MED SURG ASSESSMENT B
A nurse is caring for a client who is receiving a continuous tube feeding of 60mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr?
If there are 1.2 cal/mL, it makes sense that the total number of calories the nurse will deliver in 12 hr is 864.
A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging? "I sweat more than I used to." "Sometimes I can't remember my kids' names." "I seem to have more loose stools than I used to." "My food tastes bland even after I add seasoning."
"My food tastes bland even after I add seasoning." As clients age, their sense of smell decreases, causing a secondary decrease in taste.
A nurse is providing information regarding transmission-based precautions for a client who has C.DIFF to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all) "Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." "Use an alcohol-based hand sanitizer after client care." "Wear a face mask when in the client's room."
"Provide the client with disposable utensils and dishes for meals" is correct. Clients who have C. difficile require contact precautions, which include using disposable utensils and dishes during meals to prevent exposure to contaminants by others. "Leave blood pressure equipment in the client's room" is correct. When using contact precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen. "Clean contaminated surfaces with a bleach solution" is correct. The health care staff should use a bleach solution to clean equipment to prevent transmission of the pathogen.
A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify the client's injury occurred in which of the following lobes of the brain?
A is correct. Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully.
A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis? A) "Calcitonin will slow the breakdown of bone in your body." B) "Calcitonin will increase the level of cortisol in your blood." C) "Calcitonin will decrease the amount of calcium you are losing in your urine." D) "Calcitonin will increase the blood flow to your skeletal muscles."
A) "Calcitonin will slow the breakdown of bone in your body." Calcitonin inhibits osteoclast activity, therefore minimizing bone loss. The medication helps to preserve bone for a client who has osteoporosis.
A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching? A) "I drink bottled water." B) "I eat a salad bar for lunch." C) "I like to eat steak cooked medium." D) "I put plenty of pepper on my soft-boiled eggs"
A) "I drink bottled water." To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.
A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following client statements indicates an understanding of the teaching? A) "I inhaled the infected droplets that were in the air." B) "I must have touched someone who had TB." C) "I probably caught this disease from a mosquito bite." D) "I developed TB from having unprotected sex."
A) "I inhaled the infected droplets that were in the air." TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is reinforcing discharge teaching for a client who has a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching? A) "I will notify my dentist about this procedure." B) "I will take an enteric-coated aspirin daily." C) "I will use a firm-bristled toothbrush." D) "I will weigh myself once a week."
A) "I will notify my dentist about this procedure." The nurse should instruct the client to notify his dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk of endocardial infection.
A nurse is reinforcing teaching with a client about testicular self-examiniation. Which of the following instructions should the nurse include in the teaching? A) "Perform testicular self-examination after taking a warm shower." B) "Examine both testicles at the same time." C) "Use the palm of your hand to palpate for abnormalities." D) "Perform testicular self-examination every 6 months."
A) "Perform testicular self-examination after taking a warm shower." The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes.
A nurse is reinforcing teaching regarding the use of a continuous passive motion (cpm) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all) A) "Your knee is flexed and extended as prescribed by your provider." B) "The machine is padded with sheep skin." C) "You might have the head of the bed elevated to 45 degrees while using this machine." D) "To use the machine, you must pedal as if you are riding a bike." E) "We will store the CPM machine on the floor under the bed when not in use."
A) "Your knee is flexed and extended as prescribed by your provider" is correct. The provider will give specific instructions concerning the CPM flexion and extension motion each day. B) "The machine is padded with sheep skin" is correct. Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity.
A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP? A) Allow the weights to hang freely. B) Release the tension of the ropes. C) Remove the weights when rewrapping bandages. D) Manually lift the weights when moving the client up in bed.
A) Allow the weights to hang freely. The nurse should instruct the AP to allow the weights to hang freely and to refrain from bumping the weights. Skeletal traction maintains alignment of fractured bones through the use of counterweights. If these weights rest on the floor or another object, they do not maintain the counterbalance necessary to maintain the alignment of the fracture, which can result in client injury or pain.
