medical-surgical textbook practice questions

what mechanism of injury will the nurse document for a client in a motor vehicle accident whose airbag deployed when the car struck a tree at 40 miles per hour? (select all that apply) a. blast b. blunt c. laceration d. penetration e. acceleration-deceleration

b. blunt e. acceleration-deceleration

Which assessment data is the most relevant for the nurse to obtain from a client who has a serum potassium level of 2.9 mEq/L? a. asking about the use of sugar substitutes b. determining what drugs are taken daily c. measuring the client's response to Chvostek testing d. asking about a history of kidney disease

b. determining what drugs are taken daily

A nurse assures a client experiencing abdominal surgical pain that comfort measures, including drug therapy, will be provided as the client needs them. Which ethical principles apply in the situation? Select all that apply. A. Beneficence B. Social justice C. Autonomy D. Fidelity E. Veracity

A. Beneficence D. Fidelity E. Veracity

Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's wort

D. St. John's wort

Which electrolytes are most detrimentally affected by low magnesium levels? (Select all that apply) a. calcium b. chloride c. hydrogen d. potassium e. sodium f. sulfate

a. calcium d. potassium

The white blood cell count with differential of a client undergoing preadmission testing before surgery indicates a total count of 5000 cells per cubic millimeter of blood. Which of the following differential counts or percentages does the nurse report to the surgeon to prevent harm? a. eosinophils 300/mm3 b. monocytes 600/mm3 c. segmented neutrophils 2000/mm3 d. lymphocytes 2100/mm3

c. segmented neutrophils 2000/mm3

an older adult client receiving an infusion of 5% dextrose in NS at 150 mL/hr has developed shortness of breath with a decrease in oxygen saturation to 86%. What is the priority nursing intervention? a. notify the health care provider b. place the client on oxygen c. sit the client upright in bed d. assess the client's lung sounds

c. sit the client upright in bed

With which client does the nurse remain alert for and assess most frequent for signs and symptoms of hypokalemia to prevent harm? a. 72 year old taking the diuretic spironolactone for control of hypertension b. 62 year old receiving an IV solution of Ringer's lactate at a rate of 200 mL/hr c. 42 year old trauma victim receiving a third infusion of packed red blood cells in 12 hours d. 22 year old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

d. 22 year old receiving an IV infusion of regular insulin to manage an episode of ketoacidosis

which client does the oncoming ED nurse see first when assigned to care for 4 clients? a. 21 year old with a skin rash who has been waiting 2 hours to see a provider b. 30 year old with influenza who has infusing IV fluids and is resting quietly c. 47 year old who fell off of a curb, resulting in a sprained ankle d. 56 year old reporting chest pain and diaphoresis that started 30 minutes prior

d. 56 year old reporting chest pain and diaphoresis that started 30 minutes prior

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? (Select all that apply) a. Dementia b. Relocation stress c. Urinary incontinence d. Presbyopia e. Obesity

d. Presbyopia

Which change would the nurse expect to see in the white blood cell differential of a client who has a prolonged, severe intestinal helminth infestation? a. band neutrophils outnumber segmented neutrophils b. macrophage count is low c. monocyte count is high d. eosinophil count is high

d. eosinophil count is high

A client had a left noncemented posterolateral total hip arthroplasty 2 days ago. Which statements will the nurse include in health teaching for the client? Select all that apply. A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." C. "Be sure to cross your legs to be more comfortable in a chair." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

A. "Practice leg exercises each day as instructed." B. "Take deep breaths and use incentive spirometry every 2 hours." D. "Report sudden increased hip pain or rotation immediately to the nurse." E. "Stand on your right leg and pivot into the chair when getting out of bed."

In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

A. Blood pressure of 142/90 mm Hg

How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.

A. Carbon dioxide loss through exhalation can raise arterial pH levels.

Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood

C. Continuous metabolic production of free hydrogen ions

The family of a client experiencing terminal dehydration requests that intravenous fluids be started. What is the nurse's best response? A. "We can start fluids to help ease the dehydration." B. "Intravenous fluids can increase discomfort for the client." C. "Intravenous fluids will likely prolong life." D. "Terminal dehydration can be managed better with pain medication."

