NUR 322

The client has chronic atrial fibrillation. Which discharge teaching should the nurse discuss with the client? A. Instruct the client to use a soft-bristle toothbrush B. discuss the importance of getting a monthly partial thromboplastin time (PTT) C. teach the client about signs of pacemaker malfunction D. explain to the client the procedure for synchronized cardioversion

A. A client with chronic atrial fibrillation will be taking an anticoagulant to help prevent clot formation. Therefore, the client is at risk for bleeding and should be instructed to use soft-bristle toothbrush hint; recognize disease process, know possible complications, and know how to client can be treated to prvent complication

A client is diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement? A. Administer a stool softener bid B. Encourage the client to cough hourly C. Monitor neurological status every shift D. maintain the dopamine drip to keep BP at 160/90

A. Administer a stool softener bid (client is at risk for increased intracranial pressure whenever performing the Valsalva maneuver, which will occur when straining during defecation. Therefore, a stool softener would be appropriate.)

The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement? A. Ensure that helmets are worn in appropriate area B. implement daily exercise programs for the staff C. Provide healthy foods in the cafeteria D. Encourage employees to wear safety glasses

A. Ensure that helmets are worn in appropriate area (head injury is one of the main reasons for epilepsy that can be prevented through occupational safety precautions and high-way safety programs)

The client has been newly diagnosed epilepsy. Which discharge instructions should be taught to the client? Select all that apply A. Keep a record of seizure activity B. Take tub baths only: do not take showers C. Avoid over the counter medications D. Have anticonvulsant medication serum levels checked regularly E. Do Not drive alone: have someone in the car

A. Keeping a chart helpful when keeping follow-up appointments and identifying activities that may trigger a seizure C.over- the-counter medications may contain ingredients that may interact with antiseizure medications, or , in some cases, as with the use of stimulants, possibly cause a seizure. D. Most of the anticonvulsant medications have therapeutic serum levels that should be maintained, and regular checks of the serum levels help to ensure the correct level.

the nurse is teaching a class to pregnant teenagers. which information is MOST IMPORTANT when discussing ways to PREVENT osteoporosis? A. take at least 1,200mg of calcium supplements a day B. eat foods low in calcium and high in phosporus C. osteoporosis does not occur until around age 50 yrs D. remain as active as possible until the baby is born

A. National Institute of Health recommends daily calcium intake of 1,200 to 1,500mg/day for adolescents, young adults and pregnant and lactating women

The occupational health nurse is teaching a class on the risk factors for developing osteoarthritis (OA) Which is a MODIFIABLE risk factor for developing OA? A. being overweight B. Increasing age C. Previous joint damage D. genetic suseptibility

A. Obesity well-recognized risk factor for development of OA and is modifiable.

The client diagnosed with right-sided cerebrovascular accident is admitted to the rehab unit. Which interventions should be included in the nursing care plan? *select all that apply* A. Position the client to prevent should adduction B. turn and reposition the client every shift C. encourage the client to move the affected side D. perform quadriceps exercises 3x a day E. Instruct the client to hold the fingers in a fist

A. Position the client to prevent should adduction (adduction could cause contracture) C. encourage the client to move the affected side (should not ignore affected side) (client should be repositioned every 2 hours, exercise should be 5x a day, and fingers should be barely flexed to prevent contracture)

The 34 yr old male client presents to the outpatient clinic complaining of numbness and pain radiating down left leg. Which FURTHER data should the nurse assess? A. Posture and gait B. Bending and stooping C.Leg lefts and arm swing D. Waist twists and neck mobility

A. Posture and gait will be affected if the client is experiencing sciatica (pain radiating down leg resulting from pressure on the sciatic nerve) Hint: Anatomical positioning of spinal nerves rule out option "3" and "4"

The client with coronary artery disease is prescribed a Holter monitor. Which intervention should the nurse implement? A. instruct the client to keep a diary of activity, especially when having chest pain B. Discuss the need to remove the Holter monitor during a.m. care and showering. C. explain that all medications should be withheld while wearing a Holter monitor D. teach client the importance of decreasing activity while wearing the monitor

A. The Holter monitor is a 24 hr electrocardiogram, and the client must keep an accurate record of activity so that the health-care provider can compare the ECG recordings with different levels of acyivity.

The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical surgical unit. Which task should NOT be assigned to the UAP? A. Feed the 69 yr old client diagnosed with Parkinson's disease who is having difficulty swallowing. B.Turn and position the 89 yr old client diagnosed with a pressure ulcer secondary to Parkinson's disease. C. Assist the 54 yr old client diagnosed with Parkinson's disease with toilet training activities. D. obtain vital signs on a 72 yr old client diagnosed with pneumonia secondary to Parkinson's disease

A. The nurse should not delegate feeding a client who is at risk for complications during feeding. This requires judgement that the Uap is not expected to possess. hint: read the stem carefully. Is the question asking what to delegate or what not to delegate? anything requiring professional judgement shoud not be delegated

The client with coronary artery disease asks the nurse, "why do I get chest pain?" Which statement would be MOST APPROPRIATE response by the nurse? A. chest pain is caused by decreased oxygen to the heart muscle B. there is ischemia to the myocardium as a result of hypoxemia C. the heart muscle is unable to pump effectively to perfuse the body D. chest pain occurs when the lungs cannot adequately oxygenate the blood

A. This is a correct statement presented in layman's terms. When the coronary arteries cannot supply adequate oxygen to the heart muscle, there is chest pain

The client is prescribed phenytoin(Dilantin) an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication. A. I will brush my teeth after every meal B. I will check my Dilantin level daily C. My urine will turn orange while on Dilantin. D. I won't have any seizures while on this medication

A. Thorough oral hygiene after each meal, gum massage, daily flossing, and regular dental care are essential to prevent or control gingival hyperplasia, which is a common occurance in clients taking Dilantin.

