Med Surg A

A nurse is providing teaching to a client who just received a new hearing aid. Which of the following responses by the client indicates understanding?

"I may have the most difficulty with background noises." - The amplification of background noise is often a challenging aspect of adjusting to a hearing aid. When adjusting to a new hearing aid, the client should begin by wearing it at home in intervals during a day, and should be adjusted to the lowest volume that allows the client to hear.

A nurse is providing teaching to a client who has AIDS. Which of the following client statements indicated that the teaching has been effective?

"I should get an influenza vaccine every year." - Client who are immunocompromised should have a yearly influenza immunization. Toothbrush should be cleaned weekly in the dishwasher or in a bleach solution. Should avoid raw fruits and vegetables. It's not necessary to wear a mask outside, although the client is immunocompromised.

A nurse is providing instructions to a client who has type2 DM and a new prescription for metformin once daily. Which of the following statements by the client indicates an understanding of teaching?

"I should take this medication with a meal." - The client should take metformin with or right after meals. Metformin decreases the amount of glucose production in the liver and tissue sensitivity to insulin. Typically, clients lose wt when first start taking this medication d/t N/V.

A nurse is providing teaching to a client who has altered venous circulation of the lower extremities and has a new prescription for elasticized bandages to wear when awake. Which of the following statements by the client indicates a need for further teaching.

"I will cover my toes with the bandage." - The client should keep the toes uncovered to check for any impairment of circulation.. Wrapping start from the distal to the proximal to promote venous circulation. Hold the leg in a normal position with the knee slightly bent to avoid strain on ligaments and muscles of the joints while applying the bandage. The pressure should be even to prevent interference with circulation.

A nurse is providing teaching to client who has just been prescribed an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more high fiber foods." - Eating high fiber foods will help prevent constipation, which is a common side effect of oral iron supplements. Taking daily products or antacids at the same time as iron inhibits absorption.

A nurse is caring for a client who has chronic kidney failure. The provider prescribes erythropoietin injections three times per week. Which of the following statements by the client indicates a need for further teaching about the effects of erythropoietin?

"I will limit the amout of protein in my diet while taking this medication." - The client does not need to limit protein intake while taking erythropoietin.

A nurse is performing discharge teaching for a client who has an above the knee amputation and a temporary prosthesis. Which of the following responses by the client indicates a need for further teaching?

"I will make sure I have a soft mattress on my bed." - A firm mattress is important in preventing contractures. The client should wear the compression bandage at all times, except during physical therapy and bathing. The client should keep the residual limb in extension to prevent hip flexion contracture.

A nurse is providing discharge teaching to a client with an implantable cardioverter/defibrillator (ICD). Which of the following client statements indicates understanding of the instructions?

"I will tell my dentist that I have an ICD." - Clients who have an ICD should inform all providers of the presence of the ICD because certain diagnostic tests and procedures must be avoided to prevent ICD malfunction.

A client with atrial fibrillation is prescribed digoxin. Which of the following statements by the client indicates to the nurse that further teaching is needed?

"If I miss my morning dose, I should wait until the next day to take a pill." - A client who forgets a dose of digoxin may take it a few hours later. There is no need to wait until the next day. - Most antacids decrease digoxin absorption, and best to take antacids is at least an hr after taking digoxin. - N/V are signs of digoxin toxicity. - Take pulse rate before each dose.

A nurse in the emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

"It's like a curtain closed over my eye." - Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field. Retinal detachment is usually painless, sudden onset, and no peripheral vision loss.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects understanding of the teaching?

"My joints ache because I have Lyme disease." - A client who has stage II Lyme disease can experience joint pain, as well as cardiac and neurologic complications. If the client is not treated during this stage, the disease can become chronic and cause arthritis, peripheral neuropathy, vasculitis, and myocarditis. The provider will prescribe a penicillin, a cephalosporin, or a tetracycline for stage II Lyme disease for 30days.