B. "Intravenous fluids can increase discomfort for the client."

The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 a.m. as originally prescribed. B. Adjust the administration time to be given at 10:00 a.m. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B. Adjust the administration time to be given at 10:00 a.m.

Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

B. Binding of the virus to the CD4+ receptor and either of the two co-receptors

On entry to the ED of a client who fell from a roof, what is the nurse's priority action? A. Place nasal cannula to administer oxygen. B. Apply pressure to small bleeding wounds. C. Assess airway and stabilize cervical spine. D. Initiate large-bore IV to infuse normal saline.

C. Assess airway and stabilize cervical spine.

A client had a 20-gauge short peripheral catheter (SPC) inserted for antibiotic administration 48 hours ago. Which nursing intervention is appropriate? A. Discontinue the SPC. B. Relocate the SPC for infection control. C. Assess the SPC for redness, swelling, or pain. D. Change the occlusive dressing covering the SPC.

C. Assess the SPC for redness, swelling, or pain.

The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team

C. Assess the client's oxygen saturation

With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus

C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours

Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane

C. Clipping the newly generated viral proteins into smaller functional pieces

Which new-onset condition or symptom in a client who has systemic lupus erythematosus (SLE) now taking hydroxychloroquine does the nurse deem to have the highest priority for immediate reporting to prevent harm? A. Increased bruising B. Increased daily output of slightly foamy urine C. Failure to see letters in the middle of a word D. Sensation of nausea within an hour of taking the drug

C. Failure to see letters in the middle of a word

In reviewing the electrolytes of a client, the nurse notes the serum potassium level has increased from 4.6 mEq/L (mmol/L) to 6.1 mEq/L (mmol/L). Which assessment does the nurse perform first to prevent harm? A. Deep tendon reflexes B. Oxygen saturation C. Pulse rate and rhythm D. Respiratory rate and depth

C. Pulse rate and rhythm

The client who is confined to bed in the recumbent position has gained 5 lb (2.3 kg) in the past 24 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema? A. Foot and ankle B. Forehead C. Sacrum D. Chest

C. Sacrum

Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; Pao2 92 mm Hg; CO2 41 mm Hg; HCO3 − 28 mEq/L (mmol/L) B. pH 7.46; Pao2 98 mm Hg; CO2 38 mm Hg; HCO3 − 30 mEq/L (mmol/L) C. pH 7.22; Pao2 60 mm Hg; CO2 80 mm Hg; HCO3 − 22 mEq/L (mmol/L) D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)

which assignment will the ED charge nurse make when nurses from within the hospital are floated to the ED to care for clients affected by an earthquake? (select all that apply) a. GI laboratory nurse assigned to clients needing sedation b. psychiatric nurse assigned to care for clients with lacerations c. orthopedic nurse assigned to accompany clients to radiology d. nurse administrator assigned to sit with loved ones in the waiting room e. medical-surgical nurse assigned to health care worker who is feeling overwhelmed

a. GI laboratory nurse assigned to clients needing sedation c. orthopedic nurse assigned to accompany clients to radiology d. nurse administrator assigned to sit with loved ones in the waiting room

The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? (Select all that apply) a. Has prebyopia b. Has peripheral neuropathy c. Uses a cane d. Takes multiple medications e. Has bilateral cateracts f. Has thin papery skin

a. Has prebyopia b. Has peripheral neuropathy c. Uses a cane d. Takes multiple medications e. Has bilateral cateracts

The nurse collaborates with the registered dietitian nutritionist to improve the nutritional status of clients on a hospital unit. Which priority professional nursing concepts apply in this situation? (Select all that apply) a. Quality Improvement b. Ethics c. Health Care Disparities d. Systems thinking e. Teamwork and collaboration

a. Quality Improvement d. Systems thinking e. Teamwork and collaboration

The nurse provides an SBAR hand-off communication regarding a client whose blood pressure and respiratory rate have decreased. Where will the nurse include these data as part of the SBAR format? a. Situation b. Background c. Assessment d. Recommendation

a. Situation

A client who is HIV positive and recieving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? a. abacavir b. darunivir c. tripanavir d. raltegravir

