Medical Surgical Assessment A

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all) A) "I should expect to feel sleepy after using my albuterol inhaler." B) "I never forget to rinse my mouth after using my budesonide inhaler." C) "Between office visits, I keep a record of how many times I use my albuterol inhaler." D) "I use my albuterol inhaler before I go swimming." E) "I should use my budesonide inhaler before using my albuterol inhaler."

"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming."

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero is it applies. Do not use a trailing zero.

7mg/10 mg *1mL= 0.7 mL

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (Hotspots A,B,C,D)

C is correct. The nurse should identify that the V1 electrode should be placed in the 4th intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart.

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? A) Blurred vision B) Insomnia C) Bradycardia D) Weight loss

C) Bradycardia The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

The first action the nurse should take using the nursing process is to check the IV site for infiltration. If infiltration is found, the next step is to stop the infusion to prevent vein and tissue damage. Once the infusion is stopped, the nurse should remove the IV catheter. Then, the nurse should elevate the affected extremity to decrease swelling and notify the charge nurse. 1. Check IV site 2. Stop the infusion 3. Withdraw the IV catheter 4. Elevate the affected arm 5. Notify the charge nurse

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? A) "I should wait at least 2 hours after eating before going to bed." B) "I should eat three meals a day without eating snacks between meals." C) "I should season my food with garlic." D) "I should drink my liquids through a straw."

A) "I should wait at least 2 hours after eating before going to bed." The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? A) "This type of insulin should be given at the same time everyday" B) "This insulin can be mixed with short-acting insulin in a single syringe" C) "This type of insulin can be used in a pump" D) "This insulin has an increased risk for hypoglycemia"

A) "This type of insulin should be given at the same time everyday" Insulin glargine is released in the body over a 24 hr period. The nurse should instruct the client to administer the insulin at the same time each day to maintain consistent serum levels for optimal therapeutic effect.

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next? A) Administer epinephrine. B) Monitor the client's vital signs. C) Monitor the client's oxygen saturation level. D) Administer an antihistamine.

A) Administer epinephrine. The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? A) Allow for 30 min of rest before meals B) Provide a straw for drinking liquids C) Serve foods at room temperature D) Place 2 tsp of food in the client's mouth at a time

A) Allow for 30 min of rest before meals The nurse should allow the client to rest for 30 min before meals to prevent aspiration.

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? A) Apply a mask on the client if transport is needed B) Wear a mask when working within 4 feet of the client C) Don a gown when visiting the client D) Wear a N95 mask when entering the client's room

A) Apply a mask on the client if transport is needed The nurse should apply a mask to the client who has manifestations of pertussis during transport to prevent exposure to others.

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching? A) Apply cold packs to the inflamed joints B) Participate in high impact exercise C) Carry a hand purse rather than a shoulder bag D) Sleep on a soft foam mattress

A) Apply cold packs to the inflamed joints The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain.

A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching? A) Avoid liquids at mealtimes B) Exclude eating starchy vegetables C) Avoid eating high-protein meals D) Plan to increase intake of sweetened fruits

A) Avoid liquids at mealtimes The nurse should remind the client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? A) Ceftriaxone B) Diltiazem C) Pioglitazone D) Hydrocodone 5 mg/acetaminophen 500 mg

A) Ceftriaxone Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription.

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? A) Determine the client's daily elimination habits. B) Administer a suppository to the client 30 min prior to defecation time. C) Offer the client 4 oz of warm prune juice to promote elimination. D) Provide dietary bulk to the client to ease the passage of stool.

A) Determine the client's daily elimination habits. The first action the nurse should take using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? A) Determine the client's understanding of the procedure. B) Encourage the client to express his feelings. C) Allow the client's family to stay with him. D) Provide music as a distraction.

A) Determine the client's understanding of the procedure. Using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to provide necessary teaching, which can help manage his anxiety.