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3days. Which of the following should the nurse include when instructing the client?

"Take insulin even if you are unable to eat your regular diet." - The client should continue his medication regiment when ill to prevent hyperglycemia. The client should notify the provider if ketones are present in the urine, if the blood glucose level is greater than 25omg/dL. The clinet should monitor blood glucose levels at least every 4hr when ill.

A nurse is assessing a client who has pruritic macular rash and erythema over his trunk and forearms. While interviewing the client, which of the following questions should the nurse ask?

"What medications are you currently taking?" - The widespread nature of the rash indicates an allergic reaction; therefore, the nurse should determine if the client is experiencing an allergic reaction to a prescribed medication.

A nurse is caring for a client who is experiencing an anaphylactic reaction to latex. After ensuring a patent airway, which of the following actions should the nurse take next?

Administer oxygen via a non-rebreather mask. - After ensuring a patent airway, the priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to administer oxygen using a non-rebreather mask to prevent hypoxemia.

A nurse is caring for a client who has COPD and who reports shortness of breath, cough, and fatigue. The client has thick mucus secretions. Which of the following nursing interventions is appropriate for the client?

Administer guaifenesin as prescribed. - Mucolytic medications thin secretions, which promotes airway clearance by the client.

A nurse is caring for a client who has bilateral pneumonia and a PaO2 of 80mmHg. The client is dyspneic with a productive cough and is using accessory muscles to breathe. Which of the following nursing interventions has the highest priority?

Administer oxygen per nasal cannula. - These findings are indicative of hypoxemia. This client's PaO2 level is below the expected reference range; therefore, oxygen administration is necessary.

A nurse is preparing to administer a blood transfusion to a client. Which of the following IV solutions should the nurse use for the transfusion?

0.9% sodium chloride. - This is the appropriate IV solution for a blood transfusion.

A nurse is preparing to administer pentobarbital 3mg/kg IV bolus to a client who weights 110lb. Available is pentobarbital injection 50mg/mL. How may mL should the nurse administer?

3mL 110/2.2 = 50kg 3x50 = 150mg 150/50 = 3mL

A nurse in the emergency department is assigned to triage clients from an external disaster. The nurse should place a red tag on which of the following clients?

A client who as an incomplete amputation of the arm. - The nurse should place a red tag on this client because with immediate intervention this client has a good chance of survival. A client who has agonal respirations or third-degree burns over 75% of the body have little chance of survival and should receive a black tag.

A nurse is assessing a client who has acute pancreatitis. Which of the following findings is the highest priority?

Absent bowel sounds. - Absent bowel sounds indicate the client is at greatest risk for paralytic ileus; therefore, this is the priority finding.

A nurse is assessing a client who is diagnosed with rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain.

Alternate application of heat ad cold to affected joints. - Exercising affected joints can be painful, but regular exercise is important to prevent stiffness. Adequate calcium intake is important to prevent bone loss.

A nurse is admitted a client who has a hip fracture and will undergo hip replacement surgery in 48hr. Which of the following prescriptions requires clarification by the provider?

Apply 6.8kg (15lb) of weight to the skin traction. - The nurse should clarify this prescription because the weight providing the pulling force should be between 2.3 to 4.5kg (5-10lb) to prevent skin injury. This prescription should be clarified by the provider. Clients who have fractures and requires surgery should increase protein intake.

A nurse is providing care to a client in the PACU immediately following a coronary artery bypass graft (CABG). Which of the following interventions should the nurse implement during the immediate postoperative period?

Assess for a decrease in the client's temperature. - During a CABG procedure, the client is cooled to decrease metabolic needs. Even thought the client is warmed prior to leaving the surgical suite, body temperature can fall again; therefore, the nurse should assess the client's temperature to determine the need for rewarming procedures.

A nurse is planning care for a client who has a small bowel obstruction and nasogastric tube. Which of the following is appropriate for the nurse to include in the plan of care?

