MED SURG FINAL
A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide? A) Increase fluid intake B) Take an over the counter antidiarrheal medication C) Expect black Tarry stools D) follow a low fiber diet
A) Increase fluid intake Increasing fluid intact will help to prevent constipation.
A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? A) Its like a curtain closed over my eye B) This sharp pain in my eye started 2 hours ago C) Ive been having more and more difficulty seeing over the last few weeks D) I seem to have more problems seeing different colors.
A) Its like a curtain closed over my eye A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retina detachment typically report the sensation of a curtain being pulled over part of the visual field.
A nurse is caring for a client who has viral pneumonia. The clients pulse ox readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen> A) Nonrebreather mask B) Venturi mask C) simple face mask D) partial rebreather mask
A) Nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80-95% oxygen to the client. A client who has unstable respiratory status should receive oxygen via a nonrebreather.
A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the last 3 days. which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A) heart rate 110/min B) Blood pressure 138/90 C) Urine specific gravity 1.020 D) BUN 15
A) heart rate 110/min A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate
A nurse is caring for a client who is receiving TPN. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? A) Keep the like open with NS until the new bag arrives B) Administer dextrose 10% in water until the new bag arrives C) Flush the line and cap the port until the new bag arrives D) Decrease the infusion rate until the new bag arrives
B) Administer dextrose 10% in water until the new bag arrives TPN solution shave a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% in water to avoid a precipitous drop in the clients blood glucose level
A nurse in a community clinic is caring for a client who reports increase in the frequency of migraine headaches. To help reduce the risk of migraine headaches, which of the following foods should the nurse recommend the client avoid? A) Shellfish B) Aged cheese C) Peppermint candy D) Enriched pasta
B) Aged cheese Food that contain tyramine, such as ages cheese and sausage, can trigger migraine headaches.
A nurse is caring for a client 1 hour following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse priority? A) Initiate oxygen 2L via NC B) Apply firm pressure to the insertion site C) take the clients Vital signs D) obtain a stat order for aPTT
B) Apply firm pressure to the insertion site The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding
A nurse is caring for a client who has DKA. Which of the following lab findings should the nurse expect? A) Negative urine ketones B) BUN 32 mg/dl C) pH 7.43 D) HCO3 23mEq/L
B) BUN 32 mg/dl DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect the client who has DKA to have an elevated BUN, Creatinine, and specific gravity levels resulting from excess glucose present in the urine.
A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hours ago. Which of the following actions should the nurse take? A) Inspect the cast for drainage once every 24 hours B) Check that one finger fits between the cast and the leg C) Perform neurovascular checks every 2-3 hours D) Make sure the client has a warm blanket covering the cast
B) Check that one finger fits between the cast and the leg To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hours after application
A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab values should the nurse expect? A) Decreased PT B) Elevated bilirubin C) Decreased ammonia D) Elevated Albumin
B) Elevated bilirubin Bilirubin levels reflect the livers ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the clients degree of jaundice.
A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? A) Metabolic alkalosis B) Hyperkalemia C) Increased hemoglobin D) Hypophosphatemia
B) Hyperkalemia The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium
A nurse is providing teaching to a client who has CKD and a new prescription for erythropoietin. Which of the following statements by the client indicates and understanding of the teaching? A) I should take calcium supplements so the med will work better in my system B) I am taking this med to increase my energy level C) This med can cause my blood pressure to drop D) I will not need to restrict protein in my diet while taking this medication
B) I am taking this med to increase my energy level The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.
A nurse is providing teaching to a client who has IBS. Which of the following instructions should the nurse include in the teaching? A) Take an antacid before meals and at bedtime B) Increase fiber intake to at least 30 g per day C) Drink ginger tea daily D) Consume no more than 1L of water per day
B) Increase fiber intake to at least 30 g per day Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns
An older adult client is brought to an ED by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? A) Serum Sodium 145 B) Forearm skin tents when pinched C) respiratory rate decreased D) Urine specific gravity 1.045
D) Urine specific gravity 1.045 Urine specific gravity greater than 1.030 indicates a decrease in urine volume and increase in osmolarity, which is a manifestation of hypertonic dehydration
A nurse is providing dietary teaching to a client who is postop following a thyroidectomy with the removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet. A) 12 almonds B) One small Banana C) 1 tbsp of peanut butter D) 1/2 cup of tomato juice
A) 12 almonds The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contains 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.