A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take? A) Blow cool air into the cast using a blow dryer on a cool setting. B) Obtain a prescription for pregabalin. C) Ask the provider to bivalve the cast. D) Provide the client with a tongue blade to rub the skin under the cast.
A) Blow cool air into the cast using a blow dryer on a cool setting. Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin.
A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take? A) Check for kinks in the NG tube B) Increase the IV fluid rate C) Provide ice chips D) Administer an antiemetic
A) Check for kinks in the NG tube The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the priority action is to check the NG tube to determine if the tube is kinked, which can interfere with the suctioning function and result in nausea.
A nurse is caring for a client who has a new cast on her left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? A) Compartment syndrome B) Fat embolism C) Deep-vein thrombosis D) Osteomyelitis
A) Compartment syndrome Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities and a delay in capillary refill, and without immediate treatment, can cause nerve damage and necrosis.
A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take? A) Educate the client about choosing low-fat, low-cholesterol foods. B) Have the client flex hips and knees when lying in bed. C) Encourage the client to wear elastic support hose during the day time. D) Instruct the client to use an electric heating pad.
A) Educate the client about choosing low-fat, low-cholesterol foods. The nurse should educate the client about a low-fat, low-cholesterol diet, which is prescribed for clients who have atherosclerosis. This diet can also aid in weight reduction, which can improve activity tolerance.
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate? A) Elevated serum amylase level B) Hypertension C) Bradycardia D) Decreased leukocyte count
A) Elevated serum amylase level The nurse should anticipate an elevation in the client's serum amylase level due to injury of the pancreatic cells.
A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication? A) Frequent colds B) Vitamin deficiency C) Increased urination D) Orthostatic hypotension
A) Frequent colds The nurse should inform the client that corticosteroids can increase susceptibility to infection by suppressing the immune response. The nurse should instruct the client about infection prevention measures to implement while taking a corticosteroid.
A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care? A) Keep bed linens off of the affected areas. B) Position a heat lamp over the lower extremities. C) Apply warm, moist compresses to the affected areas. D) Initiate droplet isolation precautions.
A) Keep bed linens off of the affected areas. The nurse should keep bed linens off of the affected areas using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions.
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect? A) Muscle spasticity B) Tremors at rest C) Ptosis D) Ascending paralysis
A) Muscle spasticity Muscle spasticity is a manifestation of multiple sclerosis.
A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome? A) Place the client in the supine position after meals. B) Administer pancreatic enzymes before meals. C) Encourage the client to drink 240 mL (8 oz) of fluids with meals. D) Offer the client three meals daily.
A) Place the client in the supine position after meals. The nurse should encourage the client to lie in the supine position for a short time following meals to decrease rapid gastric emptying.
A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client? A) Semi-Fowler's with knees flexed B) Orthopneic C) Dorsal recumbent D) Prone with legs straight
A) Semi-Fowler's with knees flexed Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back and relieve pressure on the nerves.
A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort? A) Sleep on a firm mattress. B) Try jogging in place when joints feel stiff. C) Use a soft chair or recliner for sitting. D) Apply ice packs to painful joints.
A) Sleep on a firm mattress. A firm mattress or a bed board helps the client maintain joint alignment while sleeping.
A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first? A) Verify the client has given informed consent. B) Administer preoperative medication. C) Mark the location of the pedal pulses. D) Have the client void.
A) Verify the client has given informed consent. The greatest risk to the client in this situation is performing an unauthorized invasive procedure. Therefore, the first action the nurse should take is to verify that the client has given informed consent. If documentation of informed consent is not on the client's medical record, the nurse should withhold medications, which can alter the client's consciousness until consent is obtained.
A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber? A) ½ cup cooked kidney beans B) ½ cup raw cauliflower C) 1 cup cucumber with peel D) 1 cup parboiled brown rice
A) ½ cup cooked kidney beans The nurse should recommend kidney beans as the best source of fiber because ½ cup contains 6.5 g of fiber per serving.