a. abacavir

The nurse is assessing an older adult and notes that the client is at risk for constipation. Which statements will the nurse include in health teaching for this client to promote optimum bowel elimination? Select all that apply a. "Be sure to include plenty of fresh fruits and vegetables in your diet each day" b. "Eat lots of high fiber foods, including whole grains each day" c. "Be sure to take a laxative every day to clean out your bowels and prevent toxins" d. "Exercise several times a week to keep our bowels working for regular elimination" e. "Drink at least 3 caffinated beverages every day to keep your bowels stimulated" f. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom"

a. "Be sure to include plenty of fresh fruits and vegetables in your diet each day" b. "Eat lots of high fiber foods, including whole grains each day" d. "Exercise several times a week to keep our bowels working for regular elimination" f. "Drink plenty of fluids, including water, to prevent having difficulty going to the bathroom"

The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? a. "persistent pain is a warning in my body that alerts the sympathetic nervous system" b. "acute pain has a quick onset and is usually isolated to one area of my body" c. "my frozen shoulder causes musculoskeletal or somatic pain" d. "nociceptive pain follows a noraml and predictable pattern"

a. "persistent pain is a warning in my body that alerts the sympathetic nervous system"

The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday's dosages. What action does the nurse recommend? a. "take today's dosages as normally prescribed and continue to follow your therapy program" b. "don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem" c. "take double doses of the drugs for the next 2 days and do not have sex for at least 4 days" d. "go to the nearest emergency department and have an immediate blood test for assessment of viral load"

a. "take today's dosages as normally prescribed and continue to follow your therapy program"

A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? a. "this is a common side effect of gabapentin and will decrease with use" b. "stop taking the medication and contact the health care provider" c. "the dizziness is caused by the neuropathic pain, not the medication" d. "the dizziness is likely from another medication, not the gabapentin"

a. "this is a common side effect of gabapentin and will decrease with use"

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? (Select all that apply) a. "when I eat shrimp, my tongue swells and I have trouble breathing" b. "i'm feeling more anxious about my surgery than I thought I would be" c. "i'm not sure what i will do if insurance doesn't cover this expensive hip replacement" d. "my sister had anesthesia a few months ago and she said she didn't like the way she felt"

a. "when I eat shrimp, my tongue swells and I have trouble breathing"

The nurse is conducting assessments for clients at potential risk for infection. Which client is most at risk for acquiring an infection? a. A client who had an open incision for abdominal surgery b. A client who has not been immunized pneumonia of influenza c. A client who works in a high-stress job for an accounting practice d. A client who is 85 years old and in good health

a. A client who had an open incision for abdominal surgery

Which of the following factors does the nurse recognize as being a risk for altered sensory perception in the older adult client? a. Diabetes mellitus b. Hypotension c. Osteoarthritis d. Peptic ulcer disease

a. Diabetes mellitus

Which assessment findings indicate to the nurse that a client taking warfarin may have decreased clotting? (Select all that apply) a. Frequent nosebleeds b. Lower leg swelling c. Upper extremity bruising d. Difficulty breathing e. Intermittent chest pain f. Dark stools

a. Frequent nosebleeds c. Upper extremity bruising f. Dark stools

The family of a client who is near death is concerned about a loud rattling that occurs with the client's breathing. What nursing intervention is appropriate? (Select all that apply) a. administer hyoscyamine as prescribed to dry up secretions b. turn the client onto one side to help decrease the gurgling with respirations c. suction the client regularly to remove secretions in the bronchi and oropharynx d. assess the client for signs of dyspnea or respiratory distress e. administer diuretics as prescribed to help decrease the wet respirations f. teach the family about the buildup of secretions that occur when a client is near death

a. administer hyoscyamine as prescribed to dry up secretions b. turn the client onto one side to help decrease the gurgling with respirations d. assess the client for signs of dyspnea or respiratory distress f. teach the family about the buildup of secretions that occur when a client is near death