Which client teaching should the nurse implement for the client diagnosed with coronary artery disease? SELECT ALL that apply. A. encourage a low-fat, low-cholesterol diet B. instruct the client to walk 30 minutes a day C. Decrease salt intake to two g a day D. Refer to a counselor for stress reduction techniques E. teach the client to increase fiber in the diet

A. a low-fat,low-cholesterol diet will help decrease the buildup of atherosclerosis in the arteries B. walking will help increase collateral circulation D. stress reduction is encouraged for clients with CAD because this helps prevent excess stress on the heart muscle E. Increasing fiber in the diet will help remove cholesterol via the gasterointestinal system

The nurse writes the problem of PAIN for a client diagnosed with lumbar strain. Which nursing interventions should be included in the plan of care? Select ALL THAT APPLY A. Assess pain on a 1-10 scale B. Administer pain medication prn C. Provide a regular bedpan for elimination D. Assess surgical dressing every 4 hrs E. Perform a position change by the log roll method every two hrs

A. an objective of quantifying the clients pain should be used B. Once the nurse has determined the client is stable and not experiencing complications, the nurse can medicate the client

Which interventions should be incluede in the discharge teaching for a client who had a total hip replacement? SELECT ALL THAT APPLY A. discuss the client's weight-bearing limits B. Request the client demonstrate use of assitive devices C. explain the importance of increasing activity gradually D. Instruct the client not to take medication prior to ambulating E tell the client to ambulate with open-toed house shoes

A. clients need to understand the amount of weight bearing to prevent injury B. teaching the safe use of assistive devices is necessary prior to discharge C. Increases in activity should occur slowly to prevent complications

The charge nurse is making assignments. Which client should be assigned to the NEW graduate nurse? A. the client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes B. the client diagnosed with Parkinson's disease who fell during the night and is complaining of difficulty walking C. the client diagnosed with crebrovascular accident whose vital signs are P 60, R 1, and BP 198/68 D. the client diagnosed with a brain tumor who has new complaint of seeing spots before the eyes

A. headache and photophobia are expected clinical manifestations of meningitis. The new graduate could care for this client. hint: the test taker should determine if clinical manifestations are expected as part of the disease process. if they are, a new graduate can care for the client.

The nurse enters the rooms as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first? A. note the first thing the client does in the seizure B. Assess the size of the client's pupils C. Determine if the client is incontinent of urine or stool D. Provide the client with privacy during the seizure

A. note the first thing the client does in the seizure (provides information and clues as to the location of the seizure in the brain)

the nurse is discussing the importance of an exercise program for pain control to a client diagnosed with OA.Which intervention should the nurse include in the teaching? A. wear supportive tennis shoes with white socks when walking B. carry a complex carbohydrate while exercising C. alternate walking briskly and jogging when exercising D. walk at least 30 min three times a week

A. safety should always be discussed when teaching about exercises. Supportive shoes will prevent shin splints. Colored socks have dye and may cause athletes foot, which is why white socks are recommended

which foods should the nurse recommend to a client when discussing sources of dietary calcium? A. yogurt and dark-green leafy vegetables B. oranges and citrus fruits C. Bananas and dried apricots D Wheat bread and bran

A. the best dietary sources of calcium are milk and other dairy products. Other sources include oysters; canned sardines or salmon; beans; cauliflower; and dark-green, leafy vegetables

the nurse is preparing the care plan for a client with a fractured lower extremity. Which outcome is MOST APPROPRIATE for the client? A. the client will maintain function of the leg B. the client will ambulate with assistance C. The client will be turned every 2 hrs D. the client willhave no infection

A. the expected outcome for a client with a fracture is maintaining the function of the extremity

Which signs/symptoms indicate to the nurse the client has developed osteporosis? A. the client has lost one inch in height B. the client has lost 12 lbs in the last yr C. the client's hands are painful to touch D. the client's serum uric acid level is elevated

A. the loss of height occurs as vertebral bodies collapse

the client is taken to the emergency department with an injury to the left arm. Which intervention should the nurse implement first? A. assess the nailbeds for capillary refill time B. remove the clients clothing from the arm C. call radiology for a stat x-ray of the extremity D. prepare the client for the application of a cast

A. the nurse should asses the nailbeds for capillary refill time. A prolonged time(greater than 3 seconds) indicates impaired circulation to the extramity

the nurse is caring for a client diagnosed with a fracture of the right distal humerus. Which data indicate a complication? SELECT ALL THAT APPLY A. numbness and mottled cyanosis B. Paresthesia and paralysis C. Proximal pulses and point tenderness D. Coldness of the extremity and crepitus E Palpable radial pulse and functional movement

A. the nurse should assess for numbness and mottled cyanosis, which might indicate nerve damage B. the presence of paresthesia and paralysis indicates impaired criculation D Coldness indicates air in subcutaneous tissue and is not expected

which intervention is an example of a SECONDARY nursing intervention when discussing osteoporosis? A. obtain a bone density evaluation test B. perform non-weight-bearing exercises regularly C. Increase the intake of dietary calcium D. refer clients to a smoking cessation program

A. this is an example of a secondary nursing intervention, which includes screening for early detection hint; be knowledgeable of primary, secondary, and tertiary nursing interventions.

The occupational health nurse is preparing an in-service for a group of workers in a warehouse. Which information should be included to help PREVENT on-the-job injuries? A. Increase sodium and potassium in the diet during winter months B. Use the large thigh muscles when lifting and hold the weight near the body C. Use soft-cushioned chairs when performing desk duties D. Have the employee arrange for assistance with household chores

B These are instructions to prevent back injuries as a result of poor body mechanics

The nurse is preparing to administer a beta blocker to the client diagnosed with coronary artery disease. Which assessment data would cause the nurse to QUESTION administering the medication? A. the client has a BP of 110/70 B. the client has a apical pulse of 56 C. the client is complaining of a headache D. the client's potassium level is 4.5 mEq/L

B a beta blocker decreases sypathetic stimulation to the heart, thereby decreasing the heart rate, An apical rate less than 60 indicates a lower-than-normal heart rate and should make the nurse question administering this medication because it will further decreae the heart rate. hint: evaluate the options to determine if any options include abnormal data based on normal parameters

The nurse is administering 0730 medications to clients on the medical orthopedic unit. Which medication should be administered first? A. the daily cardiac glycoside to a client diagnosed with back pain and heart failure B. the routine insulin to a client diagnosed with neck strain and type I diabetes C. The oral proton pump inhibitor to a client scheduled for a laminectomy this a.m. D. the fourth dose of IV antibiotic for a client diagnosed with surgical infection

