Medsurg Online Practice A

ANS: BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? A. Negative urine ketones B. BUN 32 mg/dL C. pH 7.43 D. HCO3- 23 mEq/L

ANS: 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 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? A. Place a padded tongue blade at the client's bedside B. Keep the side rails lowered on the client's bed C. Maintain the client's bed at hip level or above D. Ensure that the client has a patent IV

ANS: B, C, E Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply) A. Expressive aphasia B. Visual spatial deficits C. Left hemianopsia D. Right hemiplegia E. One-sided neglect

ANS: Wear a mask Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? A. Wear a mask B. Wear a gown C. Keep the client's room well-lit D. Maintain the head of the bed at a 45° elevation

ANS: A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet. When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.

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 postoperative following abdominal surgery and reports a pain of 4 on a scale of 0 to 10 B. A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet 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 breath sounds

ANS: Aged cheese Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.

A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine headaches. To help reduce the risk for 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

ANS: Report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse in a provider's 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 an adverse reaction to this medication? A. Report of a night cough B. Report of tinnitus C. Report of excessive tearing D. Report of increased salivation

ANS: Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse in a provider's 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 medications interacts with feverfew? A. Metoprolol B. Bupropion C. Naproxen D. Atorvastatin

ANS: "You will not be able to use sildenafil if you are taking nitroglycerin." The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension.

A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? A. "You might need to take a stool softener while taking this medication." B. "You will not be able to use sildenafil if you have diabetes." C. "You will need to limit your caffeine intake if you start taking sildenafil." D. "You will not be able to use sildenafil if you are taking nitroglycerin."

ANS: Bradycardia A client who has increased intracranial pressure from a traumatic brain injury 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 in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? A. Hypotension B. Tachypnea C. Nuchal ridgidity D. Bradycardia

ANS: "It's 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 retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

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. "It's like a curtain closed over my eye." B. "This sharp pain in my eye started 2 hours ago." C. "I've been having more and more difficulty seeing over the last few weeks." D. "I seem to have more problems seeing different colors."

ANS: IV fluids After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total 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

ANS: A, C, D The nurse should expect the client to have 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 in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? (Select all that apply) A. Fever B. Non-pitting edema C. Hypertension D. Tachycardia E. Hypoglycemia

ANS: 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 in an emergency department is caring for a client who reports vomiting and diarrhea for the past 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 mm Hg C. Urine specific gravity 1.020 D. BUN 15 mg/dL

ANS: Administer an opioid analgesic to the client The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

A nurse in an emergency department is reviewing the provider's 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 client's puncture wounds B. Initiate corticosteroid therapy for the client C. Keep the client's leg above heart level D. Administer an opioid analgesic to the client

ANS: Respiratory paralysis The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor? A. Hyperreflexia B. Increased blood pressure C. Respiratory paralysis D. Tachycardia

ANS: 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 client's urine to confirm passage of the stones.

A nurse is assessing a client who had extracorporeal shock wave lithotripsy (ESWL) 6 hr 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

ANS: Tachycardia When using the urgent vs. non-urgent 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. The nurse should reposition the head of the client's bed flat and report this finding immediately to the provider.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority? A. Anorexia B. Abdominal pain radiating to the right shoulder C. Tachycardia D. Rebound abdominal tenderness

ANS: (Lowest image) The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.

A nurse is assessing a client who has grave's disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

ANS: 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 hr after application.

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions could the nurse take? A. Inspect the cast for drainage once every 24 hr B. Check that. one finger fits between the cast and the leg C. Perform neurovascular checks every 2 to 3 hr D. Make sure the client has a warm blanket covering the cast

ANS: Dysphagia Dysphagia indicates 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 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

ANS: A client who has multiple sclerosis and is experiencing progressive difficulty ambulating The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

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 diabetes mellitus 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 three times a day D. A client who has multiple sclerosis and is experiencing progressive difficult ambulating

ANS: C The nurse should palpate this location to assess the client for an inguinal hernia. An inguinal hernia forms from the peritoneum, which contains part of the intestine, and can protrude into the scrotum in men.