A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? A) A client should sign an informed consent before receiving a placebo during research trial. B) A client cannot refuse to sign a consent for a live saving treatment C) A client who has a mental illness is unable to give informed consent D) An unemancipated minor need guardian consent for substance use disorder treatment.
A) A client should sign an informed consent before receiving a placebo during research trial. A nurse should ensure a client has been provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an active medication because this action is a violation of client rights.
A nurse is caring for a group of clients. The nurse should plan to make a referral to PT foe which of the following clients? A) A client who is receiving preop teaching for right knee arthroplasty b) A client who states they will have difficulty obtaining a walker for home use C) A client who reports increase pain following a left hip arthroplasty D) a client who is having emotionally difficulty accepting that they have a prosthetic leg
A) A client who is receiving preop teaching for right knee arthroplasty The nurse should make a referral to PT for a client who is receiving preop teaching for a knee arthroplasty so the client can begin understanding post op exercises and physical restrictions.
A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings? A) Dysphagia B) Aphasia C) Ataxia D) Hemianopsia
A) Dysphagia Dysphagia indicated that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore the nurse should place priority on this finding.
A nurse in an ER is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? SATA A) Fever B) Nonpitting edema C) Hypertension D) Tachycardia E) Hypoglycemia
A) Fever C) Hypertension D) Tachycardia The nurse should expect a fever because of the excessive thyroid hormone release The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? A) HX of asthma B) Appendectomy 1 year ago C) Penicillin allergy D) total knee arthroplasty 6 months ago
A) HX of asthma A client who has a HX of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to food, such as shellfish, eggs, milk, and chocolate
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an ASE of this medication A) Hypokalemia B) Hypercalcemia C) GI bleeding D) Confusion
A) Hypokalemia Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration
A nurse is providing teaching to a client who is receiving chemo and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? A) I will monitor my blood pressure while taking this medication B) I should take a vitamin D supplement to increase the effectiveness of the medication C) I should inform the provider if I experience an increased appetite while taking this medication D) I will decrease the amount of protein in my diet while taking this medication
A) I will monitor my blood pressure while taking this medication The client should monitor their blood pressure while taking this medication because hypertension is a common ASE and can lead to hypertensive encephalopathy
A nurse in an ER is caring for a client who has a full thickness burns over 20% of their body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? A) IV fluids B) analgesia C) antibiotics D) tetanus toxoid
A) IV fluids After establishing a patent airway and administering oxygen, evidence based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support
A nurse is creating a plan of care for a client who has neutropenia as a result of chemo. Which of the following interventions should the nurse include in the plan? A) Monitor the client temp Q4 hours B) insert an indwelling catheter for the client C) Request the clients bathroom be cleaned 3x a week D) Place a box of latex gloves just outside of the clients room
A) Monitor the client temp Q4 hours The nurse should monitor the temp of a client who has neutropenia Q4 hours because the clients reduced amount of leukocytes greatly increases he clients risk for infection
A nurse is preparing to administer a unit of packed RBC to a client. Which of the following actions should the nurse take? A) Remain with the client for the first 15 minutes of the infusion B) Prime the blood administration IV tubing with lactated ringer solution C) Verify the clients identity by using the room number prior to starting the transfusion D) infuse the unit of Packed RBC withing 8 hours
A) Remain with the client for the first 15 minutes of the infusion The nurse should remain with the client for the first 15 minutes of the infusion because hemolytic reactions usually occur during the infusion in the first 50mL of blood
A nurse in a providers office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing ASE to this medication? A) Report of a night cough B) Report of tinnitus C) Report of excessive tearing D) Report of increased salivation
A) Report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this ASE to the provider
A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hours ago. Which of the following findings should the nurse expect>? A) Stone fragments in the urine B) Fever C) Decreased urine output D) Bruising on the lower abdomen
A) Stone fragments in the urine ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the clients urine to confirm passage of the stones.
