Med Surg Final (Quizzes)
A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 58-year-old postmenopausal client who is not taking estrogen therapy - Electrical stimulation b. A 29-year-old client after a difficult vaginal delivery - Habit training c. A 77-year-old female who has difficulty ambulating - Exercise therapy d. A 64-year-old female with Alzheimer's-type senile dementia - Bladder training
A) A 58-year-old postmenopausal client who is not taking estrogen therapy- Electrical stimulation \
A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How should the nurse respond? a. "Low estrogen levels can make the tissue more susceptible to infection." b. "Your immune system becomes less effective as you age." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted disease."
A) Low estrogen levels can make the tissue more susceptible to infection Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection.
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this client's plan of care? (Select all that apply) a. Incorporate physical exercise into your daily routine b. Participate in a smoking cessation program c. Avoid all alcoholic beverages d. Increase your intake of caffeinated beverages e. Increase your intake of fruits and vegetables
A, B
The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67 year old with benign prostatic hypertrophy. What precautions are related to the side effects of these medications? ( Select all that apply) a. Assessing for blood pressure changes when lying sitting and arising from the bed b. Asking the client to report any weakness, light headedness or dizziness c. Immediately reporting any change in the alanine aminotransferase laboratory test d. Teaching the client about the possibility of increased libido with these medications e. Taking the client's pulse rate for a minute in anticipation of bradycardia
A, B, C
A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply) a. A 32 year old body builder taking synthetic creatine supplements b. A 56 year old who is taking metformin for diabetes mellitus c. A 75 year old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer d. A 24 year old pregnant woman prescribed prenatal vitamins e. A 68 year old taking high dose anti inflammatory drugs (NSAIDS) for chronic back pain
A, B, E
A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply) a. Overflow incontinence- Constant dribbling of urine b. Reflex incontinence- Leakage of urine without lower urinary tract disorder c. Urge incontinence- Large amounts of urine with each occurence d. Functional incontinence- Urine loss results from abnormal detrusor contractions e. Stress incontinence- Urine loss with physical exertion
A, C, E
After administering a medication that stimulates the sympathetic division of the autonomic nervous system the nurse assesses the client. For which clinical manifestations should the nurse assess? (Select all that apply) a. Decreased respiratory rate b. Increased heart rate c. Decreased blood pressure d. Increased force of contraction e. Decreased level of consciousness
B, D
A nurse teaches clients about the difference between urge and stress incontinence. Which statements should the nurse include in this education ( Select all that apply) a. Urge incontinence can be managed by increasing fluid intake b. Urge incontinence occurs due to abnormal bladder contractions c. Stress incontinence occurs in people with dementia d. Urge incontinence involves a post void residual volume less than 50 ml e. Stress incontinence occurs due to weak pelvic floor muscles
B, E
A nurse reviews a female client's laboratory results. Which results from the client's urinalysis should the nurse recognize as abnormal? a. Specific gravity of 1.020 b. Ketone bodies present c. Clear and yellow color d. pH 5.6
B- ketone bodies present Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy
A nurse contacts the health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Urine culture and sensitivity b. Hemodialysis c. Intravenous fluids d. Fluid restriction
C) Intravenous fluids Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This client's creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions.
A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a) "Should we get another chest x-ray today?" b) "Do we want daily weights on this client?" c) "Can we discontinue the indwelling catheter today?" d) "Will the client be able to return home today?"
C- can we discontinue the indwelling catheter
A nurse cares for a client who is having trouble voiding. The client states, "I cannot urinate in public places." How should the nurse respond? a. "I will turn on the faucet in the bathroom to help stimulate your urination." b. "I'll move you to a room with a private bathroom to increase your comfort." c. "I will close the curtain to provide you with as much privacy as possible." d. "I can recommend a prescription for a diuretic to improve your urine output."
C- close the curtain --- it is not realistic to move the patient to a room with a private bathroom
The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? a. Post-void dribbling b. Urinary hesitancy c. Cloudy urine d. Weak urinary stream
C- cloudy urine
A nurse obtains a sterile urine specimen from a client's Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clean the injection port cap of the drainage tubing with povidone-iodine solution. b. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine. c. Clamp another section of the tube to create a fixed sample section for retrieval. d. Insert a syringe into the injection port and aspirate the quantity of urine required.