A nurse is preparing to inset a double-lumen gastric (Salem) sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select? Dark blue Light blue ball White swirly Red and yellow hahahah sorry i dont know how to upload the pics
ANSWER A The wrapped up white cord with the blue tip
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication? A) "I have been sleeping less since I started the medication." B) "I have gained 3 pounds since my last appointment." C) "My bowel movements have become more frequent." D) "I urinate more often than before."
B) "I have gained 3 pounds since my last appointment." Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective.
A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb). Which of the following statements by the client indicates an understanding of the teaching? A) "I should insert the needle at a 90-degree angle." B) "I should give my shot in my belly tissue." C) "I will pull back on the syringe plunger to look for blood before I push the medication in." D) "I will use the side of my hand to pull my skin to the side prior to administering the insulin."
B) "I should give my shot in my belly tissue." Clients who have low body weights can have very little subcutaneous tissue. Therefore, the nurse should instruct the client to administer the medication in the upper abdomen for proper absorption.
A nurse is reinforcing discharge teaching with a client who has Chron's disease. Which of the following statements should the nurse include in the teaching? A) "Increase your intake of dietary fat." B) "Maintain a low-residue diet." C) "Avoid taking antidiarrheal medications." D) "Plan to weigh yourself weekly."
B) "Maintain a low-residue diet." The nurse should instruct the client to maintain a low-fiber, low-residue diet, which helps control pain and inflammation in the small intestine and reduces episodes of diarrhea.
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching? A) "I will need to take the medication until my thyroid function returns to normal." B) "The medication should be taken before I eat breakfast every morning." C) "The medication might lower my blood sugar." D) "I will take the medication with an antacid if it gives me heartburn."
B) "The medication should be taken before I eat breakfast every morning." The nurse should instruct the client to take levothyroxine at the same time each day, preferably 1 hr before breakfast.
A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make? A) "The kidneys' ability to filter urine is decreased." B) "The tumor causes obstruction of urine from the urethra." C) "The cancer results in hormonal changes, which affect urination." D) "The protein-specific antigen in your blood is decreased."
B) "The tumor causes obstruction of urine from the urethra." As a prostate tumor grows, it compresses the urethra, resulting in obstructed urine flow.
A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. The nurse tells the client to consume foods containing vitamin C when taking the supplement to enhance iron absorption. Which of the following client food choices indicates an understanding of the teaching? A) 1 cup cooked brown rice B) 1 cup boiled broccoli C) 1 cup cottage cheese D) 1 cup cooked kidney beans
B) 1 cup boiled broccoli The nurse should determine that choosing boiled broccoli indicates an understanding of the teaching because 1 cup contains 101 mg of vitamin C per serving.
A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A) A client who had a colectomy 2 days ago and has a nasogastric tube, Jackson-Pratt drain, and indwelling urinary catheter B) A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night C) A client who had a right lower lobe lobectomy 4 days ago and has a chest tube set to continuous suction D) A client who has pneumonia and an oral temperature of 38.7º C (101.7º F)
B) A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night When using the urgent vs. nonurgent approach to client care, the nurse determines to first see the client who has mental confusion and is getting out of bed without assistance. The client is experiencing manifestations of dehydration that can cause injury due to falls. Therefore, the nurse should see this client first.
A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain? A) Methotrexate B) Acetaminophen C) Gabapentin D) Etanercept
B) Acetaminophen Acetaminophen is a nonopioid analgesic that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics. However, clients should be advised that an overdose of acetaminophen can cause liver damage.
A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective? A) Adventitious lung sounds B) Decrease in exertional dyspnea C) Respiratory rate of 26/min while sitting in a chair D) Elevation of the head of the bed is required to sleep
B) Decrease in exertional dyspnea A decrease in exertional dyspnea indicates the antibiotics are resolving the infection and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the client.
A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure? A) Changes in the client's sputum B) Decreased blood pressure C) Changes in neurological status D) Increased urinary output
B) Decreased blood pressure Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.
A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease? A) Rheumatoid arthritis B) Diabetes mellitus C) Myasthenia gravis D) Crohn's disease
B) Diabetes mellitus Clients who have diabetes mellitus are at increased risk for developing cardiovascular and peripheral vascular disease due to the changes in the microvasculature resulting from elevated levels of glucose.