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? (Select all that apply) a. anesthesia used during surgery b. surgical pain c. unfamiliar environment d. noisy hospital visit e. medications used to manage pain

a. anesthesia used during surgery b. surgical pain c. unfamiliar environment d. noisy hospital visit e. medications used to manage pain

when creating an emergency preparedness plan, which does the nurse include? (select all that apply) a. assembling a go bad b. arranging for child care c. determining who will care for pets d. noting who will be called when the plan is activated e. identifying how long the emergency is expected to last f. noting where a nurse is expected to report if the emergency plan is activated g. collecting names, addresses, and telephone numbers to be used if a crisis occurs

a. assembling a go bad b. arranging for child care c. determining who will care for pets d. noting who will be called when the plan is activated f. noting where a nurse is expected to report if the emergency plan is activated g. collecting names, addresses, and telephone numbers to be used if a crisis occurs

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED? a. assess breath sounds and respiratory efforts b. establish vascular accesss with a large-bore catheter c. remove clothing to perform a complete physical assessment d. evaluate level of consciousness (LOC) using the glasgow coma scale (GCS)

a. assess breath sounds and respiratory efforts

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? (Select all that apply) a. begin practicing leg exercises prior to surgery b. repeat leg exercises several times daily for each leg c. push the ball of the foot into the bed until the calf and thigh muscles contract d. if pain or warmth in the calf is present, discontinue exercises and contact the surgeon e. point toes of one foot toward bed bottom; then point toes of same leg toward face. switch

a. begin practicing leg exercises prior to surgery c. push the ball of the foot into the bed until the calf and thigh muscles contract d. if pain or warmth in the calf is present, discontinue exercises and contact the surgeon e. point toes of one foot toward bed bottom; then point toes of same leg toward face. switch

Which clinical indicators are most relevant for the nurse to monitor during IV fluid replacement for a client with dehydration? (Select all that apply) a. blood pressure b. deep tendon reflexes c. hand-grip strength d. pulse rate and quality e. skin turgor f. urine output

a. blood pressure d. pulse rate and quality f. urine output

After assessing four clients, which will the triage nurse identify to be seen first in the ED? a. client with fever of 101.2 F b. client who reports slurred speech c. client who reports bilateral ear pain d. client with urinary burning and frequency

a. client with fever of 101.2 F

Which assessment findings will the nurse expect for the client with early-stage rheumatoid arthritis? (select all that apply) a. joint inflammation b. subcutaneous nodules c. severe weight loss d. fatigue e. thrombocytosis f. anorexia

a. joint inflammation d. fatigue f. anorexia

The nurse is caring for a client with severe osteoarthritis. What will the nurse anticipate as the client's priority problem? a. joint pain b. ADL dependence c. risk for falls d. muscle stiffness

a. joint pain

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? (select all that apply) a. left arm prosthesis b. skin turgor <3 seconds c. blood pressure 160/100 mmHg d. presence of chest rigidity e. has been NPO since midnight f. expressed concern about surgery payment

a. left arm prosthesis c. blood pressure 160/100 mmHg d. presence of chest rigidity

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. what is the priority nursing assessment? a. perform thorough auscultation of the lungs b. assess response to pinprick stimulation from feet to mid-chest level c. determine level of consciousness and response to environmental stimuli d. compare blood pressure findings from preoperative assessment to the present

a. perform thorough auscultation of the lungs

What responses does the nurse expect as a result of infusing 500 mL liter of a 3% saline intravenous solution into a client over a 1 hour time period? a. plasma volume osmolarity increases; blood pressure increases b. plasma volume osmolarity decreases; blood pressure increases c. plasma volume osmolarity increases; blood pressure decreases d. plasma volume osmolarity decreases; blood pressure decreases

a. plasma volume osmolarity increases; blood pressure increases

Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? a. reports acute pain at the surgical site b. persistent pain reported around the surgical site c. experiences neuropathic pain near the surgical site d. discomfort has progressed to chronification of pain

a. reports acute pain at the surgical site

Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? (select all that apply) a. administering prescribed drug therapy b. ambulating in the hall c. culturing suspected infectious drainage d. performing pulmonary hygiene e. performing oral care f. providing a complete bed bath g. teaching about nutrition therapy

b. ambulating in the hall f. providing a complete bed bath g. teaching about nutrition therapy