Assess for the passage of flatus. - Passage of flatus indicates the intestines are resuming appropriate function.

A nurse is caring for a client who is newly diagnosed with hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80mmHg. - A systolic blood pressure of 170mmHg indicates this client is at greatest risk for thyroid storm; therefore, this is the priority finding. Restlessness, increased serum T3, and decreased weight are the clinical manifestations.

A client has been receiving propranolol hydrochloride 40mg PO daily for hypertension. Which of the following findings indicates the client is experiencing an adverse reaction to this medication?

Bronchoconstriction. - Non selective beta blockers can cause pulmonary bronchoconstriction, especially in clients who have a pre existing respiratory disorder.

A nurse is caring for a client who is undergoing chronic renal dialysis. The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer?

Calcitriol - Muscle cramps and tingling indicate hypocalcemia. The nurse should administer calcitriol as a calcium replacement.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following could interfere with the absorption of the medication?

Calcium supplements. - Calcium supplements interfere with the absorption of levothyroxine, and they should not be taken together.

A nurse is providing teaching for a client who is perimenopausal and has been prescribed hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider?

Calf pain. Numbness in the arms. Intense headache. - Calf pain is an indication of deep vein thrombosis. - Numbness in the arms and intense headache indicate a cerebrovascular accident.

A nurse is caring for a client who is 1day postoperative following a thoracotomy. Which of the following findings indicates a tension pneumothorax?

Chest asymmetry. - The air that is forced into the chest cavity causes the affected lung to collapse, and the air that enters the pleural space during inspiration does not exit during expiration. This causes chest asymmetry. A client who has a tension pneumothorax will have no breath sounds on the affected side.

A nurse is assisting a provider with a cholinesterase inhibitor test for a client who was previously diagnosed with myasthenia gravis. After administration of the cholinesterase inhibitor, the client demonstrates increased muscle weakness and twitching. The nurse concludes that the client is exhibiting which of the following conditions?

Cholinergic crisis.

A nurse is caring for a client who is receiving continuous IV fluids through a saline lock located in the client's forearm. The client reports discomfort and coolness to the touch at the insertion site. Which of the following actions should the nurse take first?

Compare the site to the opposite extremity. - The first action the nurse should take using the nursing process is to assess the client. By comparing the site of the IV to the opposite extremity, the nurse can measure for edema, which is an indicator of infiltration.

A nurse is caring for a client who has hypothyroidism. The nurse should monitor for which of the following findings?

Constipation - Decreased metabolism causing slow motility of the GI tract.

A nurse is caring for a client newly diagnosed with diabetes mellitus. Which of the following findings indicates hypoglycemia?

Cool, clammy skin.

A nurse is caring for a client with HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?

Decreased viral load. - A decreased viral load indicates a positive response to the prescribed HIV treatment, because viral load testing measures the presence of HIV viral genetic material.

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload?

Distended neck veins. - Presence of tenting and orthostatic hypotension occur with dehydration. Warm and moist skin is an expected assessment finding.

A nurse is providing teaching about hepatitis A for a group of adolescents. Which of the following should the nurse include in the teaching as increasing the risk of contracting hepatitis A?

Eating contaminated food.

A nurse is caring for a client who has full thickness burns of the arm and is in the rehabilitation phase of recovery. Which of the following is the priority nursing intervention during rehabilitation?

Encourage use of the affected extremity. - The greatest risk to the client during the rehabilitation phase is the development of contractures; therefore, the priority intervention is to encourage use of the affected extremity to maintain maximal limb function. During the resuscitation phase (The first 48hr): Fluid balance and maintaining electrolyte balance. During the acute phase (36-48hr): Adequate nutrition.

A nurse is providing education to the family of a client who has tuberculosis (TB). Which of the following is important to include?