D) Insert a syringe into the injection port and aspirate the quantity of urine required It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe.
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply) a. Neck and shoulder tenderness b. Abrupt loss of conciousness c. Exophthalmos d. nasal congestion e. Miosis f. Ipsilateral tearing of the eye
D, E, F
A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to the renal insufficiency?" How should the nurse respond? a. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood." b. "Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density." c. "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." d. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."
D- "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."
After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? a. "I must avoid drinking alcoholic beverages." b. "I shall try to lose about 10% of my body weight." c. "I must avoid drinking caffeinated beverages." d. "I will limit my total intake of fluids."
D- "I will limit my total intake of fluids
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 77-year-old male with mild congestive heart failure c. A 42-year-old male who is prescribed cyclophosphamide d. A 58-year-old female who is not taking estrogen replacement
D- a 58-year-old female who is not taking estrogen replacement ---- Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes of the cells in the urethra and vagina.
A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the client's recent dietary selections. d. Perform a capillary artery glucose assessment
D-perform a capillary artery glucose assessment
A nurse cares for a client with advanced Alzheimer's disease. The client's caregiver states, "She is always wandering off. What can I do to manage this restless behavior?" How should the nurse respond? a. "This is a sign of fatigue. The client would benefit from a daily nap." b. "Engage the client in scheduled activities throughout the day." c. "It sounds like this is difficult for you. I will consult the social worker." d. "The provider can prescribe a mild sedative for restlessness."
b. "Engage the client in scheduled activities throughout the day."
A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the client's capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.
a) contact the provider and recommend discontinuing the metformin. Metformin can cause lactic acidosis and renal impairment as a reaction to the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established.
A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a. "I can use a heating pad on my legs if it's set on low." b. "It's going to be really hard but I will stop smoking." c. "I will go out and buy some warm, heavy socks to wear." d. "I should not cross my legs when sitting or lying down."
a. "I can use a heating pad on my legs if it's set on low."
After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? a. "I will take this medication every morning to help prevent an acute attack." b. "I will take this medication when I start to experience an asthma attack." c. "I will be weaned off this medication when I no longer need it." d. "I will carry this medication with me at all times in case I need it."
a. "I will take this medication every morning to help prevent an acute attack."
A nurse teaches an 80-year-old client with diminished touch sensation. Which statement should the nurse include in this client's teaching? a. "Look at the placement of your feet when walking." b. "Place soft rugs in your bathroom to decrease pain in your feet." c. "Bathe in warm water to increase your circulation." d. "Walk barefoot to decrease pressure ulcers from your shoes."
a. "Look at the placement of your feet when walking."
A nurse delegates care for a client with early-stage Alzheimer's disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care? a. "Reorient the client to the day, time, and environment with each contact." b. "If she is confused, play along and pretend that everything is okay." c. "Remove the clock from her room so that she doesn't get confused." d. "Use validation therapy to recognize and acknowledge the client's concerns."
a. "Reorient the client to the day, time, and environment with each contact."
A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Make sure the client's food is visually appetizing." c. "Place the client in a high-Fowler's position for all meals." d. "Assist the client by placing the fork in the left hand."
a. "Tell the client where food items are on the breakfast tray."
A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a. "Try warm, moist heat packs on your face." b. "Limit fluids to dry out your sinuses." c. "Ice packs may help with the facial pain." d. "We will schedule you for a computed tomography scan this week."
a. "Try warm, moist heat packs on your face."
A nurse assesses a client who is scheduled for a cardiac catheterization. Which assessment should the nurse complete prior to this procedure? a. Allergies to iodine-based agents b. Cardiac rhythm and heart rate c. Client's level of anxiety d. Ability to turn self in bed
a. Allergies to iodine-based agents
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition does the nurse associate with this finding? a. Difficulty with proprioception b. Impaired cerebellar function c. Peripheral motor disorder d. Positive pronator drift
a. Difficulty with proprioception
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect? a. Heart rate of 120 beats/min b. Oxygen saturation of 90% c. Respiratory rate of 8 breaths/min d. Cool, clammy skin
a. Heart rate of 120 beats/min
While assessing a client, a nurse detects a bluish tinge to the client's palms, soles, and mucous membranes. Which action should the nurse take next? a. Use pulse oximetry to assess the client's oxygen saturation. x b. Ask the client about current medications he or she is taking. c. Palpate the client's bilateral radial and pedal pulses. d. Auscultate the client's lung fields for adventitious sounds.
a. Use pulse oximetry to assess the client's oxygen saturation.