A nursing assistant in a nursing home reports to the nurse that an 87 year old nursing home client has a 6 inch reddened wound with pus draining from it on his shin where he scratched it open yesterday. After directly assessing the client's wound, what are the most relevant priority actions for the nurse to take? (select all that apply) a. take a photo of the wound to show the primary health care provider when rounds are made 2 days from now b. assess the client for signs and symptoms of systemic infection, including temperature elevation c. notify the primary health care provider now and request a prescription for antibiotic therapy d. ask the primary health care provider to prescribe a tetanus booster vaccination e. immediately obtain a specimen for culture and sensitivity testing f. cleanse the wound and apply a dry dressing to it

a. take a photo of the wound to show the primary health care provider when rounds are made 2 days from now b. assess the client for signs and symptoms of systemic infection, including temperature elevation c. notify the primary health care provider now and request a prescription for antibiotic therapy f. cleanse the wound and apply a dry dressing to it

How do plasma cells provide immune protection? a. they actively secrete immunoglobulins against specific antigens b. they interact with virgin B lymphocytes at first exposure at an antigen, enhancing B-lymphocyte sensitization c. they regulate the function of natural killer cells, preventing unnecessary damage or death to normal healthy body cells d. they are responsible for balancing helper cell activity with regulator t-cell activity, ensuring that an immunologic response can be mounted whenever the body is invaded by pathologic microorganisms but limiting the response when the body receives antigens as drugs or food

a. they actively secrete immunoglobulins against specific antigens

Which statement regarding type 3 hypersensitivity reactions is/are true? (select all that apply) a. type 3 responses are usually directed against self cells and tissues b. susceptibility for developing a type 3 hypersensitivity response follows an autosomal dominant pattern of inheritance c. the hypersensitivity starts as a type 2 reaction that progresses to a type 3 reaction d. the major mechanism of the reaction is the release of mediators from sensitized t-cells that trigger antigen destruction by macrophages e. rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity f. the second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

a. type 3 responses are usually directed against self cells and tissues e. rheumatoid arthritis is an example of a health problem caused by this type of hypersensitivity

A client receiving palliative care for a terminal cancer diagnosis asks the nurse, "why is this happening to me?" what is the best nursing response? a. "I don't know. God knows when your time is up on this earth" b. "I'm sorry. I know that this is a very difficult time for you" c. "It's going to be ok; at least you aren't leaving any family behind" d. "we'll make sure that all of your needs are met, so don't worry"

b. "I'm sorry. I know that this is a very difficult time for you"

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? a. "you cannot have more pain medicine until an hour from now" b. "can you describe the pain you are having, and rate it on a 1 - to - 10 scale?" c. "i can help you begin a pain diary so we can see trends when your pain worsens" d. "let's try some relaxation exercises to help address the discomfort you are feeling"

b. "can you describe the pain you are having, and rate it on a 1 - to - 10 scale?"

Which dietary change does the nurse suggest for the client who has esophageal candidiasis? a. "avoid drinking alcoholic beverages" b. "eat soft, cool food such as pudding and smoothies" c. "limit your intake of fluid to no more than 1L daily" d. "increase your intake of cooked leafy green vegetables"

b. "eat soft, cool food such as pudding and smoothies"

The primary health care provider prescribes daily celecoxib for a client experiencing persistent joint pain in both knees. Which health teaching will the nurse provide for the client regarding this drug for long-term pain control? (select all that apply) a. "take the prescribed drug before breakfast each day" b. "report any sign of bleeding, including bloody or dark, tarry stool" c. "do not take other NSAIDs while on celecoxib" d. "report any major changes in the amount of urine you excrete daily" e. "follow up with lab tests to assess liver function"

b. "report any sign of bleeding, including bloody or dark, tarry stool" c. "do not take other NSAIDs while on celecoxib" d. "report any major changes in the amount of urine you excrete daily"

A client is receiving an intravenous infusion of 100 mEq (mmol) of potassium chloride in 1000 mL of normal saline. How many mEq (mmol) of potassium per hour does the nurse calculate the client will receive if the IV is infused at a rate of 150 mL/hour? a. 12 mEq (mmol) b. 15 mEq (mmol) c. 18 mEq (mmol) d. 20 mEq (mmol)

b. 15 mEq (mmol)