Family members in the household should undergo TB testing. - Family members who live in the same household with the client may or may not have an active disease, but they need to be tested for TB. The disease is usually no longer contagious after the client has been taking the TB medications for 2 to 3 consecutive weeks and a clinical improvement is seen. Airborne precautions are not necessary in the home, because household members have already been exposed to TB. Contaminated tissues should be placed in a plastic bag.

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following findings should indicate to the nurse the client's condition is improving?

Glucose 272 mg/dL. A glucose reading less than 300mg/dL indicates improvement in the client's status.

A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following should the nurse recognize as an adverse effect of this mediation?

Hypokalemia. - Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia These excessive stools can result in hypokalemia and dehydration.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values indicates a desired outcome for this therapy?

INR 2.5 - This INR value is within the therapeutic range which is the desired outcome for a client receiving warfarin.

When caring for an older adult client with pain, which of the following should the nurse consider regarding pain management?

Ibuprofen may cause gastrointestinal bleeding in older adults. - A common side effect of ibuprofen is gastrointestinal bleeding. The recommended maximum dose of acetaminophen over a 24hr period is 4g. (3g for elderly). Meperidine is not the medication of choice for older adults, because the potential accumulation of the toxic metabolite normeperidine can result in central nervous system toxicities. Risk for seizure. Oxycodone are at risk for constipation.

A nurse is caring for a client who recently had a stroke of the right hemisphere. Which of the following manifestations is consistent with this diagnosis?

Impulsive behavior.

A nurse is reviewing the laboratory findings of a client who has rheumatoid arthritis. After visiting the provider 1month ago, the client reports increased joint pain. Which of the following laboratory findings should the nurse anticipate?

Increased erythrocyte sedimentation rate. - Increased erythrocyte sedimentation rate is present in the inflammatory process. Also, WBC count and globulin level are increased. The serum complement level, esp. C4, are decreased.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following is the primary assessment finding?

Increased respiratory secretions. - When using the airway, breathing, circulation (ABC) approach to client care, the nurse determines the priority finding is increased respiratory secretions because this places the client at risk for aspiration pneumonia due to respiratory muscle weakness.

The nurse is caring for a client receiving total parenteral nutrition (TPN). The nurse observes that the bag of TPN solution has 50mL remaining and no replacement bag is available. Which of the following actions should the nurse take?

Initiate 500mL of 10% dextrose solution. - The nurse should not stop the infusion because it will lower the client's blood glucose level.

A nurse is teaching a client who has a known allergy to bee venom and a prescription for a prefilled epinephrine injector how to respond in the event he is stung by a bee. Identify the sequence the client should follow.

Inject the epinephrine into the outer thigh. Remove stinger from skin. Clean area with soapy water. Apply ice to site. Seek medical help.

A nurse is preparing to perform gastric lavage for a client who has upper GI bleeding. Which of the following actions is appropriate for the nurse to take?

Insert a large bore nasogastric tube. - For gastric lavage, the nurse should insert a large bore nasogastric tube. The client should lie on the left side to decrease the amount of 0.9% sodium chloride that leaves the stomach and to prevent aspiration. Instill 200-300mL of 0.9% sodium chloride at a time.

A nurse is caring for a client who had a gastrectomy 5days ago. Which of the following interventions will assist in the prevention of dumping syndrome?

Instruct the client to lie in a supine position after meals. - The nurse should instruct the client to lie down after consuming a meal to slow the movement of food within the intestines. To prevent dumping syndrome, the client should consume a high protein, high fat and a low to moderate carbohydrate diet. The client should not drink fluids with meals and for 1hr prior to and following meals. The client should avoid using laxatives because they can increase the incidence of dumping syndrome.

A nurse is caring for a client who has an ileostomy and is 4wk postoperative. The client reports leakage and irritation around the stoma. Which of the following is an appropriate intervention?

