzymes must be checked regularly, as H 2 receptor antagonists may cause hepatic damage. C. Small amounts of blood are likely to be present in the stools and are not cause for concern. D. Antacids may be discontinued when symptoms of heartburn subside

The client will be monitored closely to detect malignant changes

A client who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The client will obtain measurement of drainage from the T-tube. B. The client will exercise three times a week. C. The client will take immunosuppressive agents as required. D. The client will monitor for signs of liver dysfunction.

The client will take immunosuppressive agents as required

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor? A. The client has a 30 pack-year smoking history. B. The client's body mass index is 34 (obese). C. The client has primary hypertension. D. The client is 58 years old.

The client's body mass index is 34 (obese)

A client's neck dissection surgery resulted in damage to the client's superior laryngeal nerve. What area of assessment should the nurse consequently prioritize? A. The client's swallowing ability B. The client's ability to speak C. The client's management of secretions D. The client's airway patency

The client's swallowing ability

A nurse is assessing a client who is receiving traction. The nurse's assessment confirms that the client is able to perform plantar flexion. What conclusion can the nurse draw from this finding? A. The leg that was assessed is free from DVT. B. The client's tibial nerve is functional. C. Circulation to the distal extremity is adequate. D. The client does not have peripheral neurovascular dysfunction.

The client's tibial nerve is functional

A nurse at an outpatient surgery center is caring for a client who had a hemorrhoidectomy. What discharge education topics should the nurse address with this client? A. The appropriate use of antibiotics to prevent postoperative infection B. The correct procedure for taking a sitz bath C. The need to eat a low-residue, low-fat diet for the next 2 weeks D. The correct technique for keeping the perianal region clean without the use of water

The correct procedure for taking a sitz bath

A nurse is planning discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge? A. The family's ability to take care of the client's special diet needs B. The family's ability to monitor the client's changing health status C. The family's ability to provide emotional support D. The family's ability to manage the client's medication regimen

The family's ability to provide emotional support

An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery. What nursing intervention should be included in the client's subsequent care? A. Dressing changes should not be performed unless there are clear signs of infection. B. The surgical site can be soaked in warm bath water for up to 5 minutes. C. The surgical site should be cleansed with hydrogen peroxide once daily. D. The foot should be elevated in order to prevent edema.

The foot should be elevated in order to prevent edema

A client has been experiencing occasional episodes of constipation and has been unable to achieve consistent relief by increasing physical activity and improving the client's diet. When introducing the client to the use of laxatives, what teaching should the nurse emphasize? A. The effect of laxatives on electrolyte levels B. The underlying causes of constipation C. The risk of fecal incontinence D. The risk of becoming laxative-dependent

The risk of becoming laxative-dependent

A nurse is explaining a client's decreasing bone density in terms of the balance between bone resorption and formation. What dietary nutrients and hormones play a role in the resorption and formation of adult bones? Select all that apply. A. Thyroid hormone B. Growth hormone C. Estrogen D. Vitamin B12 E. Luteinizing hormone

Thyroid hormone Growth hormone Estrogen

An older adult has a diagnosis of Alzheimer disease and has recently been experiencing fecal incontinence. However, the nurse has observed no recent change in the character of the client's stools. What is the nurse's most appropriate intervention? A. Keep a food diary to determine the foods that exacerbate the client's symptoms. B. Provide the client with a bland, low-residue diet. C. Toilet the client on a frequent, scheduled basis. D. Liaise with the primary provider to obtain an order for loperamide.

Toilet the client on a frequent, scheduled basis

A client is brought to the emergency department by ambulance after stepping in a hole and falling. While assessing the client the nurse notes that the client's right leg is shorter than the left leg; the right hip is noticeably deformed and the client is in acute pain. Imaging does not reveal a fracture. What is the most plausible explanation for this client's signs and symptoms? A. Subluxated right hip B. Right hip contusion C. Hip strain D. Traumatic hip dislocation

Traumatic hip dislocation

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to three soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool

Two to three soft bowel movements daily

A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend what action? A. Rinse the mouth with alcohol before bedtime for the next 7 days. B. Use warm saline to rinse the mouth as needed. C. Brush around the area with a firm toothbrush to prevent infection. D. Use a toothpick to dislodge any debris that gets lodged in the socket

Use warm saline to rinse the mouth as needed

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12 . The nurse should question the client about a history of: A. total gastrectomy. B. bariatric surgery. C. diverticulitis. D. gastroesophageal reflux disease (GERD).

total gastrectomy