A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the clients bedside. A) Suction machine B) Wire cutters C) Padded clamp D) Communication board
A) Suction machine The nurse should ensure that a suction machine is at bedside of a client who has dysphagia to clear the clients airway as needed and reduce the risk of aspiration.
A nurse is caring for a client who has type 1 diabetes mellitus and has had an acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? A) Take insulin even if you are unable to eat your regular diet B) Its okay if your ketone levels are temporarily high C) monitor your blood glucose every 12 hours D) call the provider if your blood glucose reaches 170
A) Take insulin even if you are unable to eat your regular diet The client should continue the prescribed medication regimen when ill to prevent hyperglycemia
A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium sparing diuretic. Which of the following information should the nurse include in the teaching? A) Try to walk at least 3 times per week for exercise B) To increase stamina, walk for 5 minutes after fatigue begins C) Take OTC cough medicine for persistent cough D) Use a salt substitute to reduce sodium intake
A) Try to walk at least 3 times per week for exercise The development of a regular exercise routine can improve outcomes in clients who have heart failure
A nurse and a CNA are caring for a client who has bacterial meningitis. The nurse should give the CNA which of the following instructions? A) Wear a mask B) Wear a gown C) Keep the clients room well lit D) maintain the HOB at 45 degrees
A) Wear a mask Bacterial meningitis requires droplet precautions; therefore the CNA and the nurse should wear a mask when coming within 3 feet of the client until 24 hours after the client has begun receiving ATB therapy
A nurse has received change of shift report for a group of clients. Which of the following clients should the nurse assess first? A) A client who is 1 day postop following abdominal surgery and reports pain of 4 out of 10 B) A client who had a MI 4 days ago and is asking for PRN sublingual nitro C) A client who has atopic dermatitis manifesting with scaling and excoriation of the skin and reports severe itching D) a client who has pneumonia manifesting with bilateral crackles and diminished lung sounds.
B) A client who had a MI 4 days ago and is asking for PRN sublingual nitro When using stable vs unstable approach to client care, the nurse should assess this client first. A client who has a MI 4 days ago and is asking for PRN sublingual nitro could be unstable. The client might be experiencing angina or could be having another MI.
A nurse is teaching a client who has a family HX of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend? A) Add full-fat yogurt to the diet B) Add cabbage to the diet C) Replace butter with coconut oil D) Replace shellfish with red meat
B) Add cabbage to the diet To help reduce the risk of colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbs. Brassica veggies, such as cabbage, cauliflower, and broccoli are high in fiber
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent pseudomonas aeruginosa infection? A) Encourage the client to eat raw fruits and vegetables B) Avoid placing plants of flowers in the clients room C) Limit visitors to members of the clients immediate family D) Wear an N95 respirator mask when providing care to the client.
B) Avoid placing plants of flowers in the clients room Live plants can harbor P. aeruginosa and this bacterium can infect burn wounds and cause life-threatening complications.
A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching? A) I am taking my progesterone daily B) I am dieting to lose weight C) I am limiting my daily fluid intake D) I have switched my morning cups of coffee to tea
B) I am dieting to lose weight Excess weight creates increased abdominal pressure that can result in stress incontinence.