A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome? A) Reduced cough B) Diminished headache C) Relaxed muscles D) Decreased peripheral edema
B) Diminished headache Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor the client for a diminished headache as an expected outcome of the medication.
A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect? A) Seeing halos around artificial lights B) Distorted central vision of the eyes C) Colored spots before the visual fields D) Spontaneous tearing of the eyes
B) Distorted central vision of the eyes Macular degeneration results in a distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center.
A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures? A) Fasciotomy B) Escharotomy C) Skin grafting D) Hyperbaric oxygen therapy
B) Escharotomy The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible and the client's oxygenation should improve.
A nurse in reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching? A) Weekly sputum cultures will be needed. B) Household family members should be tested for TB. C) TB is no longer contagious after 2 to 3 days of medication therapy. D) Family members should wear N95 masks when in contact with the client.
B) Household family members should be tested for TB. The nurse should instruct the client that family members or others who have been in close contact with the client should schedule testing for TB.
A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of the following actions should the nurse take first? A) Administer antituberculosis medication. B) Institute airborne precautions. C) Obtain sputum cultures. D) Auscultate breath sounds.
B) Institute airborne precautions. The greatest risk from this client is transmitting TB to staff and other clients. Therefore, the first action the nurse should take is to implement airborne precautions.
A nurse is reinforcing teaching with the parent of a toddler who has type 1 diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. Which of the following information should the nurse include in the teaching? A) Lispro is given once a day. B) Lispro should be given before eating. C) Lispro cannot be given with other insulin. D) Lispro does not cause hypoglycemia.
B) Lispro should be given before eating. Lispro insulin should be given around mealtime, within 15 min before or after eating.
A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first? A) Place the client in Fowler's position. B) Obtain the client's blood pressure. C) Dangle the client's legs at the bedside. D) Apply nonskid slippers.
B) Obtain the client's blood pressure. The greatest risk to the client is postural hypotension due to decreased blood volume following surgery. Therefore, the first action the nurse should take is to obtain the client's baseline blood pressure to determine whether it is safe to have the client get out of bed.
A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin? A) Store unopened insulin vials in the freezer for up to 1 month. B) Opened insulin can be stored on a cool countertop away from light. C) Roll discolored insulin gently to mix it before use. D) Use refrigerated insulin immediately after removing it from the refrigerator.
B) Opened insulin can be stored on a cool countertop away from light. The nurse should inform the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight.
A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team members should the nurse recommend a referral prior to initiating oral intake for the client? A) Occupational therapist B) Speech-language pathologist C) Physical therapist D) Case manager
B) Speech-language pathologist The nurse should recommend a referral for a speech-language pathologist to evaluate the client's ability to safely swallow. A client who has had a CVA is at increased risk for dysphagia and aspiration of fluids, food, and medications. The speech-language pathologist should conduct a swallowing study to determine the client's risk for aspiration and provide teaching to the client regarding swallowing techniques.
A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding body image changes. Which of the following should the nurse recognize as a physical change caused by this disease? A) Bronze skin B) Truncal obesity C) Lordosis D) Exophthalmos
B) Truncal obesity Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns.
A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate? A) Granulation tissue is present. B) Urine output is 50 mL/hr. C) Lung sounds are clear. D) Oxygen saturation level is 95%.
B) Urine output is 50 mL/hr. The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.
1. A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery A) Serious drainage from the incision B) WBC count of 15,000/mm C) Temperature of 37.2 C (99 F) D) Urine output of 400 mL over the past 8 hr
B) WBC count of 15,000/mm
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? A) Pleural friction rub B) Wheezes C) Vesicular D) Crackles
B) Wheezes The nurse should identify the breath sound auscultated as wheezes. These are high-pitched, musical sounds that occur as air passes through narrowed airways, such as when a client is experiencing an asthma attack.
A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching? A) "I will eat more bananas." B) "I will walk for 20 minutes 3 days a week." C) "I will limit my coffee intake." D) "I will take a calcium supplement at bed time."