B the client with type I insulin diabetes are insulin dependent. Thus medication should be administered before the client eats

The 66 yr old male client has his blood pressure (BP) checked at a health fair. Which action should the nurse implement FIRST? A. recommend that the client have his blood pressure checked in one month B. Instruct the client to see his health-care provider as soon as possible C. Discuss the importance of eating low-salt, low-fat, low- cholesterol diet. D. Explain that this BP is within the normal range for an elderly person

B the diagnostic blood pressure should be less than 85 m m Hg according to the american heart association: therefore, this client should see the health-care provider hint: the first to be implemented should be one that affects client

the nurse is working on anorthopedic floor. Which client should the nurse assess FIRST after the chang-of-shift report? A. the 84 yr old female with a fractured right femoral neck in Buck's tractio B. the 64 yr old female with a left total knee replacement who has confusion C. the 88 yr old male post-right total hip replacement with an abduction pillow D. the 50 yr old postop client with a continuous passive motion (CPM) device

B this is an abnormal occurrenc from this information. The client should be seen first because confusion is a symptom of hypoxia.

Which intervention should the nurse implement when administering a loop diuretic to a client diagnosed with coronary artery disease? A. Assess the client's radial pulse B. Assess the client's serum potassium level C. Assess the client's glucometer reading D. Assess the client's pulse oximeter reading

B. Loop diuretics cause potassium to be lost in the urine output. Therefore, the nurse should assess the client's potassium level, and if the client is hypokalemic, the nurse should question administering this medication. hint: knowing diuretics increae urine output would lead test taker to eliminate glucose level and oxygenation. in very few instances does nurse asses radial pulse: apical is assessed.

The client is diagnosed with osteoarthritis. Which sign/symptom should the nurse expect the client to exhibit? A. severe bone deformity B. Joint stiffness C. Waddling gait D.Swan-neck fingers

B. Pain, stiffness, and functional impairment are the primary clinical manifestations of OA. Stiffness of the joints is commonly experienced after resting but usually lasts less than 30 min and decreases with movement

The nurse is assessing a client experiencing motor loss as a result of a lift-sided CVA. which clinical manifestations would the nurse document? A. Hemiparesis of the clients left arm and apraxia B. Paralysis of the right side of the body and apraxia C. Homonymous hemianopsia and diplopia D. Impulsive behavior and hostility toward family

B. Paralysis of the right side of the body and apraxia

The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care? A. potential for injury B. Powerlessness C. Disturbed thought processes D. sexual dysfunction

B. Powerlessness (client cannot communicate thoughts but understands what is being communicated; this leads to frustration)

The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take? A. Help the UAP to insert the oral airway in the mouth. B.Tell the UAP to stop trying to insert anything in the mouth. C.Take no action because the UAP is handling the situation. D.Notify the charge nurse of the situation immediately.

B. The nurse should tell the UAP to stop trying to insert anything in the mouth of the client experiencing a seizure. Broken teeth and injury to the lips and tongue may result from trying to place anything in the clenched jaws of a client having a tonic-clonic seizure. Hint: nurse responsible for uap and must correct behavior immediately.

which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? SELECT ALL THAT APPLY. A. apply an immobilizer snugly to prevent edema B. apply an ice pack for 10 min and remove for 20 min C. place extremity in the dependent position to allow drainage D. obtain an x-ray of the ankle after applying the immobilizer E. administer tetanus toxoid, 0.5 ml intramuscularyly, in the deltoid

B. ice packs should be applied 10 min on and 20 min off. this allows for vasoconstriction and decreases edema. Ice is a nonpharmacological pain management technique. E. anytime trauma occurs, tetnus should be considered. In an open fracture, this is an appropriate technique. hint; this is an alternative type question. consider descriptive words that make options incorrect. Read adjectives and adverbs carefully. "snugly", "dependent", and "after" make option 1,3 and 4 incorrect

The nurse is discussing angina with a client who is diagnosed with coronary artery disease. Which action should the client take FIRST when experiencing angina? A. put a nitroglycerin tablet under the tongue B. stop the activity immediately and rest C. Document when and what activity caused angina D. notify the health-care provider immediately

B. stopping the activity decreases the heart's need for oxygen and may help decrease the angina (chest pain) hint: select answer that will help client directly and quickly

Which statement by the client diagnosed with coronary artery disease indicates that the client UNDERSTANDS the discharge teaching concerning diet? A. I will not eat more than six eggs a week B. I should bake or grill any meats I eat C. I will drink eight oz of whole milk a day D. I should not eat any type of pork products

B. the american heart association recommends a low-fat, low-cholesterol diet for a client with coronary artery disease. The client should avoid any fried foods, especially meats, and bake, broil or grill any meat.

The client is scheduled for a right femoral catherterization. Which nursing intervention should the nurse implement AFTER the procedure? A. perform passive range-of-motion excercises B. Assess the clients neurovascular status C.Keep the client high Fowler's position D. Assess the gag reflex prior to feeding the client

B. the nurse must make sure that blood is circulating to the right leg, so the client should be assessed for pulses, paresthesia, paralysis, coldness, and pallor

The client diagnosed with cervical disk degeneration has undergone a laminectomy. Which interventions should the nurse implement? A. Position the client prone with knees slightly elevated B. Assess the client for difficulty speaking or breathing C. Measure drainage in the Jackson Pratt bulb every day D. Encourage the client to postpone the use of narcotic medications

B. the surgical position of the wound places the client at risk for edema of tissues in the neck. Difficulty speaking or breathing should alert the nurse to a potentially life-threatening problem

The nurse is conducting a support group for clients diagnosed with Parkinson's disease and their significant others. Which information regarding psychosocial needs should be included in the discussion? A. the client should discuss feelings about being placed on a ventilator B. the client may have rapid mood swings and become easily upset C. Pill-rolling tremors will become worse when the medication is wearing off. D. the client may automatically start to repeat what another person says

B. these are psychosocial manifestations of PD. These should be discussed in the support meeting.

the female client diagnosed with osteoporosis tells the nurse she is going to perform swim aerobics for 30 min every day. Which response is MOST APPROPRIATE by the nurse? A. praise the client for committing to do this activity B. explain to the client wlaking 30 min a day is a better acticity C. encourage the client to swim every other day instead of daily D. discuss with the client how sedentary activities help prevent osteoporosis