Instruct the client to use a skin barrier when refitting the pouch system. - The client should use a skin barrier to protect the skin from enzymes and bile salts from gastrointestinal drainage at the stoma site. The client should clean the skin around the stoma with mild soap and water to promote healing and prevent infection. The client should avoid high fiber foods because the ileostomy only drains liquid stool. The client should empty the ileostomy pouch when the bag is 1/3 to 1/2 full.

A nurse is obtaining a medical history from a client who tells the nurse he is taking sildenafil, which he bought on the Internet. The nurse should instruct the client to discontinue the use of sildenafil if he also is taking which of the following medications?

Isosorbide mononitrate - Concurrent of isosorbide mononitrate and sildenafil use can result in severe hypotension.

A nurse is caring for a client who had an open thoracotomy with chest tube insertion. Which of the following actions should the nurse take?

Keep the chest tube collection chamber below the level of the lungs. - It allows drainage by gravity. The nurse should notify the provider when drainage is greater than 70mL/hr. The nurse should gently milk the chest tube only if blood clots are visible in the tubing.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction?

Low back pain and apprehension. - Low back pain and apprehension are manifestations of a hemolytic transfusion reaction.

A nurse is assessing a client who has peripheral vascular disease. Findings include respiratory rate of 16/min and oxygen saturation of 90%. Which of the following interventions should the nurse take first?

Move the pulse oximetry probe to a different location. - When nursing care, the nurse should first use the least restrictive intervention. Peripheral vascular disease can decrease peripheral blood flow and lead to a false low reading. The nurse should first move the prove to a different location with increased blood flow to obtain a more accurate reading.

A nurse is caring for a client who is receiving morphine via a PCA pump. The nurse should monitor the client for which of the following?

Nausea and vomiting. - Nausea and vomiting are common adverse effects of morphine, particularly for clients who do not use opioids on a regular basis. Opioids decrease heart rate, slow motility, and cause pupil constriction.

a nurse is caring for a client who has an arteriovenous fistula for dialysis. Which of the following requires intervention by the nurse?

Numb fingers distal to the fistula.

A nurse is caring for a client who has portal hypertension. The client had vomiting of blood mixed with food after a meal. Which of the following actions should the nurse take first?

Obtain vital signs. - Using the assessment first priority setting framework, the first action the nurse should take is assessment of the client's vital signs. This will provide information about the client's condition.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Oliguria during the day. - It's an expected finding in a client who has left-sided heart failure because of decreased blood flow to the kidneys.

A nurse is caring for a client receiving oxygen therapy for respiratory acidosis related to an exacerbation of asthma. Which of the following ABG values indicates a therapeutic response to the treatment?

PaCO2 44mmHg. - This PaCO2 is within the expected reference range, which indicates a therapeutic response to the oxygen therapy, and that the respiratory acidosis is resolving.

A nurse is caring for a client who has an arterial line. Which of the following actions is appropriate for the nurse to take?

Place a pressure bag around the flush solution. - It is necessary to infuse normal saline under pressure, because the pressure from an artery is greater than that of the line. An arterial line is not appropriate access for administering antibiotics. Arterial lines are used to obtain arterial blood gas samples and monitor hemodynamic pressures. Supine with the head elevated up to 60 is the appropriate positioning while recording values obtained from an arterial line.

A client is admitted to the emergency department with anxiety, loss of muscle coordination, and skin that is hot and dry. The client had been working in the yard prior to coming t the hospital. Which of the following actions should the nurse anticipate taking first?

Place the client on a cooling blanket. - Theses findings indicate the client is at greatest risk for hyperthermia; therefore, the first action the nurse should take is to place the client on a cooling blanket.

A nurse is planning to administer platelets to a client who has thrombocytopenia. Which tubing is appropriate for the nurse to use when administering platelets.

Platelet administration set is with a smaller filter to prevent trapping of platelets, a second filter to remove WBCs, and shorter tubing to decrease platelet adherence to the lumen.

A nurse is caring for a client who is malnourished. Upon review of the client's medical record, which of the following findings places the client at risk for skin breakdown?