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan? A) Encourage abdominal breathing B) Direct the client to inhale with pursed lips C) Set the oxygen therapy at 5L/min D) Instruct the client to lean back while coughing

A) Encourage abdominal breathing The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes.

A nurse is preparing to auscultate bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? A) Hyperactive bowel sounds B) Friction rub C) Normal bowel sounds D) Abdominal bruit

A) Hyperactive bowel sounds A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward.

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching? A) Increase intake of fiber-rich foods B) Take a laxative every morning C) Maintain a fluid intake of 1200 mL per day D) Limit activity to preserve energy

A) Increase intake of fiber-rich foods The nurse should instruct the client to increase the amount of fiber-rich foods in his diet. Dried beans and brown rice are examples of fiber-rich foods.

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? A) Keep the skin dry and free of perspiration. B) Use hot water and antibacterial soap to bathe the client. C) Massage the skin over bony prominences to promote circulation. D) Limit the use of moisturizers on the skin over bony prominences.

A) Keep the skin dry and free of perspiration. The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take? A) Minimize the time the head of the bed is elevated. B) Apply a sterile gauze dressing to the site. C) Massage the site with moisturizing lotion. D) Place a donut-shaped cushion under the client's sacral area.

A) Minimize the time the head of the bed is elevated. The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching? A) Mohs surgery is a horizontal shaving of thin layers of the tumor. B) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue. C) Mohs surgery is the preferred treatment for melanoma skin cancer. D) Mohs surgery is a palliative treatment for metastatic skin cancer.

A) Mohs surgery is a horizontal shaving of thin layers of the tumor. Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high treatment rate.

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all) A) Monitor the insertion site for bleeding B) Position the affected extremity at a 45 degree angle C) Restrict the client's fluid intake D) Maintain the pressure dressing E) Check the client's peripheral pulses

A) Monitor the insertion site for bleeding The nurse should monitor the client's insertion site for manifestations of hemorrhaging. D) Maintain the pressure dressing. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. E) Check the client's peripheral pulses. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider? A) Onset of nausea B) Increased urinary output C) Weight loss of 0.9 kg (2 lb) per week D) Missed dose of the medication

A) Onset of nausea The nurse should instruct the client to report a new onset of nausea, which can be an indication of hyponatremia or hypokalemia resulting from the diuretic effects of the hydrochlorothiazide.

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take? A) Perform pin site care daily B) Remove the overbed trapeze C) Remove the boot every 2 hr D) Keep the weights on a stable, flat surface

A) Perform pin site care daily The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take? A) Position pillows between the bony prominences B) Check for incontinence every 3 hr C) Massage reddened areas of the skin D) Elevate the head of the bed to 45 degrees

A) Position pillows between the bony prominences The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure ulcer development.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take with communicating with the client? A) Rephrase client instructions when not understood B) Cup hands around the mouth and direct speech toward the client C) Accentuate vowel sounds by using a higher pitch when speaking D) Sit to the side of the client and speak instructions into her best eat

A) Rephrase client instructions when not understood When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? A) Stop the medication infusion B) Notify the charge nurse C) Administer a PRN dose of diphenhydramine D) Follow facility policy for appropriate reporting of the adverse reaction

A) Stop the medication infusion The greatest risk to the client is injury from an allergic response to the medication. Therefore, the priority action the nurse should take is to stop the medication infusion.

A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy? A) Thrombophlebitis B) Infiltration C) Hematoma D) Venous spasms

A) Thrombophlebitis The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis.

A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider? A) Urinary retention B) Administration of celecoxib 24 hr ago C) History of immunosuppression D) Administration of levothyroxine 12 hr ago

A) Urinary retention The nurse should recognize that administering morphine to the client can cause urinary retention. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisone orally. Which of the following statements should the nurse include in the teaching? A) "Take the medication on an empty stomach" B) "Limit contact with large groups of people" C) "Avoid taking over-the-counter calcium supplements" D) "Follow a low-protein diet"

B) "Limit contact with large groups of people" Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? A) Polyuria B) Abdominal cramps C) Renal insufficiency D) Insomnia

B) Abdominal cramps Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? A) Consume a low-purine diet. B) Avoid stopping this medication suddenly. C) Use chamomile tea to alleviate insomnia. D) Take this medication on an empty stomach.