A nurse is providing instructions to a client who has type 2 DM and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching? A) I will monitor my BS carefully because the medication increases the secretion of insulin B) I should take this medication with a meal C) I can expect to gain weight while taking the medication D) While taking this medication, i will experience flushing of the skin
B) I should take this medication with a meal Taking it with a meal or right after a meal improves absorption and minimizes GI distress
A nurse is evaluating a client who has a new diagnosis of type 1 diabetes. Which of the following client statements indicates the client is successfully coping with the change? A) It is just easier to let my partner administer my insulin B) I used to never worry about my feet. Now, I inspect my feet everyday with a mirror C) I'm concerned i wont be able to read my blood sugar level because the screen is so small D) I know a lot of people who have DM and do not take insulin. I wish I didn't have to
B) I used to never worry about my feet. Now, I inspect my feet everyday with a mirror This statement indicates the client is successfully coping with the change because the client is performing preventative foot care to reduce the risk of complications.
A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A)I will wash the ink markings off the radiation area after each treatment B) I will use my hands rather than a washcloth to clean the radiation area C) I will be able to be out in the sun 1 month after my radiation treatments are done D) I will use a heating pad on my neck if if becomes sore during radiation therapy.
B) I will use my hands rather than a washcloth to clean the radiation area The client should gently wash the radiation area with their hands using warm water and a mild soap to protect the skin from further irritation.
A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurses priority A) Temp of 101.1 B) Increased respiratory secretions C) Fluid intake of 200ml in the prior 8hr D) limited ROM
B) Increased respiratory secretions Airway is priority.
A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want anymore morphine because I don't want to get addicted." which of the following actions should the nurse take? A) Administer a placebo to the client without their knowledge B) Instruct the client on alternative therapies for pain reduction C) Tell the client not to worry about addiction to prescribed narcotics D) Suggest the client receive a different opioid for pain reduction
B) Instruct the client on alternative therapies for pain reduction The nurse should respect the clients concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.
A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: Heart rate 200/min, blood pressure 78/40, and a RR of 30/min. Which of the following actions should the nurse take first? A) Defibrillate the clients heart B) Perform synchronized cardioversion. C) begin CPR D) administer lidocaine IV bolus
B) Perform synchronized cardioversion. The nurse should perform synchronizes cardioversion for a client who has supraventricular tachycardia
A Home health nurse is assigned to a client who has recently discharged from a rehab center after experiencing right hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client SATA A) Expressive aphasia B) Visual spatial deficits C) left hemianopsia D) right hemiplegia E) one sided neglect
B) Visual spatial deficits, C) left hemianopsia, E) one sided neglect Visual spatial deficits and loss of depth perception occur secondary to right hemispheric stroke Left hemianopsia, or blindness in the left half of the visual field occurs secondary to right hemispheric stroke One sided neglect, or an unawareness of the affected side, occurs secondary to right hemispheric stroke
A nurse is discussing activity modification with a client who has a right total hip arthroplasty. Which of the following statements should the nurse include in the information A) plan to sit in a straight backed chair when out of bed B) place a pillow between your legs when lying in bed C) You can cross your legs at the ankles when sitting D) You should bend at the waist when tying your shoes
B) place a pillow between your legs when lying in bed Place an abductor pillow between the legs to prevent adduction of the hip and possible dislocation
A nurse is teaching a young client how to perform testicular self-examination. Which of the following instructions should the nurse include? A) Compare both testicles by examining them simultaneously. B) roll each testicle between the thumb and fingers C) Perform testicular self-examination before a warm bath or shower D) Perform self-examination of the testicles every 2 weeks
B) roll each testicle between the thumb and fingers The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle.
A nurse is teaching a client who asks about taking a glucosamine supplement for osteoarthritis. Which of the following information should the nurse include in the teaching? A) Avoid using glucosamine with chondroitin B) Glucosamine can cause degradation of cartilage when used over a long time C) Avoid taking Glucosamine if you have an allergy to shellfish D) You can take glucosamine when an anticoagulant medication
C) Avoid taking Glucosamine if you have an allergy to shellfish The client should avoid taking glucosamine if they have a shellfish allergy because this medication is made from the exoskeletons of shellfish, such as shrimp.