A nurse is assessing a male client for an inguinal hernia. Which of the following areas should the nurse palpate to verify that the client has an inguinal hernia? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer)

ANS: 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 1 hr 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's priority? A. Initiate oxygen at 2 L/min via nasal cannula B. Apply firm pressure to the insertion site C. Take the client's vital signs D. Obtain a stat order for an aPTT

ANS: 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 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

ANS: C, D, E Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Both decerebrate and decorticate posturing indicate increased ICP.

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply) 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

1. Places body weight on the crutches 2. Advances the unaffected leg onto the stair 3. Shifts weight from the crutches to the unaffected leg 4. Brings the crutches and the affected leg up to the stair

A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. (Use all the steps) - Shifts weight from the crutches to the unaffected leg - Places body weight on the crutches - Brings the crutches and the affected leg up to the stair - Advances the unaffected leg onto the stair

ANS: Blood pressure 170/80 mm Hg Using the urgent vs. non-urgent approach to client care, the nurse should determine that the priority finding is a systolic pressure of 170 mm Hg, which indicates that the client is at risk for a thyroid storm.

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 ng/dL C. Blood pressure 170/80 mm Hg D. Decreased weight

ANS: 167 mL/hr

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

ANS: Hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

A nurse is caring for a client who has a potassium level of 3 mEq/L. 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

ANS: Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? A. Bradycardia B. Tremors C. Orthostatic hypotension D. Drowsiness

ANS: Increased respiratory secretions Using airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and pneumonia.

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 nurse's priority? A. Temperature 38.4°C (101.1°F) B. Increased respiratory secretions C. Fluid intake of 200 mL in the prior 8 hr D. Limited range of motion

ANS: 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 anorexia, 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

ANS: Place the client in high-Fowler's position The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange.

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 antibiotics to the client C. Instruct the client to use the incentive spirometer D. Place the client in high-Fowler's position

ANS: 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 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

ANS: 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 has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. 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

ANS: 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 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 adverse effect of this medication? A. Hypokalemia B. Hypercalcemia C. Gastrointestinal bleeding D. Confusion

ANS: Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium

ANS: Obtain vital signs The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

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 laboratory values for recent hemoglobin and hematocrit levels. B. Establish a peripheral IV line for possible transfusion C. Call the laboratory to obtain a stat platelet count D. Obtain vital signs

ANS: Urine output 25 mL/hr Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

A nurse is caring for a client who has stage III pressure injury. Which of the following findings contributes to delayed wound healing? A. WBC count 6,000/mm^3 B. BMI 24 C. Urine output 25 mL/hr D. Albumin 4 g/dL

ANS: "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 caring for a client who has type 1 diabetes mellitus and has had 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. "It's okay if your ketone levels are temporarily high." C. "Monitor your blood glucose levels every 12 hours." D. "Call the provider if your glucose levels reach 170 milligrams per deciliter."

ANS: Non-rebreather mask The nurse should initiate a non-rebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a non-rebreather mask.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter 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. Non-rebreather mask B. Venturi mask C. Simple face mask D. Partial rebreather mask

ANS: The nurse should place a pillow between the client's legs The nurse should place a pillow between the client's legs to prevent hip dislocation

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? A. Maintain adduction of the client's legs B. Encourage range of motion of the hip up to a 120° angle C. Place a pillow between the client's legs D. Keep the client's hip internally rotated

ANS: Loosen restrictive clothing The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

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

ANS: Perform synchronized cardioversion The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

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 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take? A. Defibrillate the client's heart B. Perform synchronized cardioversion C. Begin cardiopulmonary resuscitation D. Administer lidocaine IV bolus

ANS: Turn the client to the side The greatest risk to this 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 is having a seizure. Which of the following interventions is the nurse's priority? A. Loosen the clothing around the client's neck B. Check the client's pupillary response C. Turn the client to the side D. Move furniture away from the client

ANS: 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 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 client's 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

ANS: Increase fiber intake to at least 30 g per day Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is providing teaching to a client who has irritable bowel syndrome (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 1 L of water per day

ANS: Instruct the client on alternative therapies for pain reduction The nurse should respect the client's concerns and offer non-pharmacologic alternatives to pain management, such as relaxing activities and distraction.

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

ANS: Administer dextrose 10% in water until the new bag arrives TPN solutions have a high concentration of dextrose. Therefore, if a TPN solution is temporarily unavailable, the nurse should administer dextrose 10% or 20% in water to avoid a precipitous drop in the client's blood glucose level.