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Visual disturbances b. Numbness of the tongue c. Vertigo d. Lethargy
a. Visual disturbances
A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. "What is your occupation and what are your hobbies?" b. "Do you have any chronic breathing problems?" c. "Are you taking any medications or herbal supplements?" d. "How often do you perform aerobic exercise?"
b. "Do you have any chronic breathing problems?"
An emergency room nurse obtains the health history of a client. Which statement by the client should alert the nurse to the occurrence of heart failure? a. "I have lost weight over the past month." b. "I get short of breath when I climb stairs." c. "I see halos floating around my head." d. "I have trouble remembering things."
b. "I get short of breath when I climb stairs."
A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. "I will ask your provider to prescribe you with an antianxiety agent." b. "Share any thoughts and feelings that cause you to limit social activities." c. "There are a variety of support groups for people who have COPD." d. "Friends can be a good support system for clients with chronic disorders."
b. "Share any thoughts and feelings that cause you to limit social activities."
A nurse cares for an older adult client who has a chronic skin disorder. The client states, "I have not been to church in several weeks because of the discoloration of my skin." How should the nurse respond? a. "Religious people are nonjudgmental and will accept you." b. "Tell me more about your concerns related to your skin." c. "You do not need to go to church; God is everywhere." d. "I will consult the chaplain to provide you with spiritual support."
b. "Tell me more about your concerns related to your skin."
The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client? a. "My normal routine of drinking a quart of water during exercise needs to change." b. "There should be no problem with a glass of wine with dinner each night." c. "I need to inform my allergist that I cannot take my normal decongestant." d. "I am so glad that I weaned myself off of coffee about a year ago."
b. "There should be no problem with a glass of wine with dinner each night."
A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 68-year-old who has dependent edema and clubbed fingers b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 74-year-old with a chronic cough and thick, tenacious secretions d. A 46-year-old with a 30-pack-year history of smoking
b. A 52-year-old in a tripod position using accessory muscles to breathe
An emergency department nurse triages clients who present with chest discomfort. Which client should the nurse plan to assess first? A 53-year-old female who reports substernal pain that radiates to her abdomen b. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest c. A 49-year-old male who reports moderate pain that is worse on inspiration d. A 42-year-old female who describes her pain as a dull ache with numbness in her fingers
b. A 58-year-old male who describes his pain as intense stabbing that spreads across his chest
When transferring a client into a chair, a nurse notices that the pressure-relieving mattress overlay has deep imprints of the client's buttocks, heels, and scapulae. Which action should the nurse take next? a. Do nothing because this is an expected occurrence. b. Apply a different pressure-relieving device. c. Turn the mattress overlay to the opposite side. d. Reinforce the overlay with extra cushions.
b. Apply a different pressure-relieving device.
A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Let the client have a small sip to see whether he or she can swallow. b. Assess the client's gag reflex before giving any food or water. c. Provide the client with ice chips instead of a drink of water. d. Call the physician and request a prescription for food and water.
b. Assess the client's gag reflex before giving any food or water.
A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Raise the head of the bed to at least 45 degrees. b. Assess the client's level of consciousness. c. Encourage the client to increase fluid intake. d. Provide the client with humidified oxygen.
b. Assess the client's level of consciousness.