The primary health care provider has prescribed 1 L of D5NS to infuse at a rate of 125 mL/hr. The nurse begins the infusion at 0700. When will the nurse anticipate completion of the infusion? a. 1300 hours (1 pm) b. 1500 hours (3pm) c. 1900 hours (7pm) d. 2100 hours (9pm)

b. 1500 hours (3pm)

After a mass casualty event, which client will the nurse triage with a yellow tag? a. 29 year old with 3rd degree burns over 80% of the body b. 36 year old with closed fractures of both legs c. 48 year old with wheezing and difficulty breathing d. 52 year old with multiple abrasions and contusions

b. 36 year old with closed fractures of both legs

Which nursing activities may be safely delegated to competent assistive personnel (AP) (Select all that apply) a. Discharge teaching b. Blood pressure monitoring c. Gastrostomy feeding d. Oxygen administration e. Ambulation assistance

b. Blood pressure monitoring e. Ambulation assistance

A client reports increasing diffuse pain in the entire right leg. What is the nurse's priority action at this time? a. Elevate the right leg on a pillow b. Perform a peripheral vascular assessment c. Check for swelling in the right leg d. Notify the rapid response team immediately

b. Perform a peripheral vascular assessment

An older adult's furosemide dosage was increased 2 days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? a. Encourage fluid intake b. Withhold this morning's dose of furosemide c. Review the most recent serum electrolyte levels d. Place the patient on strict intake and output

b. Withhold this morning's dose of furosemide

Which specific information will the nurse teach to the client with systemic lupus erythematosus newly prescribed belimumab therapy? a. avoiding injecting it in a site near a cutaneous lesion b. the drug can only be given by a health care professional c. do not chew, crush, or split the tablet containing this drug d. the drug must be taken at bedtime because it causes extreme drowsiness

b. the drug can only be given by a health care professional

Which statement regarding type 1 hypersensitivity reactions is/are true? (select all that apply) a. antihistamines are of minimal benefit because the reactions are mediated by IgE rather than histamine b. the response is characterized by the five cardinal symptoms of inflammation c. type 1 responses are usually directed against non-self but the response is excessive d. susceptibility for developing a type 1 hypersensitivity response follows an x-linked recessive pattern of inheritance e. this type of hypersensitivity reaction is most strongly associated with systemic lupus erythematosus f. responses always occur within minutes of exposure to the allergen g. the second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

b. the response is characterized by the five cardinal symptoms of inflammation c. type 1 responses are usually directed against non-self but the response is excessive g. the second phase of the reaction with accumulation of excess bradykinin is responsible for development of angioedema

A client has been receiving the same dose of an intravenous opioid for 2 days to manage postsurgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? a. there is likely a history of addiction b. tolerance to the opioid is developing c. physical dependence is developing d. the client is opioid naive.

b. tolerance to the opioid is developing

Which statement made by the client with stage HIV-3 disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 X 10^9/L) to 400 cells/mm3 (0.2 X 10^9/L) indicates to the nurse that more teaching is needed? a. "now my viral load is also probably lower" b. "I am so relieved that my drug therapy is working" c. "Although I am still HIV positive, at least I no longer have AIDS" d. "This change means I am less likely to develop an opportunistic infection"

c. "Although I am still HIV positive, at least I no longer have AIDS"

What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed to this drug? a. "Do you have glaucoma or any other problem with your eyes?" b. "Do you take medications for a seizure disorder?" c. "Are you allergic to sulfa drugs?" d. "Are you diabetic?"

c. "Are you allergic to sulfa drugs?"