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? A) restlessness B) T3 level 215 C) Blood pressure 170/80 D) Decreased weight
C) Blood pressure 170/80 Using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170, which indicates that the client is at risk for thyroid storm
A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of this medication A) Ginkgo Biloba B) Glucosamine C) Calcium D) Vitamin C
C) Calcium Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hours of levothyroxine administration
A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A) I should avoid walking as much as possible B) I should sit down and read for several hours a day C) I will wear clean graduated compression socks everyday D) I will keep my legs level with my body when I sleep at night
C) I will wear clean graduated compression socks everyday The client should apply clean compression socks each day and clean the socks with a mild detergent and warm water by hand
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take> A) Monitor the clients INR daily B) Expel air bubbles when using a prefilled syringe C) Inject the medication into the anterolateral abdominal wall D) massage the injection site after administration
C) Inject the medication into the anterolateral abdominal wall The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation
A nurse in a providers office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client manifestations interacts with feverfew? A) Metoprolol B) Bupropion C) Naproxen D) Atorvastatin
C) Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding
A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an ASE of the medication A) Bradycardia B) Tremors C) Orthostatic hypotension D) Drowsiness
C) Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an ASE of enalapril
A nurse is planning to provide discharge teaching for the family of an older client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? A) Keep the clients personal care items in the bathroom B) Keep the overhead lights on in the clients bedroom while the client is sleeping C) Remind the client to scan their complete range of vision during ambulation D) Secure the clients extension cords under carpeting.
C) Remind the client to scan their complete range of vision during ambulation The nurse should instruct the family to remind the client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help reduce the risk for falls.
A nurse is assessing a client following administration of magnesium sulfate 1 g IV bolus. For which of the following ASE should the nurse monitor? A) hyperreflexia B) Increased B/P C) Respiratory paralysis D) Tachycardia
C) Respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the ASE can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening ASE of magnesium sulfate.
A nurse is caring for a client who has a close head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing ICP? SATA A) Flat jugular veins B) A Glasgow coma scale score of 15 C) Sleepiness exhibited by the client D) Widening pulse pressure E) decerebrate posturing
C) Sleepiness exhibited by the client D) Widening pulse pressure E) decerebrate posturing Sleepiness or difficulty arousing the client from sleep is and indication of ICP A widening pulse pressure is an indication of ICP Both decerebrate and decorticate posturing indicate ICP
A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurses priority? A) anorexia B) Abdominal pain radiating to the right shoulder C) Tachycardia D) Rebound abdominal tenderness
C) Tachycardia When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock.
A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurses priority? A) Loosen the clothing around the clients neck B) Check the clients pupillary response C) Turn the client to the side D) move furniture away from the client
C) Turn the client to the side The greatest risk to the client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration
A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? A) WBC count of 6000 B) BMI 24 C) Urine output 25ml/hr D) Albumin 4g/dl
C) Urine output 25ml/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the plan of care? A) Collect and place the clients urine or feces in a biohazard bag B) Limit the clients ambulation to their own room C) Wear a lead apron while providing care to the client D) Limit each visitor to 1 hour per day
C) Wear a lead apron while providing care to the client The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish ureterostomy. Which of the following statements should the nurse include in the teaching? A) You will still have the urge to void B) You can apply an aspirin tablet in the pouch to reduce the odor C) You should cut the opening of the skin barrier one eighth inch wider than the stoma D) You should use a moisturizing soap when washing the skin around the stoma
C) You should cut the opening of the skin barrier one eighth inch wider than the stoma The client should cut the opening of the skin barrier 0.3 cm wider than the stoma to minimize irritation of the skin from exposure to urine.
A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? A) It is an expected effect to sleep through the day when taking this medication B) your constipation will be lessened as you develop a tolerance to this medication C) You should void Q4 hours to decrease the risk of urinary retention D) If you experience ringing in your ears, your dose will need to be reduced
C) You should void Q4 hours to decrease the risk of urinary retention The nurse should instruct the client to void at least Q4 to decrease the risk of urinary retention, which is an ASE of opioid analgesics.