A nurse is caring for a client who is receiving total parenteral nutrition (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 line open with 0.9% sodium chloride 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

ANS: Calcium carbonate Hypocalcemia is a manifestation of EKSD and an adverse effect 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 is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer? A. Epoetin alfa B. Furosemide C. Captopril D. Calcium carbonate

ANS: Heart rate 55/min The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

A nurse is caring for a client who presents to a clinic for a 1-week-follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (See exhibit information below) Exhibit 1: Prescriptions - Digoxin 0.25 mg PO daily - Furosemide 40 mg PO daily - Potassium chloride 20 mEq/L PO daily Exhibit 2: History and Physical Discharge: Weight 66.7 kg (147 lb) SaO2 94% 2+ pedal edema Heart rate 74/min Current: Weight 67.1 kg (148 lb) SaO2 92% 1+ pedal edema Heart rate 55/min Exhibit 3: Laboratory Results Discharge: Sodium 137 mEq/L Potassium 4.2 mEq/L Digoxin 1.2 ng/dL Current: Sodium 135 mEq/L Potassium 4.1 mEq/L Digoxin 1.8 ng/dL

ANS: A client who is receiving preoperative teaching for a right knee arthroplasty The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A. A client who is receiving preoperative teaching fro a right knee arthroplasty B. A client who states they will have difficulty obtaining a walker for home use C. A client who reports an increase in pain following a left hip arthroplasty D. A client who is having emotional difficulty accepting that they have a prosthetic leg

ANS: Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.

A nurse is caring or a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider? A. Potassium 4 mEq/L B. WBC count 10,000/mm^3 C. Hct 45% D. Hgb 8 g/dL

ANS: History of asthma A client who has a history 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 foods, such as shellfish, eggs, milk, and chocolate.

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. History of trauma B. Appendectomy 1 year ago C. Penicillin allergy D. Total knee arthroplasty 6 months ago

ANS: Monitor the client's temperature every 4 hr The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan? A. Monitor the client's temperature every 4 hr B. Insert an indwelling urinary catheter for the client C. Request the client's bathroom to be cleaned three times each week D. Place a box of latex gloves just outside the client's room

ANS: "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." This statement indicates that the client is successfully coping with the change because the client is performing preventative foot care to reduce the risk for complications.

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. 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 every day with a mirror." C. "I'm concerned I won't be able to read by blood sugar level because the screen is so small." D. "I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to."

ANS: Listen with the client on their left side When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound: two beats followed by a murmur A. Obtain a 12-lead ECG for the client B. Request to obtain the client's cardiac enzymes C. Check the client's blood pressure manually D. Listen with the client on their left side

ANS: 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 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 vital signs C. Cover the wound with a sterile, saline-moistening dressing D. Call for help

ANS: Avoid placing plants or flowers in the client's room Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

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 a Pseudomonas aeruginosa infection? A. Encourage the client to eat raw fruits and vegetables B. Avoid placing plants or flowers in the client's room C. Limit visitors to members of the client's immediate family D. Wear an N95 respirator mask when providing care to the client

ANS: Wear a led apron while providing care to the client The nurse should wear a led 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 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 client's plan of care? A. Collect and place the client's urine or feces in a biohazard bag B. Limit the client's ambulation to their own room C. Wear a lead apron while providing care to the client D. Limit each visitor to 1 hr per day

ANS: 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 care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. 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

ANS: "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 (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a 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 to the pouch to reduce odor." C. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." D. "You should us a moisturizing soap when washing the skin around the stoma."

ANS: Use a 30-mL syringe The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

A nurse is planning to irrigate and dress a clean, granulating would for a client who has a pressure injury. Which of the following actions should the nurse take? A. Apply a wet-to-dry gauze dressing B. Irrigate with hydrogen peroxide solution C. Use a 30-mL syringe D. Attach a 24-gauge angiocatheter to the syringe

ANS: 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 to reduce the risk for falls.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? A. Keep the client's personal care items in the bathroom B. Keep the overhead lights on in the client's bedroom while the client is sleeping C. Remind the client to scan their complete range of vision during ambulation D. Secure the client's extension cords under carpeting

ANS: 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 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 hr prior to cardioversion? A. Enoxaparin B. Metformin C. Diazepam D. Digoxin

ANS: Remain with the client for the first 15 min of the infusion The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15 min of the infusion. B. Prime the blood administration IV tubing with lactated Ringer's solution C. Verify the client's identity by using the client's room number prior to starting the transfusion D. Infuse the unit of packed RBCs within 8 hr

ANS: Suction machine The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside? A. Suction machine B. Wire cutters C. Padded clamp D. Communication board

ANS: 12 almonds The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with 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 peanut butter D. 1/2 cup tomato juice

ANS: Increase fluid intake Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is providing discharge instructions to a client following an upper gastrointestinal 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

ANS: Wrap 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 perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.