C) "I will limit my coffee intake." Coffee contains caffeine, which can cause excretion of calcium through diuretic effects. Clients often drink caffeinated beverages instead of beverages that contain calcium, and caffeine might interfere with the absorption of Vitamin D. Therefore, the nurse should identify this statement as an indication that the client understands the teaching.
A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching? A) "I will add a banana to my morning cereal." B) "I will decrease my intake of carbohydrates." C) "I will limit my daily intake of protein." D) "I will season my foods with a salt substitute."
C) "I will limit my daily intake of protein." The client should decrease his intake of protein to slow the progression of kidney failure. Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching? A) "I should perform pursed-lip breathing exercises before going to bed." B) "When I'm fatigued, I should inhale slowly through pursed lips." C) "Pursed-lip breathing works best for activities like walking up stairs." D) "I will exhale through my nose after breathing in through pursed lips."
C) "Pursed-lip breathing works best for activities like walking up stairs." The nurse should acknowledge that performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain.
A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching? A) "You should thaw frozen meat at room temperature." B) "You should use paprika as a seasoning for your food." C) "You should place your toothbrush in hydrogen peroxide overnight." D) "You should use a glycerin-based soap while bathing."
C) "You should place your toothbrush in hydrogen peroxide overnight." Clients who are receiving chemotherapy should clean their toothbrushes by soaking them overnight in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection.
A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take? A) Prepare for intubation of the client. B) Administer opioid medication. C) Administer oxygen via nasal cannula. D) Place the client in low-Fowler's position.
C) Administer oxygen via nasal cannula. The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed.
A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG? A) Position the client in Sims' position before electrode placement. B) Ensure that each electrode is dry before application. C) Cleanse the client's skin prior to electrode placement. D) Place the electrodes on the client's abdomen and back.
C) Cleanse the client's skin prior to electrode placement. The nurse should cleanse the client's skin prior to electrode placement to improve electrode conduction.
A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects? A) Bradycardia B) Tremors C) Cough D) Hyperglycemia
C) Cough Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough. Therefore, the nurse should monitor the client for this adverse effect.
A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider? A) Absent gag reflex B) Blood-tinged mucus C) Diminished breath sounds D) Oxygen saturation 95%
C) Diminished breath sounds Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse should report this finding to the provider for further evaluation of the client.
A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include? A) Limit protein in daily meal plan. B) Use a bronchodilator 1 hr before meals. C) Drink beverages at the end of meals. D) Lie down for 1 hr after meals.
C) Drink beverages at the end of meals. The client should drink beverages at the end of meals, rather than during meals, to prevent shortness of breath while eating. This also prevents early satiety and promotes adequate nutrient intake during the meal.
A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion? A) Restrict visitors to three at a time. B) Avoid touching the client during care. C) Encourage reminiscence of past experiences. D) Give the client multiple options for daily events.
C) Encourage reminiscence of past experiences. The nurse should encourage reminiscence of past experiences to reduce the client's confusion.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching? A) The expected therapeutic reference range for HbA1c for a client who has diabetes mellitus is 9.5% to 10%. B) An HbA1c level below the expected reference range indicates poor glucose control. C) HbA1c results measure glucose control for the prior 3 months. D) HbA1c testing is used to provide a diagnosis of diabetes mellitus.
C) HbA1c results measure glucose control for the prior 3 months. HbA1c testing reflects average overall glucose control over a 3-month period. The nurse should inform the client that HbA1c testing is the best measure of long-term glucose control.
A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider? A) Hemoglobin 13 g/dL B) Blood pressure 110/55 mm Hg C) Heart rate 120/min D) Potassium 3.6 mEq/L
C) Heart rate 120/min The client's heart rate of 120/min is above the expected reference range and indicates the client's dehydration has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement.
A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care? A) Check neurovascular status on the extremity every 8 hr. B) Have the client perform incentive spirometry every 4 hr. C) Keep an abduction pillow between the client's legs. D) Maintain the client on bed rest until the third postoperative day.