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Diabetes mellitus b. Chronic kidney disease c. Prinzmetal's angina d. Bronchial asthma
b. Chronic kidney disease
A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectively coping with the disorder? a. Disheveled appearance b. Clean hair and nails c. Poor eye contact d. Drapes a scarf over the face
b. Clean hair and nails
A nurse cares for clients who have various skin infections. Which infection is paired with the correct pharmacologic treatment? a. Bacterial infection - Acyclovir (Zovirax) b. Fungal infection - Ketoconazole (Nizoral) c. Yeast infection - Linezolid (Zyvox) d. Viral infection - Clindamycin (Cleocin)
b. Fungal infection - Ketoconazole (Nizoral)
A nurse performs a skin screening for a client who has numerous skin lesions. Which lesion does the nurse evaluate first? a. Large cluster of pustules in the right axilla b. Irregular blue mole with white specks on the lower leg c. Beige freckles on the backs of both hands d. Thick, reddened papules covered by white scales
b. Irregular blue mole with white specks on the lower leg
A student nurse is assessing the peripheral vascular system of an older adult. What action by the student would cause the faculty member to intervene? a. Auscultating the carotid arteries for any bruits b. Palpating both carotid arteries at the same time c. Classifying capillary refill of 4 seconds as normal d. Assessing blood pressure in both upper extremities
b. Palpating both carotid arteries at the same time
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse take when providing education about newly prescribed medications to this client? a. Allow the client to use a white board to ask questions. b. Sit on the client's right side and speak into the right ear. c. Help the client identify each medication by its color. d. Provide written materials with large print size.
b. Sit on the client's right side and speak into the right ear.
Which teaching point is most important for the client with bacterial pharyngitis? a. Use a humidifier in the bedroom. b. Take all antibiotics as directed. c. Gargle with warm salt water. d. Wash hands frequently.
b. Take all antibiotics as directed.
A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a. Instruct the client to have a flu vaccine. b. Teach the client to sneeze in the upper sleeve. c. Facilitate admission to the hospital. d. Educate the client on oseltamivir (Tamiflu).
b. Teach the client to sneeze in the upper sleeve.
A nurse assesses a client who has two skin lesions on his chest. Each lesion is the size of a nickel, flat, and darker in color than the client's skin. How should the nurse document these lesions? a. Two 1-inch moles b. Two 2-cm hyperpigmented patches c. Two 1-inch erythematous plaques d. Two 2-mm pigmented papules
b. Two 2-cm hyperpigmented patches
A nurse teaches a client who has very dry skin. Which statement should the nurse include in this client's education? a. "Use lots of moisturizer several times a day to minimize dryness." b. "Take a cold shower instead of soaking in the bathtub." c. "After you bathe, put lotion on before your skin is totally dry." d. "Use antimicrobial soap to avoid infection of cracked skin."
c. "After you bathe, put lotion on before your skin is totally dry."
A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. "What do you understand about your disease?" b. "What medications are you prescribed to take each day?" c. "Do you experience shortness of breath with basic activities?" d. "Do you have a strong support system?"
c. "Do you experience shortness of breath with basic activities?"
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching? a. "I must increase my fluids because of the dye used for the MRI." b. "My urine will be radioactive so I should not share a bathroom." c. "I can return to my usual activities immediately after the MRI." d. "My gag reflex will be tested before I can eat or drink anything."
c. "I can return to my usual activities immediately after the MRI."
A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this client's teaching? a. "Use the toilet when you first feel the urge, rather than at specific intervals." b. "Initially try to use the toilet at least every half hour for the first 24 hours." c. "Try to consciously hold your urine until the scheduled toileting time." d. "The toileting interval can be increased once you have been continent for a week."
c. "Try to consciously hold your urine until the scheduled toileting time."
A nurse cares for a client who is recovering from a myocardial infarction. The client states, "I will need to stop eating so much chili to keep that indigestion pain from returning." How should the nurse respond? a. "When did you start experiencing this indigestion?" b. "The provider has prescribed an antacid for you to take every morning." c. "What do you understand about what happened to you?" d. "Chili is high in fat and calories; it would be a good idea to stop eating it."
c. "What do you understand about what happened to you?"
A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high risk for coronary artery disease. Which statement related to nutrition should the nurse include in this client's teaching? a. "The best way to lose weight is a high-protein, low-carbohydrate diet." b. "If you exercise more frequently, you won't need to change your diet." c. "You should balance weight loss with consuming necessary nutrients." d. "A nutritionist will provide you with information about your new diet."
c. "You should balance weight loss with consuming necessary nutrients."