A nurse is providing preop teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? A) Teach the importance of a clear liquid diet after discharge B) tell the client to remove the incisional adhesive strips 3 days after discharge C) demonstrate ways to deep breathe and cough D) instruct the client to maintain bed rest for 48 hours
C) demonstrate ways to deep breathe and cough The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high pressure alarm is sounds. Which of the following actions should the nurse take first? A) Obtain ABGs B) Administer propofol to the client C) instruct the client to allow the machine to breathe for them D) disconnect the machine and manually ventilate the client
C) instruct the client to allow the machine to breathe for them When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator"
A nurse is caring for a client who is 12 hours postop following a total hip arthroplasty. Which of the following actions should the nurse take? A) Maintain adduction of the clients legs B) Encourage ROM of the hip up to 120 degrees C) place a pillow between the clients legs D) keep the clients hip internally rotated.
C) place a pillow between the clients legs The nurse should place a pillow between the clients legs to prevent hip dislocation
A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for CKD. Which of the following interventions should the nurse include in the plan? A) Remind the client that dialysis treatments are not difficult to incorporate into daily life B) inform the client that dialysis will result in a cure C) tell the client that it is possible to return to similar previous levels of activity D) begin health promotion teaching during the first dialysis treatment.
C) tell the client that it is possible to return to similar previous levels of activity The nurse should help the client develop realistic goals and activities to have a productive life
A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take? A) Apply a wet-to-dry dressing B) irrigate with hydrogen peroxide solution C) use a 30-mL syringe D) attach a 24 gauge Angio catheter to the syringe
C) use a 30-mL syringe The nurse should use a 30mL to 60mL syringe with an 18 or 19 gauge catheter to deliver the ideal pressure of 8LBs per square inch when irrigating a wound.
A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change? A) A client who has type 1 DM and is starting to self monitor blood glucose B) A client who had a cholecystectomy and is starting on a modified fat diet C) A client who has Crohn's disease and is experiencing diarrhea 3x a day D) A client who has multiple sclerosis and is experiencing progressive difficulty ambulating
D) A client who has multiple sclerosis and is experiencing progressive difficulty ambulating The nurse should identify that progression of a neurologic disease such as MS can lead to a role change as the client becomes less independent.
A nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A) Apply ice to the puncture wounds B) Initiate corticosteroid therapy C) Keep the clients leg above heart level D) Administer an opioid analgesic to the client
D) Administer an opioid analgesic to the client To promote comfort following a rattlesnake bite
A nurse in an ICU is assessing a client who has a TBI. Which of the following findings should the nurse identify as a component of Cushing's triad? A) Hypotension B) Tachypnea C) Nuchal rigidity D) Bradycardia
D) Bradycardia A client who has ICP from a TBI can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following lab results to be below expected reference range? A) Amylase B) Alkaline phosphatase C) Bilirubin D) Calcium
D) Calcium A client who has pancreatitis is expected to have a decreased calcium and magnesium levels due to fat necrosis
A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first? A) Place the client in a supine position B) measure vitals C) cover the would with a sterile, saline moistened dressing D) Call for help
D) Call for help Evidence based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance.
A nurse is caring for a client who has visual loss. Which of the following actions should the nurse implement? A) Remove all objects from the clients bedside table B) Instruct the client to open items on the food tray C) Walk a step behind the client when assisting with ambulation D) Count steps to the bathroom with the client
D) Count steps to the bathroom with the client Reduces the risks for falls
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A) Decreased T cells B) Increased creatinine clearance C) Increased eosinophils D) Decreased viral load
D) Decreased viral load Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hours prior to cardioversion? A) Enoxaparin B) Metformin C) Diazepam D) Digoxin
D) Digoxin Cardiac glycosides such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? A0 Place a padded tongue blade at the clients bedside B) Keep the side rails lowered on the clients bed C) Maintain the clients bed at hip level or above D) Ensure that the client has a patent IV
D) Ensure that the client has a patent IV The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.