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 every 72 hr. B. Immobilize the hand with a pressure dressing C. Take pain medication 30 min after changing the dressing D. Wrap fingers with individual dressings

ANS: Try to walk at least three times per week for exercise The development of a regular exercise routine can improve outcomes in clients who have heart failure.

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 three times per week for exercise B. To increase stamina, walk for 5 min after fatigue begins C. Take over-the-counter cough medicine for persistent cough D. Use a salt substitute to reduce sodium intake

ANS: "I should take this medication with a meal." The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.

A nurse is providing instructions to a client who has type 2 diabetes mellitus 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 blood sugar 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 this medication." D. "While taking this medication, I will experience flushing of my skin."

ANS: 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 providing preoperative 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 hr

ANS: 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 the occurrence of infection.

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 1 L of fluid daily C. Wear underwear made of nylon D. Void before and after intercourse

ANS: Suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is providing teaching to a client who has a 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

ANS: "I am taking this medication 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 chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take calcium supplements so the medication will work better in my system." B. "I am taking this medication to increase my energy level." C. "This medication can cause my blood pressure to drop." D. "I will not need to restrict protein in my diet while taking this medication."

ANS: "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 mild soap to protect the skin from further irritation.

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 over." D. "I will use a heating pad on my neck if it becomes sore during the radiation therapy."

ANS: 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 hr of levothyroxine administration.

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 the medication? A. Ginkgo biloba B. Glucosamine C. Calcium D. Vitamin C

ANS: "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 adverse effect and can lead to hypertensive encephalopathy.

A nurse is providing teaching to a client who is receiving chemotherapy 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."

ANS: Take daily 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 to a female client who has a history of urinary tract infections (UTIs). 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 tub bath C. Urinate every 6 hr. D. Take daily cranberry supplements

ANS: "You should void every 4 hours to decrease the risk of urinary retention." The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

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 the medication." C. "You should void every 4 hours to decrease the risk of urinary retention." D. "If you experience ringing in your ears, your dose will need to be reduced."

ANS: "I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence.

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."

ANS: Current medications The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophyline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (See exhibit information below) Exhibit 1: Prescriptions Ibuprofen PRN for headaches Olmesartan 20 mg PO daily Prednisone 5 mg PO daily Exhibit 2: History and Physical Gouty arthritis for 3 years HTN diagnosed 5 years ago 1 PPD cigarette use for 15 years Family history of prostate cancer Exhibit 3: Laboratory Results Blood glucose (fasting) 102 mg/dL BUN 15 mg/dL Creatinine 1 mg/dL Prostate Specific Antigen (PSA) 1.5 ng/mL A. Disease processes B. Laboratory findings C. Current medications D. Family history

ANS: Elevated bilirubin level Bilirubin levels reflect the liver's 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 client's degree of jaundice.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect? A. Decreased prothrombin time B. Elevated bilirubin level C. Decreased ammonia level D. Elevated albumin level

ANS: A client should sign an informed consent before receiving a placebo during a research trial A nurse should ensure a client has 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 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 a research trial B. A client cannot refuse to sign a consent form for a life-saving treatment C. A client who has a mental illness is unable to give informed consent D. An un-emancipated minor needs guardian consent for substance abuse disorder treatment

ANS: 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 carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

A nurse is teaching a client who has a family history 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

ANS: "I will wear clean graduated compression stockings every day." The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

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 graduation compression stockings every day." D. "I will keep my legs level with my body when I sleep at night."

ANS: 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 young adult 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 two weeks

ANS: Urine specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

An older adult client is brought to an emergency department 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 level 145 mEq/L B. Forearm skin tents when pinched C. Respiratory rate decreased D. Urine specific gravity 1.045