B. weight-bearing activity, such as walking, is beneficial in preventing or slowing bone loss. The mechanical force of weight-bearing exercises promotes bone growth

The healthcare-provider prescribes angiotensin-converting enzyme (ACE) inhibitor for the client diagnosed with essential hypertension. Which statement is the MOST APPROPRIATE rationale for administering this medication? A. ACE inhibitors prevent beta receptor stimulation in the heart B. this medication blocks the alpha receptors in the vascular smooth muscle C. ACE inhibitors prevent vasoconstriction and sodium and water retention D, ACE inhibitors decrease blood pressure by relaxing vascular smooth muscle

C. Angiotensin-converting enzyme (ACE) inhibitors prevent the conversion of angiotensin I and II and this, in turn, prevents vasoconstriction and sodium and water retention

The client diagnosed with PD is being disharged on carbidopa/levodopa (Sinemet), an antiparkinsinsnian drug. Which statement is the scientific rationale for combining these medications? A. There will be fewer side affects with this combination than with Carbidopa alone. B. Dopamine D requires the presence of both of these medications to work. C. Carbidopa makes more levodopa available to the brain. D.Carbidopa crosses the blood-brain barrier to treat Parkinson's disease

C. Carbidopa enhances the effects of levadopa by inhibiting decarboxylase in the periphery, thereby making more levadopa available to the central nervous system. Sinemet is the most effective treatment for PD hint: nurse must be knowledgeable of the rationale for administering a medication for a specific disease.

The occupational health nurse is planning health promotion activities for a group of factory workers. Which activity is an example of PRIMARY prevention for clients AT RISK for low back pain? A. Teach back exercises to workers after returning from an injury B. Place signs in the work area about how to perform first aid C. Start a weight-reduction group to meet at lunchtime D. Administer a nonnarcotic analgesic to a client complaining of back pain

C. Excess weight increases the workload on the vertebrae. Weight-loss activities help prevent back injury

The client is scheduled for EEG to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement? A. Tell the client to take any routine anti-seizure medication prior to the EEG B. tell the client not to eat anything for 8 hours prior to the procedure C. Instruct the client awake for 24 hours prior to the EEG D. Explain to the client that there will be some discomfort during the procedure

C. Instruct the client awake for 24 hours prior to the EEG (the goal is for the client to have a seizure during the EEG)

The nurse working on a medical-surgical floor feels a pilling in the back when lifting a client up on the bed. Which should be the FIRST action taken by the nurse? A. Continue working until the shift is over and then try to sleep on a heating pad B. Go immediately to the emergency department for treatment and muscle relaxants C. Inform the charge nurse and nurse manager on duty and document the occurence D. See a private health-care provider on the nurse's time off but charge the hospital

C. The nurse's first action is to notify the charge nurse so a replacement can be arranged to take over the care of the clients. The nurse should notify the nurse manager. Complete an occurence for documentation.This provides documentation for workers comp case.

The client who just had a 3 min seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement? A. perform a complete neurological assessment B. Awaken the client every 30 min C. Turn the client to the side and allow the client to sleep D. Interview the client to find out what caused the seizure

C. Turn the client to the side and allow the client to sleep (during postictal phase, client is very tired and should be allowed to rest quietly)

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke? A. blood glucose level of 480 mg/dL B. A right-sided carotid bruit C. a blood pressure of 220/120 mmHg D. the presence of bronchogenic carcinoma

C. a blood pressure of 220/120 mmHg (uncontrolled HTN is a risk factor for hemorrhagic stroke)

the client one day postoperative total hip replacement complains of hearing a "popping sound" when turning. Which assessmenst data should the nurse report IMMEDIATELY to the surgeon? A. dark red-purple discoloration B. equal length of lower extremeties C. groin pain in the affected leg D. edema at the incision site

C. groin pain or increasing discomfort in the affected leg and the "popping sound" indicate the leg has dislocated, which should be reported immediately to the HCP for a possible closed reduction

the nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider IMMEDIATELY? A. localized edema and discoloration occurrinr hrs after the injury B. generalized weakness and increasing sensitivity to touch C. Dorsalis pedal pulse cannot be located with doppler and increasing pain D. pain relieved after taking four mg hydromorphone, a narcotic analgesic

C. if the nurse cannot hear the pedal pulse with a Dopplerband the client's pain is increasing, the nurse should notify the health-care provider. These are signs of neurovascular compromise

The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? A. placing the gait belt around the clients waist prior to ambulating B. places the client on the back with the clients head to the side C. places a hand under the clients right axilla to move up in bed D. praises the client for attempting to perform ADL's independent

C. places a hand under the clients right axilla to move up in bed

The client diagnosed with Parkinson's disease is being discharged. Which statement made by the significant other indicates UNDERSTANDING of the discharge instructions? A. All of my spouse's emotions will slow down now just like his body movements B.My spouse may experience hallucinations until the medication starts working C. I will schedule appointments late in the morning after his morning bath D. it is fine if we don't follow a strict medication schedule on the weekends

C. scheduling appointments late in the morning gives the client the chance to complete ADLs without pressure and allows the medications time to give the best benefits

The elderly client has coronary artery disease. Which question should the nurse ask the client during the client teaching? A. do you have a daily bowel movement? B. Do you get yearly chest x-rays (CXRs)? C. are you sexually active? D. Have you had any weight gain?

C. sexually activity is a risk factor for angina resulting from coronary artery disease. The clients being elderly should not affect the nurse's assessment of the client's concerns about sexual activity.