A nurse is caring for a client who is postop following a total hip arthroplasty. Which of the following lab values should the nurse report to the provider? A) Potassium 4meq B) WBC count 10,000 C) HCT 45% D) Hgb 8g/dl
D) Hgb 8g/dl The nurse should report a Hgb level of 8 which is below the expected reference range and is an indicatory of postop hemorrhage or anemia
A nurse is caring for a client who has a potassium level of 3. Which of the following assessment findings should the nurse expect? A) Positive Trousseau's sign B) 4+ deep tendon reflexes C) Deep respirations D) Hypoactive bowel sounds.
D) Hypoactive bowel sounds. Hypokalemia decreases smooth muscle contraction in the GI tract leading to decreased peristalsis
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A) Insert a padded tongue blade B) Apply oxygen C) Restrain the client D) Loosen restrictive clothing
D) Loosen restrictive clothing The nurse should loosen tight, restrictive clothing to prevent injury and suffocation
A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first? A) Obtain a prescription for ABGs B) Administer IV ATB C) Instruct the client to use the incentive spirometer D) Place the client in high fowlers
D) Place the client in high fowlers The greatest risk to this client is injury from airway obstruction. therefore, the priority intervention the nurse should take is to move the client in to high fowlers position. High fowlers position facilitates lung expansion and improves ventilation and gas exchange.
A nurse is providing teaching to a client who has gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? A) Neutralizing gastric acid B) reducing the growth of ulcer causing bacteria C) Coating the stomach lining D) Suppressing gastric acid production
D) Suppressing gastric acid production omeprazole is a PPI. It relieves manifestations of gastric ulcers by suppressing gastric acid production
A nurse is providing discharge instructions to a client who has a partial thickness burn on the hand. Which of the following instructions should the nurse include? A) Change the dressing Q72 hours B) Immobilize the hand with a pressure dressing C) take pain medication 30 minutes after changing the dressing D) Wrap the fingers with individual dressings
D) Wrap the fingers with individual dressings The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to preform ROM exercises to each finger Q hour while awake to promote function of the injured hand.
A nurse in a providers office is caring for a client who requests sildenafil to treat ED. Which of the following statements should the nurse make? A) You might need to take a stool softener while taking this med B)You will not be able to use this med if you have DM C) You will need to limit your caffeine intake if you start taking this med D) You will not be able to use sildenafil if you are taking nitroglycerin
D) You will not be able to use sildenafil if you are taking nitroglycerin The client use not use sildenafil when taking nitro because both meds cause vasodilation and can lead to significant hypotension
A nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease. The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should this nurse plan to administer? A) Epoetin Alfa B) lasix C) Captopril D) calcium carbonate
D) calcium carbonate Hypocalcemia is a manifestation of ESKD and an ASE of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement such as calcium carbonate as a calcium replacement.
A nurse is caring for a client who has anorexia, a low grade fever, night sweats and a productive cough. Which of the following actions should the nurse take first? A) Obtain a sputum sample B) Administer antipyretics C) provide hand hygiene education D) initiate airborne precautions
D) initiate airborne precautions This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.
A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? A) Check lab values for recent H&H levels B) Establish a peripheral IV line for possible transfusion C) call the lab to obtain a stat platelet count D) obtain vital signs.
D) obtain vital signs. The first action the nurse should take using the nursing process is to assess the clients vital signs. A client who has a portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vitals provides information about the clients condition that can contribute to decision making
A nurse is providing teaching to a female client who has a history of UTI. Which of the following information should the nurse include in the teaching? A) Avoid foods that are high in ascorbic acid B) Add oatmeal to the water when taking a bath C) urinate Q6 hours D) take cranberry supplements.
D) take cranberry supplements. The client should take cranberry supplements or drink low fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI
A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching?> A) Take tub baths daily B) Drink at least 1L of fluid a day C) Wear underwear made of nylon D) void before and after intercourse
D) void before and after intercourse The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents occurrence of infection.