C) Keep an abduction pillow between the client's legs. The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery.
A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement? A) Offer the client fresh fruits and vegetables. B) Monitor the client's platelet count daily. C) Limit visitors to healthy adults. D) Apply firm pressure to injection sites.
C) Limit visitors to healthy adults.
A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury? A) Anorexia B) Hoarseness C) Muscle twitching D) Blurred vision
C) Muscle twitching A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth.
A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? A) Encourage the client to ambulate. B) Administer an antipyretic medication. C) Notify the charge nurse of the client's BUN level. D) Keep the temperature in the client's room warm.
C) Notify the charge nurse of the client's BUN level. The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which indicates dehydration and impaired renal function. The nurse should notify the charge nurse of this finding and anticipate interventions to restore the client's fluid volume.
A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan? A) Encourage stimulating activities after dinner. B) Encourage a late afternoon nap. C) Offer a small snack at bedtime. D) Offer hot chocolate at bedtime.
C) Offer a small snack at bedtime. The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep.
A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain? A) Semi-Fowler's B) Supine with lower extremities elevated C) Upright, leaning forward D) Side-lying with knees bent
C) Upright, leaning forward The nurse should plan to place a client who has pericarditis in an upright position, leaning forward, to facilitate breathing and decrease pain.
A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan? A) Measure rectal temperature every 4 hr. B) Remind the client to cough as needed. C) Use a turn sheet to reposition the client. D) Apply wrist restraints.
C) Use a turn sheet to reposition the client. The nurse should change the client's position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client provides the nurse with the ability to better control the client's movement and alignment. The nurse should instruct the client to exhale during the position change to prevent an increase in ICP.
A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan? A) Observe for impulsive behavior. B) Approach the client from the right side. C) Use simple verbal cues when directing tasks. D) Place the client in low-Fowler's position during meals.
C) Use simple verbal cues when directing tasks. The nurse should expect a client who experiences a left hemispheric stroke to manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication.
A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include? A) Withdraw both types of insulin and then add 0.2 mL of air to the syringe. B) Gently shake the NPH insulin prior to withdrawing the dose. C) Withdraw the regular insulin before withdrawing the NPH insulin. D) Inject air into the NPH vial after withdrawing regular insulin.
C) Withdraw the regular insulin before withdrawing the NPH insulin. The nurse should instruct the client to withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.
A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include in the teaching? A) "Use condoms when lesions are present." B) "Look for lesions that have a wart-like appearance." C)"The virus can be transmitted without lesions present." D) "The lesions resolve in 2 weeks and usually do not recur."
C)"The virus can be transmitted without lesions present." The nurse should inform the client that viral shedding and spreading of the infection can occur even when lesions are not present.
A nurse is caring for a client who begings to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow.
Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client.
A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching? A) "Place throw rugs on wooden floors at home." B) "Supplement your diet with vitamin E." C) "Swim laps for 20 minutes twice per week." D) "Take calcium supplements with meals."
D) "Take calcium supplements with meals." The nurse should instruct the client to take calcium carbonate supplements with or following meals to increase absorption and effectiveness.
A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take? A) Give the dose as prescribed. B) Use a different route to administer the medication. C) Administer half of the prescribed dose. D) Withhold the dose.
D) Withhold the dose. The nurse should withhold the digoxin dose for an apical pulse less than 60/min and notify the provider. Digoxin slows the heart rate, so administering the dose can cause harm to the client.
A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements indicate to the nurse that the client understands the teaching? A) "I will scrub the skin to remove the old skin flakes." B) "I can expect to my leg to be swollen after the cast is removed." C) "I can go back to my usual activities as soon as the cast is off." D) "I will feel vibrations on my leg from the cast cutter."
D) "I will feel vibrations on my leg from the cast cutter." The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain.
A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. Which of the following instructions should the nurse include in the teaching? A) "Maintain fat intake of 40 percent of total calories." B) "Have your white blood cell count checked." C) "Sustain an HDL level of 25 milligrams per deciliter." D) "Add oily fish to your diet twice weekly."