To which member of the healthcare-team should the nurse refer the client diagnosed with OA who is complaining of nit being able to get in and out of the bathtub? A. Physiatrist B. social worker C. Physical therapist D.Counselor

C. the physical therapist is able to help the client with transferring, ambulation, and other lower extremity difficulties

the client is being evaluated for osteoporosi. Which diagnostic test is the MOST ACCURATE when diagnosing osteoporosis? A. X-ray of the femur B. serum alkaline phosphatase C. Dual-energy x-ray absorptiometry (DEXA) D. serum bone Gla-protein test

C. this test measures bone density in the lumbar spine or his and is considered to be highly accurate

the client is complaining of joint stiffness, especially in the morning. Which DIAGNOSTIC tests should the nurse expect the health-care provider to order to R/O osteoarthritis? A. full-body magnetic resonance imaging scan B. serum studies for synovial fluid amount C. X-ray of the affected joints D. Serum erythrocyte sedimentation rate (ESR)

C. x-rays reveal the loss of joint cartilage, which appears as a narrowing of the joint space in clients diagnosed with OA

the nurse is preparing the preoperative client for a total hip replacement (THR). Which intervention should the nurse implement postoperatively? A. keep an abduction pillow in place between the legs at all times B. cough and deep breathe at least every 4 to 5 hrs C. turn to both sides every 2 hrs to prevent pressure ulcers D. Sit in a high-seated chair for a flexion of less than 90 degrees

D using a high-seated toilet and chair will help prevent dislocatio by limiting the flexion to less than 90 degrees

The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first? A. Push aside any furniture B. place the client on his side C. Assess the client's vital signs D. Ease the client to the floor

D. Ease the client to the floor ( the should not remain in the chair during a seizure. He should be brought safely to the floor so that he will have room to move the extremities)

The nurse researcher is working with clients diagnosed with Parkinson's disease. Which is an example of an EXPERIMENTAl therapy? A. Stereotactic pallidotomy/thalamotomy B. Dopamine receptor agonist medication C. Physical therapy for muscle strengthening D. Fetal tissue transplantation

D. Fetal tissue transplantation has shown some success in PD, but it is an experimental and highly controversial procedure. hint:test taker should not overlook adjective "experimental".

the nurse is discharging a client who had a total hip replacement.Which statement indicates FURTHER teaching is needed? A. i should not cross my legs because my hip may come out of the socket B. i will call my HCP if i have a sudden increase in pain C. I will sit on a chair with arms and a firm seat D. After 3 weeks I don't have to worry about infection

D. Infections are possible months after surgery. Clients should monitor temperatures and report any signs of infection

The nurse is admitting a client with the diagnosis of Parkinson's disease. Which assessment data SUPPORT this diagnosis? A. crackles in the upper lung fields and jugular vein distention B. Muscle weakness in the upper extremities and ptosis C.Exaggerated arm swinging and scanning speech D. Masklike facies and shuffling gait

D. Masklike facies and a shuffling gait are two clinical manifestations of PD

The male client diagnosed with essential hypertension has been prescribed an alpha-adrenergic blocker. Which intervention should the nurse discuss with the client? A. eat at least one banana a day to help increase the potassium level B.explain the impotence is an expected side effect of the medication C. take the medication on an empty stomach to increase absorption D Change position slowly when going from a lying to sitting position

D. Orthostatic hypotension may occur when the blood pressre is decreasing and may lead to dizziness and light-headedness, so the client should change position slowly

The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care? A. Observe the client swallowing for possible aspiration B. position the client in a semi-Fowler's position when sleeping C. Place a suction setup at the clients bedside during meals D. Refer to the client to an occupational therapist for evaluation

D. Refer to the client to an occupational therapist for evaluation (ONLY collaborative intervention)

The nurse caring for a client diagnosed with Parkinson's disease writes a problem of "impaired nutrition". Which nursing intervention would be included in the plan of care? A. Request the physical therapist to consult for equipment needed. B. Request a low-fat, low-sodium diet from the dietary department. C. Provide three (3) meals per day that include nuts and whole-grain breads. D. Offer six (6) meals per day with soft consistency

D. The clients energy levels will not sustain eating for long periods. offering frequent and easy-to-chew (soft) meals of small proportions is the preferred dietary plan. hint: the correct answer for a nursing problem question must address the actual problem.

the 34 yr old client is a resident in a long-term care facility. Which intervention should be implemented to help PREVENT complications secondary to osteoporosis? A. keep the bed in the high position B. perform passive range-of-motion exercises C. turn the client every 2 hrs D. provide nighttime lights in the room

D. nighttime lights will help prevent the client from falling: fractures are the number one complication of osteoporosis

the client newly diagnosed with osteoporosis is prescribed calcitonin by nasal spray. Which assessment data indicate to the nurse an ADVERSE effect of the medication? A. the client complains of nausea and vomitting B. the client is drinking 2 glasses of milk a day C. the client has a runny nose and nasal itching D> the client has had numerous episodes of nosebleeds

D. nosebleeds are adverse affects and should be reported to the client's HCP hint: if no idea of answer, select bleeding. bleeding is abnormal and indicates an adverse affect

The male client is diagnosed with coronary artery disease (CAD) and is prescribed sublingual nitroglycerin.. Which statement indicates the client needs more teaching? A. I should keep the tablets in the dark-colored bottle they came in B. if tablets do not burn under my tongue, they are not effective C. I should keep the bottle with me in my pocket at all times D. if my chest pain is not gone with one tablet, i will go to the ER

D. the client should take one tablet every five minutes and, if no relief occurs after the third tablet,have someone drive him to emergency or call 911

the nurse is caring for the client who has had total hip repalcement. Which data indicate the surgical treatment is EFFECTIVE? A. the client states the pain is at a "3" on a 1 to 10 B. the client has limited ability to ambulate C. the client's left leg is shorter than the right leg D. the client ambulates to the bathroom

D. the hip should have functional motion and the client should be able to ambulate to the bathroom. This indicates surgical treatment has been effictive

the nurse is discharging a client with a health-care facility aquired urinary tract infection. Which information should the nurse include in the discharge teaching? A. limit fluid intake so the urinary tract can heal B. Collect a routine urine specimen for culture C. take all the antibiotics as prescribed D. tell the client to void every five to six hours

. the client should be taught to take all the prescribed medication anytime a prescription is written for antibiotics

the nurse performsbladder irrigation through an indwelling catheter. The nurse instilled 90 ml of sterile normal saline. The catheter drained 710 mL. What is the client's output? ____________________

620 mL of urine. the amount of sterile normal saline is subracted from the total volume removed from the catheter

the nurse emptied 2,000 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There was 1,800 mL left in the bag eight hrs later. What is the correct urine output at the end of the eight hrs. ? ______________________