Prealbumin 5mg/dL - A prealbumin level of 5mg/dL is below the expected reference range and indicates the client is at risk for skin breakdown.

A client with a tracheostomy requires suctioning. Which of the following actions by the nurse is appropriate for this procedure?

Preoxygenate the client for at least 30 seconds. - Preoxygenate with 100% oxygen for 30secontds to 3min to prevent hypoxemia. - Limit each suction pass to 10-15sec with suction pressure btw 80-120mmHg. Up to 3 times.

A nurse is performing preoperative teaching for a client scheduled to have a right modified radical mastectomy. Which of the following should the nurse include in the client's plan of care?

Presence of one or more surgical drains. - Start exercises of the right arm 24hr after surgery. - Elevate the right arm on a pillow to promote lymphatic fluid return while in bed. - Elevate HOB at least 30 to promote optimal drainage from the surgical site and facilitate breathing.

A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory paralysis. - Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A client is receiving albuterol via a nebulizer for an acute exacerbation of asthma. The nurse recognizes that which of the following findings indicates the nebulizing treatment has been effective?

SaO2 increases to 95% - SaO2 measures the oxygen saturation of the blood. Increases above 95% represent a normal oxygenation of the hemoglobin in the body.

A nurse is caring for a male client who has heart failure and has a prescription for digoxin. Which of the following finding indicates the client is at risk for digoxin toxicity?

Serum creatinine 1.8mg/dL. - This finding is outside the expected reference range and indicates impaired renal function, which increase the risk of digoxin toxicity.

A nurse is reviewing the medical record of a client who has osteomyelitis and is to receive a dose of gentamicin. Which of the following findings indicates the nurse should withhold the medication and notify the provider?

Serum creatinine. - A client who has an elevated serum creatinine level should not receive gentamicin because it is nephrotoxic.

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central venous catheter. Which of the following laboratory findings should the nurse report to the provider?

Serum magnesium 1.1mg/dL. - The nurse should report this value because this finding is below the expected reference range. 1.3 - 2.1mg/dL

A nurse is caring for a client who has a closed head injury and has an intraventicular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)?

Sleepiness exhibited by client. Widening pulse pressure. Decerebrate posturing.

A nurse is providing instruction about traveling for a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip by airplane. Which of the following should the nurse include in the teaching?

Take additional pairs of shoes. - The client should change shoes frequently due to the increase in walking when traveling and the risk of developing blisters and sores. The client should limit physical activity if blood glucose is less than 65mg/dL. Insulin should be carried in a insulated tote bag to protect against temperature variations with him on the airplane. The client should drink water every 2hr to reduce the risk of dehydration.

A nurse is caring for a client who is receiving chemotherapy. Which of the following assessment findings should the nurse report to the provider?

Temperature of 38.3C (100.9F). - It can indicate an infection due to myelosuppression.

A nurse is caring for a client during conscious sedation. For which of the following findings should the nurse intervene?

The client has a pulse oximetry of 90%. - A pulse oximetry reading of 90% requires immediate nursing intervention, because respiratory depression is a side effect of medications used during conscious sedation. Slurred verbal responses during conscious sedation are a typical response.

A nurses is caring for a client who has pneumonia and has been prescribed incentive spirometry. Which of the following findings indicates the desired outcome of this intervention?

The client has clear breath sounds in the lung bases bilaterally. - Incentive spirometry is used to expand the lower lobes of the lungs and prevent atelectasis.

A nurse is assessing a client who had a transurethral resection of the prostate (TURP) 12hr ago. Which of the following should the nurse identify as the priority finding?

The client has concentrated red urine with intermittent clots. - Concentrated red urine with intermittent clots indicates the client is at greatest risk for hemorrhage. Bladder spasms are expected. The nurse should administer an antispasmodic medication. Low grade temperature and pain is expected after a TURP.