D) "Add oily fish to your diet twice weekly." The nurse should reinforce teaching about dietary changes to manage coronary artery disease, such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice weekly or taking a fish oil supplement daily.
A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine? A) "I am allergic to shrimp." B) "I am allergic to latex balloons." C) "I had a tuberculosis skin test 2 days ago." D) "I had a low fever this morning."
D) "I had a low fever this morning." Clients who have a febrile illness should not receive the influenza vaccine.
A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan? A) Massage both lower extremities to promote comfort. B) Begin the client on a regular diet when the gag reflex returns. C) Encourage the client to use the incentive spirometer every 4 hr while awake. D) Assist the client to change positions at least every 2 hr.
D) Assist the client to change positions at least every 2 hr. The nurse should assist the client to change positions at least every 2 hr to promote return of respiratory function following anesthesia and prevent atelectasis and pneumonia.
A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first? A) Obtain the client's temperature. B) Observe for phantom pain. C) Measure urinary output. D) Check the incisional dressing.
D) Check the incisional dressing. The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding.
A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take? A) Secure the drainage tube to the client's bedding. B) Wear sterile gloves to empty the drainage system. C) Cut an absorbent gauze dressing to fit around the drainage tube. D) Cleanse the drainage plug with alcohol swabs.
D) Cleanse the drainage plug with alcohol swabs. The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system.
A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take? A) Fill the bulb reservoir with 0.9% sodium chloride. B) Allow the Jackson-Pratt drain to hang freely. C) Cut a slit in a gauze sponge and apply it around the tubing insertion site. D) Compress the bulb reservoir and then close the drainage valve.
D) Compress the bulb reservoir and then close the drainage valve. The nurse should fully compress the bulb reservoir and then replace the valve plug using aseptic technique to establish suction after emptying or activating a Jackson-Pratt drain.
A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction? A) Decreased lipase B) Decreased erythrocyte sedimentation rate (ESR) C) Elevated creatinine D) Elevated troponin
D) Elevated troponin Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication that the client is experiencing a myocardial infarction.
A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity? A) Potassium chloride B) Famotidine C) Levothyroxine D) Furosemide
D) Furosemide The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect? A) Clamp the urethral catheter for 30 min. B) Place the urethral catheter drainage bag at the client's heart level. C) Slow the bladder irrigation flow rate. D) Irrigate the urethral catheter with 0.9% sodium chloride.
D) Irrigate the urethral catheter with 0.9% sodium chloride. The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow.
A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching? A) Avoid weight-bearing until healing of the hip incision is complete. B) Cross legs intermittently several times a day. C) Lean forward to change positions when sitting in a chair. D) Maintain hip flexion to 90° or less when sitting.
D) Maintain hip flexion to 90° or less when sitting. A client who has had a cemented total hip arthroplasty should maintain hip flexion to 90° or less when sitting to prevent hip dislocation.
A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse? A) Reported pain level of 6 on a scale of 0 to 10 B) Urinary output of 110 mL in the past 4 hr C) Temperature of 38.0º C (100.4º F) D) Oxygen saturation of 88%
D) Oxygen saturation of 88%
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include? A) Place a "no visitors" sign on the client's door. B) Have the client wear an N95 respiratory mask during transport. C) Initiate droplet precautions for the client. D) Place the client in a negative-pressure airflow room.
D) Place the client in a negative-pressure airflow room. The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms.
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis? A) Metoprolol B) Methimazole C) Furosemide D) Prednisone
D) Prednisone Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis.
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take? A) Massage the area. B) Remove the weights. C) Loosen the ropes. D) Reposition the client.
D) Reposition the client. When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed.
A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend to include in the pamphlet? A) The number of sexual partners does not affect the risk for STIs. B) Oral contraceptive use decreases the risk for STIs. C) Men seek treatment for STIs later than women. D) Women have a higher risk of contracting STIs than men.
D) Women have a higher risk of contracting STIs than men. The nurse should include that oral contraceptive use, prolonged contact with male secretions, and increased cervical permeability during hormone fluctuations increase a woman's risk of acquiring STIs.