800 mL irrigation fluid: 3,000 - 1,800 = 1,200 mL of irrigation fluid Subract 1,200 mL of irrigation fluid from the drainage of 2,000 mL to determine urine output: 2,000 - 1,200 = 800 mL of urine output

the nurse is inserting an indwelling catheter into a female client. Which interventions should be implemented? RANK IN ORDER OF PERFORMANCE A. explain procedure to client B. set up the sterile field C. inflate the catheter bulb D. place absorbent pads under the client E. clean the perineum from clean to dirty with Betadine

A, D, B, C, E A. the procedure should be explained to client D. incontinence pads should be placed under the client before beginning the sterile part of the procedure B. the sterile field must be set up prior to checking the bulb and cleaning the client's perineum C. the bulb of the catheter should be tested to make sure it will inflate and deflate prior to inserting the catheter into the client E. during the procedure, the perineum is swiped with Betadine swabs from front to back and also down the middle, then side to side with new swabs (clean to dirty)

Which client would the nurse identify as being most at risk for experiencing a CVA? A. 55 African American male B. 84 Japanese female C. 67 Caucasian male D. 39 pregnant female

A. 55 African American male AA's have twice the rate of CVAs as Caucasians

the home health nurse is completing the admission assessment for a 76 yr old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care? A. Assess the client's ability to read small print B. Monitor the client's serum prothrombin time (PT) level C. Teach the client how to perform a hemoglobin A1c test daily D. Instruct the client to check the feet weekly

A. Age related visual changes and diabetic retinopathy could cause the client to have difficulty in reading and drawing up insulin dosage accurately

which oral medication should the nurse QUESTION before administering to the client with peptic ulcer disease? A. E-mycin, an antibiotic B. Prilosec, a proton pump inhibitor C. Flagyl, an antimicrobial agent D. Tylenol, a nonnarcotic analgesic

A. E-mycin is irritating to the stomach, and its use in a client with petic ulcer disease should be questioned

the nurse administererd 28 units of Humulin N, an intermediate -acting insulin, to a client diagnosed with type I diabetes at 1600. Which intervention should the nurse implement? A. ensure the client eats the bedtime snack B. determine how much food the client ate at lunch C. perform a glucometer at 0700 D. offer the client protein after administering insulin

A. Humulin N peaks in six (6) to eight hrs, making the client at risk for hypoglycemia around midnight, which is why the client should receive a bedtime snack. This snack will prevent nighttime hypoglycemia

the client diagnosed with IBD is prescribed total parenteral nutrition (TPN). Which intervention should the nurse implement? A. check the client's glucose level B. administer an oral hypoglycemic C. assess the peripheral inravenous site D. monitor the client's oral food intake

A. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely

the nurse is caring for the following clients. After receiving the shift report, which client should the nurse assess FIRST? A. the client with a total knee replacement who is complaining of a cold foot B. the client diagnosed with osteoarthritis who is complaining of stiff joints C. the client who needs to receive a scheduled intravenous antibiotic D the client diagnosed with back pain who is scheduled for a lumbar myelogram

A. a cold foot in a client who has had surgery may indicate a neurovascular compromise and must be assessed first

the client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit? A. complaints of extreme fatigue and hair loss B. exophthalmos and complaints of nervousness C. complaints of profuse sweating and flushed skin D. tetany and complaints of stiffness of the hands

A. a decreased in thyroid hormone causes decreased metabolism, which leads to fatigue and hair loss

the nurse is caring for a pregnant client diagnosed with acute pyelonephritis. Which scientific rationale supports the client being hospitalized for this condition? A. the client must be treated aggressively to prevent maternal/fetal complications B. the nurse can force the client to drink fluids and avoid nausea and vomiting C. the client will be dehydrated and there won't be sufficient blood flow to the baby D. pregnant clients historically are afraid to take the antibiotics as ordered

A. a pregnant client diagnosed with a UTI will be admitted for agressive IV antibiotic therapy. After symptoms subside, the client will be sent home to complete the course of treatment with oral medications.

The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, I don't know what you mean. What are auras? Which statement by the nurse would be the best response? A.Some people have a warning that the seizure is about to start B. Auras occur when you are physically and psychologically exhausted C.you're concerned that you do not have auras before your seizures? D. Auras usually cause you to be sleepy after you have a seizure

A. an aura is a visual, an auditory, or an olfactory occurrence that takes place prior to a seizure and warns the client a seizure is about to occur. The aura oftens allows tiime for client to lie down on the floor or find safe place to have seizure. Hint: if stem of question has client asking question, give factual information.

the client asks, "what does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? A. an elevated PSA can result from several different causes B. an elevated PSA can be only from prostate cancer C. an elevated PSA can be diagnostic for testicular cancer D. an elevated PSA is the onlytest used to diagnose BPH

A. an elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct

which physical examination should the nurse implement FIRST when assessing the client diagnosed with peptic ulcer disease? A. ausculate the client's bowel sounds in all four qudrants B. palpate the abdominal area for tenderness C. percuss the abdominal borders to identify organs D. assess the tender area progressing to nontender

A. ausculation should be used prior to palpation or percussion when assessing the abdomen. Manipulation of the abdomen can alter bowel sounds and give false information

the nurse identifies the client problem "riskfor imbalaced body temperature" for the client diagnosed with hypothyroidism. Which intervention should be included in the plan of care ? A. discourage the use of an electric blanket B. assess the client's temperature every two hrs C. keep the room temperature cool D. space activities to promote rest

A. external heat sources 9 heatings pads, electric or warming blankets) should be discouraged because they increase the risk of peripheral vasodilation and vascular collapse

the client is reporting chills, fever and left costovertebrel pain. Which diagnostic test should the nurse expect the HCP to prescribe FIRST? A. a midstream urine for culture B. a sonogram of the kidney C. an intravenous pyelogram for renal calculi D. a CT scan of the kidneys

A. fever, chills, and costovertebral pain are symptoms of a urinary tract infection (acute pyelonephritis), which requires a urine culture first to confirm the diagnosis

the client diagnosed with AIDS is experiencing voluminous diarrhea. Which interventions should the nurse implement? SELECT ALL THAT APPLY A. monitor diarrhea, charting amount, character, and consistecy B. assess the client's tissue turgor every day C. encourage the client to drink carbonated soft drinks D. wegh the client daily in the same clothes and at the same time E. assist the client with a warm sitz bath PRN