B) Avoid stopping this medication suddenly. The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? A) Muscle weakness B) Dysrhythmia C) Abdominal pain D) Lethargy

B) Dysrhythmia When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia.

A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group? A) Meningococcal B) Herpes zoster C) Human papillomavirus (HPV) D) Measles, mumps, and rubella (MMR)

B) Herpes zoster The nurse should recommend the herpes zoster immunization for adults 60 years of age and older.

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective? A) BUN 40 mg/dL B) Hgb 11 g/dL C) Urine specific gravity 1.035 D) Blood glucose 105 mg/dL

B) Hgb 11 g/dL Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective.

A nurse is collecting data from a 55 yr old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? A) 5 yr history of menopause manifestations B) History of treatment for blood clots C) Topiramate use for migraine headaches D) Increased serum cholesterol levels

B) History of treatment for blood clots Estrogen increases the risk of blood clots. Therefore, a woman who has a history of blood clots should not receive HRT.

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? A) Use a commercial mouthwash before taking the medication. B) Instruct the client to swish the medication in her mouth. C) Discontinue the medication as soon as the lesions are healed. D) Combine the medication with applesauce.

B) Instruct the client to swish the medication in her mouth. The nurse should instruct the client to place half the dose in each side of her mouth, swish the medication, and then swallow. This action will allow the medication to coat the entire oral mucosa and treat the fungal infection.

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? A) Store the CPM machine on the floor when it is not in use B) Keep a sheepskin pad between the client's extremity and the CPM C) Check the cycle and range-of-motion settings at least every 12 hr D) Align the frame joint of the CPM with the middle of the client's calf

B) Keep a sheepskin pad between the client's extremity and the CPM The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM.

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? A) Gown B) Mask C) Sterile gloves D) Protective eyewear

B) Mask The nurse should identify that a client who has Meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 3 feet of the client.

A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? A) Administer doxazosin. B) Palpate the abdomen. C) Insert an indwelling urinary catheter. D) Notify the primary care provider.

B) Palpate the abdomen. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing? A) HbA1c 6% B) Prealbumin 12 mg/dL C) WBC 8,000/mm3 D) Creatinine 0.8 mg/dL

B) Prealbumin 12 mg/dL This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications? A) Wound infection B) Pulmonary embolism C) Thrombophlebitis D) Paralytic ileus

B) Pulmonary embolism Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.

A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? A) Place the client on a low-calorie diet to prevent weight gain B) Remind the client to avoid watching her feet when walking C) use small area rugs in the client's home for traction D Instruct the client to take tub baths instead of showers

B) Remind the client to avoid watching her feet when walking The nurse should instruct the client's family to frequently remind the client to maintain correct posture and prevent falls by not watching her feet when walking.

Following a blood draw for fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take? A) Offer the client breakfast then repeat the FBS request. B) Reschedule the FBS test for early the next morning. C) Request that the phlebotomist obtain another specimen. D) Ask the laboratory technician to repeat the test on the same specimen.

B) Reschedule the FBS test for early the next morning. An FBS test requires the client to have no food or juice for at least 8 hr. The result of the FBS test would be invalid because the client drank juice during the fasting time period. The nurse should reinforce with the client to only drink water and have no food or other beverages for 8 hr before the phlebotomist obtains the blood specimen.

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? A) The client asks questions each time the nurse stops talking. B) The client stops the nurse and asks for pain medication. C) While the nurse is speaking, the client refers to the written materials. D) A family member who is present asks the client to repeat important points.