The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a. 2, 1, 3, 4, 5, 6, 7 b. 1, 3, 2, 5, 6, 7, 4 c. 4, 2, 1, 3, 5, 6, 7 d. 3, 4, 1, 2, 5, 7, 6
c. 4, 2, 1, 3, 5, 6, 7
A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 27-year-old client with a heart rate of 120 beats/min d. A 35-year-old client who has a longer expiratory phase than inspiratory phase
c. A 27-year-old client with a heart rate of 120 beats/min
A nurse assesses clients on a medical-surgical unit. Which client should the nurse identify as having the greatest risk for cardiovascular disease? a. A 32-year-old Asian-American man with colorectal cancer b. An 86-year-old man with a history of asthma c. A 45-year-old American Indian woman with diabetes mellitus d. A 53-year-old postmenopausal woman who is on hormone therapy
c. A 45-year-old American Indian woman with diabetes mellitus
A nurse is caring for a client who has a pressure ulcer on the right ankle. Which action should the nurse take first? a. Draw blood for albumin, prealbumin, and total protein. b. Prepare for and assist with obtaining a wound culture. c. Assess the right leg for pulses, skin color, and temperature. d. Place the client in bed and instruct the client to elevate the foot.
c. Assess the right leg for pulses, skin color, and temperature.
The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet? a. Spaghetti with meat sauce, garlic bread b. A 4-ounce steak, French fries, iceberg lettuce c. Baked chicken breast, broccoli, tomatoes d. Fried catfish, cornbread, peas
c. Baked chicken breast, broccoli, tomatoes
After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAP's understanding. Which action indicates the UAP needs additional teaching? a. Toileting the client after breakfast b. Encouraging the client to drink fluids c. Changing the client's incontinence brief when wet d. Recording the client's incontinence episodes
c. Changing the client's incontinence brief when wet
A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Cromone - Disrupts the production of pathways of inflammatory mediators b. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators c. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system d. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors
c. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system
A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met? a. Remains on bedrest as directed b. Verbalizes understanding of procedure c. Distal pulse on affected extremity 2+/4+ d. Pain rated as 2/10 after medication
c. Distal pulse on affected extremity 2+/4+
A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete? a. Identify the client's ability to perform self-care activities. b. Ask the client about relationships with family members. c. Evaluate the client's reaction to a change of environment. d. Assess religious and spiritual needs while in the hospital.
c. Evaluate the client's reaction to a change of environment.
The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a. Torsemide (Demadex)/sodium: 142 mEq/L b. Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c. Furosemide (Lasix)/potassium: 2.1 mEq/L d. Spironolactone (Aldactone)/potassium: 5.1 mEq/L
c. Furosemide (Lasix)/potassium: 2.1 mEq/L
After teaching a client who is at risk for the formation of pressure ulcers, a nurse assesses the client's understanding. Which dietary choice by the client indicates a good understanding of the teaching? a. Vegetarian diet with nutritional supplements and fish oil capsules b. Low-fat, low-cholesterol, high-fiber, low-carbohydrate diet c. High-protein diet with vitamins and mineral supplements d. Low-fat diet with whole grains and cereals and vitamin supplements
c. High-protein diet with vitamins and mineral supplements
A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Encourage the client to be completely honest about both tobacco and marijuana use. b. Avoid giving the client false hope regarding cancer treatment and prognosis. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Tell the client that he needs to quit smoking to stop further cancer development.
c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.
A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. A small amount of drainage from the site is noted. b. Pulse oximetry is 93% on 2 liters of oxygen. c. The trachea is deviated toward the opposite side of the neck. d. The client rates pain as a 5/10 at the site of the procedure.
c. The trachea is deviated toward the opposite side of the neck.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching? a. "Drink at least 3 liters of fluid during the first 24 hours after the test." b. "Remove your dentures and any metal before the test begins." c. "Do not take your cardiac medication the morning of the test." d. "Avoid caffeine-containing substances for 12 hours before the test."
d. "Avoid caffeine-containing substances for 12 hours before the test."
A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." How should the nurse respond? a. "Your family will be here soon. Let's get you dressed." b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning." d. "I see you are still hungry. I will get you some toast."
d. "I see you are still hungry. I will get you some toast."