A nurse is caring for a client who is 2hr postoperative following a traditional open approach cholecystectomy. Which of the following indicates the need for further nursing assessment?

The client has unilateral swelling of a lower extremity. - Unilateral swelling of a lower extremity might indicate the development of a deep vein thrombosis, which will require further assessment. Greenish brown drainage form T tube and sanguineous drainage on the dressing are expected findings. A sore throat following endotracheal intubation is an expected finding.

nurse is preparing to perform a bladder scan prescribed for a client who reports difficulty urinating following a hysterectomy. Identify the area of the abdomen where the nurse should place the probe while conducting the scan.

The nurse should place the probe along the midline of the abdomen and about 1.5in (4cm) above the pubic bone.

A nurse is caring for a client who has a pacemaker in synchronous mode. Which of the following findings indicates the pacemaker is functioning appropriately?

The pacemaker discharges to maintain the programmed heart rate. - If the client's heart rate is below the programmed rate, the pacemaker will discharge to maintain the programmed rate. Pacer spikes should be seen before each QRS complex.

A client newly diagnosed with heart failure is being discharged home with a prescription for a potassium sparing diuretic. Which of the following should the nurse include in the discharge teaching?

Try to walk at least three times per week for exercise. - The development of a regular exercise routine has been determined to improve client outcomes in clients who have heart failure. A persistent cough could indicate worsening heart failure. The use of OTC cough medication for a persistent cough should be approved by the provider prior to use.

A nurse is caring for a client who is receiving peritoneal dialysis while resting in bed. The nurse notices the peritoneal fluid is sluggish in draining. Which of the following actions should the nurse take to facilitate drainage?

Turn the client onto her side. - Turning the client onto her side could reposition the catheter if it is up against the peritoneal wall and could move the catheter if it is kinked to facilitate the drainage.

A nurse observes a client in the hallway who is having a generalized tonic-clonic seizure. The client become cyanotic. Which of the following nursing interventions is appropriate for the client?

Turn the client onto her site. - Turning the client onto her side will maintain an open airway.

A nurse if planning to irrigate and dress a clean, granulating wound of a client who has a pressure ulcer. Which of the following actions should the nurse take?

Use a 30mL syringe. - The nurse should use a 30mL to 60mL syringe with a 19 gauge catheter to deliver the ideal pressure when irrigating a wound.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips. - Using crutches with rubber tips prevents slipping and decreases the risk of falls. The client will wear the external fixation device continuously for a period of 4-6wk. Only the provider can adjust the external fixation device.

A nurse is obtaining a nursing history from a client who has suspected cholecystitis. Which of the following findings should the nurse expect?

Vague pain radiating to the right shoulder. - Pain that radiates to the right shoulder can indicate cholecystitis. Intense, piercing abdominal pain can indicate pancreatitis. A rigid, board like abdomen can indicate peritonitis. Flank pain extending to the perineum can indicate urolithiasis.

A nurse is caring for a client who is scheduled for a total hip arthroplasty the next day. Upon review of the client's medical history, which of the following medications taken by the client should the nurse report to the provider?

Warfarin - Warfarin is an anticoagulant and the client should stop taking this medication one week prior to surgery.

A nurse is assisting with the insertion of nontunneled percutaneous central venous catheter (CVC) for a client who requires parenteral nutrition.. Which of the following actions should the nurse take?

lace the client in the Trendelenburg position. - The nurse should place the client in a Trendelenburg position to provide easier access to vessels and to decrease the risk of an air embolus. The nurse should cleanse the upper chest or neck for a CVC. The client should remain motionless during the procedure. The nurse should apply a sterile transparent dressing to the insertion site.

A nurse is providing teaching on the use of a prednisone inhaler to a client who has asthma. The nurse should recognize the client needs further instruction if the client

spaces the two puffs 15 seconds apart. - The client should wait at least 20 to 30 seconds between puffs.