B) The client stops the nurse and asks for pain medication. The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with his ability to learn.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? A) Visitors should call prior to visiting the client. B) Visitors must don a gown and gloves prior to entering the client's room. C) Visitors need to wear a mask when in close proximity to the client. D) Visitors may not bring fresh flowers into the client's room.

B) Visitors must don a gown and gloves prior to entering the client's room. The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRSA to prevent the spread of infection.

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? A) "You may cross your legs in 60 days" B) "Avoid lying on your operative side" C) "Avoid bending your hips more than 90 degrees" D) You may sleep on a soft mattress"

C) "Avoid bending your hips more than 90 degrees" The nurse should instruct the client to avoid bending her hips more than 90° to prevent dislocation of the replacement hip.

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching? A) "I will perform the exam before I shower" B) "I will check my testicles every 6 months" C) "I understand that testicular cancer is painless" D) "I understand that pea-sized lumps are normal"

C) "I understand that testicular cancer is painless" Clients should report a lump that is not painful because testicular cancer is typically painless.

A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching? A) "The HbA1c test should be performed 2 hr after I eat a meal that is high in carbohydrates" B) "The HbA1c test can help detect the presence of ketones in my body" C) "I will have my HbA1c checked twice per year" D) "I will plan to fast before I have my HbA1c tested"

C) "I will have my HbA1c checked twice per year" An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have her HbA1c tested twice yearly to manage her glucose.

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? A) "Your partner will not require treatment for this infection" B) "You can resume sexual activity as soon as you begin treatment" C) "You are at risk for infertility with this infection, regardless of treatment" D) "You will not be at further risk for this infection following treatment"

C) "You are at risk for infertility with this infection, regardless of treatment" The nurse should inform the client that there is a risk for infertility as a result of this infection.

A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching? A) Clean the pin sites every 72 hr B) Use the halo ring to reposition the client when in bed C) Change the sheepskin liner weekly D) Tighten the traction bar as needed

C) Change the sheepskin liner weekly The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner when soiled, or at least once per week, to prevent skin irritation.

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? A) Intrauterine device B) Latex condom C) Combination oral contraceptives D) Contraceptive sponge

C) Combination oral contraceptives The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells.

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? A) Sodium 136 mEq/L B) Potassium 4.8 mEq/L C) Creatinine 1.9 mg/dL D) Calcium 10 mg/dL

C) Creatinine 1.9 mg/dL Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.

A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include? A) Place moist heat pads on the extremities. B) Perform manual massage of the affected extremities. C) Dangle the extremities off the side of the bed. D) Apply support stockings before getting out of bed.

C) Dangle the extremities off the side of the bed. The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include? A) "You can take acetaminophen for pain" B) "Consume a diet high in animal protein" C) "Sleep lying flat on your back" D) "Consume foods low in sodium"

D) "Consume foods low in sodium" The nurse should instruct the client to consume foods low in sodium to reduce the development of edema and ascites.

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? A) Apply hot packs to the client's muscles B) Schedule physical therapy in the afternoon C) Encourage the client to complete ADLs D) Administer valerian to promote sleep

C) Encourage the client to complete ADLs The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications? A) Offer sips of water to the client following oral care. B) Massage the client's lower extremities with lotion every 2 hr. C) Encourage the client to use an incentive spirometer every hour while awake. D) Place one or two pillows beneath the client's knees while he is in bed.

C) Encourage the client to use an incentive spirometer every hour while awake. The nurse should assist the client to use the incentive spirometer in addition to coughing and deep breathing every hour while awake for the first 24 hr postoperatively and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first? A) Collect a sputum culture B) Administer ceftriaxone by intermittent IV bolus C) Initiate oxygen at 4 L/min via nasal cannula D) Obtain blood cultures

C) Initiate oxygen at 4 L/min via nasal cannula When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? A) Cirrhosis of the liver B) Hypermotility of the bowel C) Intra-abdominal bleeding D) Acute cholecystitis

C) Intra-abdominal bleeding Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? A) Scaly patches B) Silvery white plaques C) Irregular borders D) Raised edges

C) Irregular borders The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority? A) Encourage the client to participate in self-care B) Assist the client with active range-of-motion exercises C) Keep the client in a side-lying position D) Maintain the client's body alignment

C) Keep the client in a side-lying position The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying position, which will allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction available in the event that any secretions are present in the oral cavity.