After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "It may take a while before I notice a change in my asthma." b. "I will be careful not to let the drug escape out of my nose and mouth." c. "I will be certain to shake the inhaler well before I use it." d. "I will use the drug when I have an asthma attack."
d. "I will use the drug when I have an asthma attack."
A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this client's caregiver? a. "Allow the client to rest most of the day." b. "Provide a high-calorie and high-protein diet." c. "Place a padded throw rug at the bedside." d. "Install deadbolt locks on all outside doors."
d. "Install deadbolt locks on all outside doors."
A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "You need to take your medicine or you will get kidney failure." b. "You are lucky; most people get severe morning headaches." c. "Do you have trouble affording your medications?" d. "Most people with hypertension do not have symptoms."
d. "Most people with hypertension do not have symptoms."
An older client with peripheral vascular disease (PVD) is explaining the daily foot care regimen to the family practice clinic nurse. What statement by the client may indicate a barrier to proper foot care? a. "I nearly always wear comfy sweatpants and house shoes." b. "My daughter makes sure I have plenty of lotion for my feet." c. "I'm glad I get energy assistance so my house isn't so cold." d. "My hands shake when I try to do things requiring coordination."
d. "My hands shake when I try to do things requiring coordination."
A nurse is teaching a larger female client about alcohol intake and how it affects hypertension. The client asks if drinking two beers a night is an acceptable intake. What answer by the nurse is best? a. "No, you should not drink any alcohol with hypertension." b. "Yes, since you are larger, you can have more alcohol." c. "Yes, two beers per day is an acceptable amount of alcohol." d. "No, women should only have one beer a day as a general rule."
d. "No, women should only have one beer a day as a general rule."
A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching? a. "Rise slowly when getting out of bed in the morning." b. "Stopping this medication suddenly increases your risk for a heart attack." c. "Make a list of reasons why smoking is a bad habit." d. "Smoking while taking this medication will increase your risk of a stroke."
d. "Smoking while taking this medication will increase your risk of a stroke."
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client's teaching? a. "Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache." b. "This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines." c. "This drug will relieve the pain during the aura phase soon after a headache has started." d. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."
d. "Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches."
A nurse assesses a client who has multiple areas of ecchymosis on both arms. Which question should the nurse ask first? a. "Do you have a family history of this?" b. "Are you using lotion on your skin?" c. "Do your arms itch?" d. "What medications are you taking?"
d. "What medications are you taking?"
A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a. Women's health clinics b. Asian-American groceries c. High school sports camps d. African-American churches
d. African-American churches
A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate? a. Ask the client what foods cause trouble swallowing. b. Palpate the client's jaw while swallowing. c. Determine if the client can swallow saliva. d. Assess the client for pain when swallowing.
d. Assess the client for pain when swallowing.
A nurse assesses a client 2 hours after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action should the nurse take? a. Elevate the leg and apply a sandbag to the entrance site. b. Increase the flow rate of intravenous fluids. c. Document the finding as "left pedal pulse of +1/4." d. Assess the color and temperature of the left leg.
d. Assess the color and temperature of the left leg.
The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best? a. Place the "clients" on enhanced Droplet Precautions. b. Admit the "clients" on Contact Precautions. c. Do not allow pregnant caregivers to care for these "clients." d. Cohort the "clients" in the same area of the unit.
d. Cohort the "clients" in the same area of the unit.
A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement? a. Place an indwelling urinary catheter to closely monitor output. b. Contact the provider to cancel the procedure. c. Educate the client about strict bedrest after the procedure. d. Obtain a prescription for intravenous fluids.
d. Obtain a prescription for intravenous fluids.
A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete? a. Perform a funduscopic examination. b. Assess the gag reflex prior to eating. c. Obtain orthostatic blood pressure readings. d. Palpate bilateral lower extremity pulses.
d. Palpate bilateral lower extremity pulses.
A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Explain the procedure in detail to the client and the family. b. Verify that the client understands all possible complications. c. Measure oxygen saturation before and after a 12-minute walk. d. Validate that informed consent has been given by the client.
d. Validate that informed consent has been given by the client.