A. it is important to keep track of the amounts, color, and other characteristics of body fluids excreted D. daily weights are the best method of determining fluid loss and gain E. sitz baths will assist in keeping the client's parianal area clean without having to rub. The warm water is soothing, providing comfort

the nurse is caring for clients on a medical unit. Whch client information should be brought to attention of the HCP IMMEDIATELY? A. a serum sodium of 128 mEq/L in a client diagnosed with obstipation B. the client diagnosed with fecal impaction who had two hard formed stools C. a serum potassium level of 3.8 mEq/L in a client diagnosed with diarrhea D. the client with diarrhea who had two semiliquid stools totaling 300 mL

A. normal serum sodium levels are 135 to 152 mEq/L, so the client's 128 mEq/L value requires intervention

the nurse is caring for an adult client diagnosed with GERD. which condition is the MOST COMMON comorbid disease associated with GERD? A. adult-onset asthma B. pancreatitis C.Peptic ulcer disease D. increased gastric emptying

A. of adult-onset asthma cases, 80% to 90% are caused by gastroesophageal reflux disease (GERD)

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge? A. oral anticoagulant B. beta blocker C. anti-hyperuricemic D. thrombolytic

A. oral anticoagulant

the nurse is performing an admission assessment on a client diagnosed with GERD. Which signs and symptoms would indicate GERD? A. pyrosis, water brash, and flatulence B. weight loss, dysarthria, and diarrhea C. decreased abdominal fat, proteinuria, and constipation D. midepigastric pain, positive h. pylori test, and melena

A. pyrosis is heartburn, water brash is the feeling of saliva secretion as a result of reflux, and flatulence is gas- all symptoms of GERD

the 68 yr old client diagnosed with hyperthyroidism is being treated with radioactive iodine therapy. Which interventions should the nurse discuss with the client? A. explain it will take up to a month for symptoms of hyperthyroidism to subside B. teach the iodine therapy will have to be tapered slowly over one week C. discuss the client will have to be hospitalized during radioactive therapy D. inform the client after therapy the client will not have to take any medication

A. radioactive iodine therapy is used to destroy the overactive thyroid cells. After treatment, the client is followed closely for three to four weeks until the euthyroid state is reached

the nurse carinf for a client diagnosed with GERD writes the client problem of "behavior modification". Which intervention should be included for this problem? A. teach the client to sleep with a foam wedge under the head B. encourage the client to decrease the amount of smoking C. instruct the client to take over-the-counter medication for relief of pain D. discuss the need to attend alcoholics annonymous to quit drinking

A. the client should elevate the head of the bed on blocks or use a foam wedge to use gravity to help keep the gastric acid in the stomach and prevent reflux into the esophagus. Behavior modification is changing one's behavior

which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? A. sit in a warm sitz bath for 10 to 20 min several times daily B. sit in the chair with the feet elevated for two hrs daily C. drink at least 3,000 mL of oral fluids, especially tea and coffee, daily D. stop broad-spectrum antibiotics as soon as the symptoms subside

A. the client should sit in a warm sitz bath for 10 to 20 min several times each day to provide comfort and assist with healing

the nurse is caring for a client diagnosed with rule-out peptic ulcer disease. Which test CONFIRMS this diagnosis? A. esophagogastroduodenoscopy B. magnetci resonance imaging (MRI) C. occult blood test D. gastric acid stimulation

A. the esophagogastroduodenoscpy (EGD) is an invasive diagnostic test that visualizes the esophgus, stomach, and duodenum to accurately diagnose an ulcer and evaluate the effectiveness of the client's treatment

the elderly client is admitted to the intensive care department diagnosed with severe HHNS. Which collaborative intervention should the nurse include in the plan of care? A. infuse 0.9% normal saline intravenously B. Administer intermediate-acting insulin C. perform blood glucometer checks daily D. Monitor arterial blood gas (ABG) results

A. the initial fluid replacement is 0.9% normal saline ( an isotonic solution) intravenously, followed by 0.45% saline. The rate depends on the client's fluid volume status and physical health, especially of the heart

the diabetic educator is teaching a class on diabetes type I and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? SELECT ALL THAT APPLY A. take diabetic medication even if unable to eat the client's normal diabetic diet B. If unable to eat, drink liquids equal to the client's normal cloric intake C. it is not necessary to notify the health-care provider (HCP) if ketones are in the urine D. test blood glucose levels and test urine ketones once a day and keep a record E. call the health-care provider if glucose levels are higher than 180 mg/dl

A. the most important issue to teach client's is to take insulin eve if they are unable to eat. Glucose levels are increased with illness and stress B. the client should drink liquids such as regular cola or orange juice, or eat regular gelatin, which provide enough glucose to prevent hypoglycemia when receiving insulin E. the HCP should be notified if the blood glucose level is high. Regular insulin may need to be prescribed to keep the blood glucose level within acceptable range

the client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? SELECT ALL THAT APPLY A. maintain adequate ventilation B. assess fluid volume status C. administer intravenous potassium D. check for urinary ketones E. monitor intake and output

A. the nurse should always address the airway when a client is seriously ill. B. the client must be assessed for fluid volume deficit and then for fluid volume excess after fluid replacement is started C. the electrolyte imbalance of primary concern is depletion of potassium D. ketones are excreted in the urine; levels are documented from negative to large amount. Ketones should be monitored frequently E. the nurse must ensure the client's fluid intake and output are equal hint; select all answers that apply. Do not try to outguess the item write. In some instances all options are correct.

the client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40 and cool and clammy skin. which interventions should the nurse implement? SELECT ALL THAT APPLY A. assess the urine in the continuous irrigation drainage bag B. decrease the irrigation fluid in the continuous irrigation catheter C. lower the head of the bed while raising the foot of the bed D. contact the surgeon to give an update on the client's condition E. check the client's postoperative creatine and BUN