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? A) Get out of bed if unable to fall asleep within 60 min. B) Take a brisk walk before sleeping. C) Listen to soft music before sleeping. D) Drink adequate amounts of fluids before sleeping.

C) Listen to soft music before sleeping. Listening to soft music can help the client to relax and reduces environmental stressors.

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take? A) Use a traction boot to keep the client's right leg internally rotated. B) Have the client sit in a reclining chair when out of bed. C) Maintain abduction of the client's right leg while in bed. D) Encourage the client to perform passive range-of-motion exercises.

C) Maintain abduction of the client's right leg while in bed. The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? A) Expect decreased sensation for the first postoperative week. B) Avoid lying on the operative side. C) Obtain a raised toilet seat. D) Cross legs at the ankles.

C) Obtain a raised toilet seat. The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.

A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals? A) Butter B) Coconut Oil C) Olive Oil D) Shortening

C) Olive Oil The nurse should instruct the client who has cardiovascular disease to consume foods which contain primarily monounsaturated and polyunsaturated fats, such as olive oil or other vegetable oils, rather than foods that are high in saturated fat. The nurse should reinforce that oils high in monounsaturated fats help decrease the client's cardiovascular risk by lowering LDL cholesterol and triglyceride levels.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first? A) Collaborate with a dietitian. B) Provide nutritional supplements. C) Recommend a referral for a speech language pathologist. D) Inform assistive personnel about proper positioning.

C) Recommend a referral for a speech language pathologist. The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids.

A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect? A) Flaccid neck B) Stooped posture with shuffling gait C) Red macular rash D) Masklike facial expression

C) Red macular rash The nurse should expect to find a red macular rash, sometimes called a petechial rash, which is a manifestation of meningococcal meningitis.

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first? A) Count the client's respiratory rate B) Ask the client if chest pain is present C) Stop the infusion D) Administer an antihistamine

C) Stop the infusion Evidence-based practice indicates the nurse should stop the infusion of the blood product as soon as manifestations occur because they can indicate a transfusion reaction.

A nurse is preparing to suction a client who has tracheostomy. Which of the following actions should the nurse take first? A) Insert the suction catheter into the tracheostomy. B) Rinse the catheter with sterile 0.9% sodium chloride. C) Ventilate with 100% oxygen. D) Occlude the vent on the catheter for 10 seconds.

C) Ventilate with 100% oxygen.

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions? A) "I apply rubbing alcohol to my feet every day to prevent infection" B) "I will wear clean, knee-high wool socks everyday to help improve my circulation" C) "I use hot water bottles to keep my feet warm at night" D) "I don't cross my legs anymore"

D) "I don't cross my legs anymore" Clients who have peripheral vascular disease should not cross their legs because it can impede circulation.

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process? A) "I should call my doctor if I get a headache" B) "I may develop gastric reflux" C) "I may develop excessive bruising" D) "I should call my doctor if my ankles swell"

D) "I should call my doctor if my ankles swell" Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? A) "Can I get you something for the pain?" B) "You should talk about this with your family." C) "Tomorrow will be a better day." D) "Tell me more about the way you are feeling."

D) "Tell me more about the way you are feeling." The nurse is establishing a trusting relationship by seeking clarification and encouraging the client to verbalize feelings.

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include? A) "You should have a screening for glaucoma every 5 years" B) "You should have a physical examination every other year" C) "You should have your hearing checked every 2 years" D) "You should have a pneumococcal immunization every 10 years"

D) "You should have a pneumococcal immunization every 10 years" The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect her from acquiring pneumonia.