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? (select all that apply) a. "why don't you think you're going to get hooked?" b. "don't you worry, I won't give you any opioid medications" c. "have you had concerns with drug dependence in the past?" d. "tell me what makes you most fearful about taking opioid medications" e. "there are proper ways of taking opioids so you will not become dependent"

c. "have you had concerns with drug dependence in the past?" d. "tell me what makes you most fearful about taking opioid medications" e. "there are proper ways of taking opioids so you will not become dependent"

Assistive personnel (AP) are assigned to care for a client who had cemented total knee arthroplasty yesterday. Which observation by the AP indicates a need for follow-up by the nurse? a. "the client's surgical knee is very swollen and discolored" b. "the client states that the surgical knee is very painful when removing it" c. "the client's lower leg on the surgical side is painful and red" d. "the client needs assistance with walking to the bathroom"

c. "the client's lower leg on the surgical side is painful and red"

A nurse conducts an assessment of the older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? a. Vitamin D b. Losartan c. Notriptyline d. Hydrochlorothiazide (HCTZ)

c. Notriptyline

A client with severe diarrhea reports tingling lips and foot cramps. What is the nurse's best first action to prevent harm? a. hold the next dose of the prescribed antidiarrheal drug b. assess bowel sounds in all four abdominal quadrants c. assess the client's response to the Chvostek test d. increase the IV flow rate of the normal saline infusion

c. assess the client's response to the Chvostek test

how do macrophages contribute to the neutrophilia that occurs in response to an acute bacterial infection? a. when invasion occurs, macrophages mature into neutrophils, increasing their circulating numbers b. macrophages have only an indirect role in neutrophilia by secreting substances that reduce bone marrow production of erythrocytes and platelets c. at the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils d. inflammatory damage to macrophages allows release of proteolytic enzymes that enhance liver production of all white blood cell types, including mature segmented neutrophils

c. at the onset of invasion, macrophages secrete a colony-stimulating factor to induce the bone marrow to increase production and release of neutrophils

The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? (Select all that apply) a. blood pressure 130/72 mmHg b. serum potassium 3.5 mEq/L c. diffuse rash on upper torso d. took 650 mg of aspirin yesterday e. has not had food or water since 9:00 p.m. last night

c. diffuse rash on upper torso d. took 650 mg of aspirin yesterday

Which action will the nurse perform first for a client in anaphylaxis to prevent harm? a. applying oxygen by nonrebreather mask b. administering IV diphenhydramine c. injecting epinephine d. initiating IV access

c. injecting epinephine

Which cells, products, or actions are involved in long-lasting immunity resulting from exposure to a specific antigen (select all that apply) a. antibody attenuation b. interleukin 10 (IL-10) c. memory B-cells d. monocyte maturation e. neutrophilia f. phagocytosis

c. memory B-cells d. monocyte maturation

What is the appropriate nursing response when asked to report to work to assist with a mass casualty event? a. report to work whe asked by a supervisor b. refrain from working to care for family members c. refer to the ANA code of ethics for nurses for direction d. agree to work for several hours until other nurses arrive to assist

c. refer to the ANA code of ethics for nurses for direction

A client receiving palliative care who has advanced dementia is nonverbal and restless and moans when the family attempts to touch or comfort the client. Which nursing intervention is appropriate for the client? a. administer acetaminophen rectally for pain b. instruct the family to avoid touching the client to prevent pain c. provide passive range of motion to increase mobility once a shift d. obtain a prescription for transdermal fentanyl for pain

d. obtain a prescription for transdermal fentanyl for pain

what is the appropriate nursing action when assessing that a client scored 40 on the IES-R? a. triage with a black tag b. prepare for discharge to home c. administer oxygen and assess saturation d. refer to a psychiatrist or mental health counselor

d. refer to a psychiatrist or mental health counselor

A client receiving gentamycin intravenously reports that the peripheral IV insertion site has become painful and reddened. What is the priority nursing action? a. contact the primary health care provider b. document findngs in the electronic health record c. change the IV site to a new location d. stop the infusion of the drug

d. stop the infusion of the drug

Which condition or manifestation in the client with serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss? a. the client has calf muscle cramping b. the serum chloride level is low c. the urine specific gracity is high d. the hematocrit is 52%

d. the hematocrit is 52%

the nurse is caring for a client who had an anterior total hip arthoplasty yesterday. For which commonly occurring post operative complication will the nurse monitor for this client? a. pneumonia b. paralytic ileus c. wound dehiscence d. venous thromboembolism

d. venous thromboembolism