A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure? A) Albumin B) Phosphorus C) TSH D) BUN

D) BUN BUN levels indicate kidney function. Contrast media used during cardiac catheterization can cause renal failure. The nurse should review this laboratory level to determine if the client can tolerate the IV contrast dye during the procedure.

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia? A) Polyuria B) Constipation C) Anorexia D) Bradycardia

D) Bradycardia The client who has hyperkalemia can have an irregular, slow heart rate, known as bradycardia.

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? A) Increased weight B) Increased heart rate C) Decreased urinary output D) Decreased shortness of breath

D) Decreased shortness of breath The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? A) Reduces bacteria in the urinary tract B) Suppresses urge to void C) Prevents nerve stimulation to the bladder muscle D) Decreases pain during urination

D) Decreases pain during urination Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? A) Restrict the time pregnant women are allowed in the client's room to 15 min B) Pick up a radiation implant with a double-gloved hand if it becomes dislodged C) Limit time spent in the client's room to 2 hr during an 8 hr shift D) Dispose of radiation implants in a lead container

D) Dispose of radiation implants in a lead container Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? A) Pruritus B) Nausea C) Urinary retention D) Dyspnea

D) Dyspnea When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion.

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? A) Drink water before and after each bite. B) Consume foods that are served hot rather than cold. C) Rinse with a glycerin-based mouthwash before meals. D) Eat several, small-portioned meals daily.

D) Eat several, small-portioned meals daily. Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake.

A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss? A) Increase fluid intake B) Encourage range of motion exercises C) Massage bony prominences D) Encourage weight-bearing exercises

D) Encourage weight-bearing exercises Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? A) Provide small, frequent meals. B) Tell the client to extend his neck when swallowing. C) Provide mouth care before meals. D) Give the client liquids with increased viscosity.

D) Give the client liquids with increased viscosity. Thickened liquids are easier for the client to swallow and can prevent aspiration.

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? A) Keep the door of the client's room closed at all times. B) Remove gloves after leaving the client's room. C) Wear a mask when working within 1 m (3 feet) of the client. D) Have a designated stethoscope in the client's room.

D) Have a designated stethoscope in the client's room. The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room.

A nurse is monitoring a client who recently has a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal? A) Report of a dull, throbbing pain B) Extremities that are cool bilaterally C) Capillary refill of 3 seconds in the nail beds of the toes D) Lack of sensation between the first and second toes

D) Lack of sensation between the first and second toes Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. The nurse should notify the provider immediately.

A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend? A) Ketchup B) Mayonnaise C) Soy sauce D) Lemon juice

D) Lemon juice The nurse should recommend that the client use lemon juice to flavor his food because it is low in sodium.

A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A) Lower the side rails of the client's bed B) Apply wrist restraints to the client C) Position the client in the semi-Fowler's position D) Loosen clothing around the client's neck

D) Loosen clothing around the client's neck The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration? A) Instill 10mL of air through the NG tube B) Place the client in supine position C) Irrigate the NG tube D) Pinch the NG tube

D) Pinch the NG tube The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching? A) Administer an analgesic following wound care. B) Irrigate the wound with povidone iodine. C) Cleanse the wound with a cotton-tipped applicator. D) Report purulent drainage to the provider.

D) Report purulent drainage to the provider. The nurse should remind the family member to report signs of infection, including purulent drainage.

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction? A) Halitosis B) Hemorrhoids C) Rebound tenderness D) Small liquid stools

D) Small liquid stools Small liquid stools can be the result of fecal material being expelled around an impaction.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Elevated sodium Elevated blood pressure Decreased potassium Decreased urine output

Decreased potassium The nurse should notify the provider immediately of a decreased potassium level because potassium is lost when a diuretic such as furosemide is administered, which can cause hypokalemia.