A. the nurse should assess the drain postoperatively C. the head of the bed should be lowered and the foot should be elevated to shunt blood to the central circulating system D. the surgeon needs to be notified of the change in condition

the client diagnosed with type I diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement FIRST? A. administer 50% dextrose (IVP) B. notify the health-care provider C. move the client to the ICU D. check the serum glucose level

A. the nurse should assume the client is hypoglycemic and administer IVP dextrose, which will rouse the client immediately. If the collapse is the result of hyperglycemia, this additional dextrose will not further injure the client hint; test taker should select the intervention directly treating the client; do not select a diagnostic test

the nurse is developing a care plan for the client diagnosed with type I diabetes. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an APPROPRIATE short-term goal for the client? A. the client will have a blood glucose level between 90 and 140 mg/dl B. the client will demonstrate appropriate insulin injection technique C. the nurse will monitor the client's blood glucose levels four (4) times a day D. the client will maintain normal kidney function with 30-mL/hr urine output

A. the short-term goal must address the response part of the nursing diagnosis, which is "high risk for hyperglycemia", and this blood glucose level is within acceptable ranges for a client who is noncompliant

the client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? A. my pain goes away when I have a bowel movement B. I have bright red blood in my stool all the time C. I have episodes of diahhrea and constipation E. my abdomen is hard and rigid and I have a fever

A. the terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation

the client presents to the emergency department experiencing frequent watery, bloody stools after eating some undercooked meat at a fast -food restaurant. Which intervention should be implemented FIRST? A. obtain a stool sample from the client B. initiate antibiotic therapy intravenously C. have the laboratory draw a complete blood count D. administer the antidiarrheal medication Lomotil

A. this client may have developed an infection from the undercooked meat. The nurse should obtain a stool specimen for the laboratory to analyze

which statement indicates discharge teaching has been effective for the client who is postopperative TURP? A. i will call the surgeon if I experience any difficulty urinating B. i will take my Proscar daily, the same as before my surgery C. i will continue restricting my oral fluid intake D. i will take my pain medication routinely even if I do not hurt

A. this indicates the teaching is effective

the client has dark, watery, and shiny-appearing stool. Which intervention should the nurse implement FIRST? A. check for fecal impaction B. encourage the client to drink fluids C. check the chart for sodium and potassium levels D. apply a protective barrier cream to the perianal area

A. this is a symptom of diahhrea moving around an impaction higher up in the colon. The nurse should assess for an impaction when observing this finding

The nurse is teaching the client recently diagnosed with essential hypertension. Which instruction should the nurse provide when discussing heart healthy exercise? A. walk at least 30 minutes a day on flat surfaces. B. Perform light weight lifting three times a week C. Recommend high-intensity aerobics daily D. Encourage the client to swim laps once a week

A. walking 40 to 45 min a day will help to reduce blood pressure, weight, and stress and will increase a feeling of overall well-being

the nurse is teaching the client that is diagnosed with hyperthyroidism. Which information should be taught to the client? SELECT ALL THAT APPLY A. notify the HCP if 3 lb weight loss occurs in two days B. discuss ways to cope with the emotional lability C. Notify the HCP if taking over-the-counter medication D. Carry a medical identificatin card or bracelet E. Teach how to take thyroid medications correctly

A. weight loss indicates the medication may not be effective and will probably need to be increased B. the client needs to know emotional highs and lows are secondary to hyperthyroidism. With treatment, this emotional lability will subside. C. any over-the-counter medications may negatively affect the client's hyperthyroidism or medications being used for treatment D. this will help any HCP immediately know of the client's condition, especially if the client is unable to tell the HCP

which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? A. twenty bloody stools a day B. oral temperature at 102 F C. hard, rigid abdomen D. urinary stress incontinence

A.the colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten to 20 bloody stools is the most commonsymptom of ulcerative colitis

which assessment data indicate to the nurse the client's gastric ulcer ha PERFORATED? A. complaints of sudden, sharp, substernal pain B. Rigid, boardlike abdomen with rebound tenderness C. frequent, clay-colored, liquid stool D. complaints of vague abdominal pain in the right upper quadrant

B a rigid boardlike abdomen with rebound tenderness is the classic sign/symptom of peritonitis, which is a complication

the nurse is caring for a client with chronic pyelonephritis. Which assessment data support the diagnosis of chronic pyelonephritis? A. the client has fever, chills, flank pain, and dysuria B. the client complains of fatigue, headaches, and increased urination C. the client had a group B beta-hemolytic strep infection last week D. th client has an acute viral pneumonia infection

B fatigue, headache, and polyuria as well as loss of weight, anorexia, and excessive thirst are symptoms of chronic pyelonephritis

which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU? A. glucose B. Potassium C. Calcium D. Sodium

B the client in DKA loses potassium from increased urinary output, acidosis, catabolic state, and vomiting. Replacement is essential for preventing cardiac dysrhythmias secondary to hypokalemia

an 18 yr old female client, 5' 4" tall, weighing 113kg, comes to the clinic for a nonhealing wound on her lower leg, which she has had two weeks. Which disease process should the nurse suspect the client has developed? A. type I diabetes B. type II diabetes C. Gestational diabetes D. acanthosis nigricans

B type 2 diabetes is a disorder occurring around the age of 40, but it is now being detected in children and young adults as a result of obesity and sedentary lifestyles. Nonhealing wounds are a hallmark sign of type 2 diabetes. The client weighs 248,6 lbs and is short

the client admitted with the diagnosis of a fractured hip who is in Buck's traction is complaining of severe pain. Which intervention should the nurse implement? A. adjust the patient-controlled analgesia (PCA) machine for a lower dose B. Ensure the weights of the Buck's traction are off the floor and hang freely C. Raise the head of the bed to 45 degrees and the foot 15 degrees D. Turn the client on the affected leg using pillows to support the other leg

B weights from the traction should be off the floor and hanging freely. Buck's traction is used to reduce muscle spasms preoperatively in client's who have fractured hips.

the client with type 2 diabetes controlled with biguanide oral diabetic medication is scheduled for a computed tomography (CT) scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? A. Provide a high-fat diet 24 hrs prior to test B. Hold the biguanide medication for 48 hrs prior to test C. Obtain an informed consent form for the test D. Administer pancreatic enzymes prior to the test

B. Biguanide medication must be held for a test with contrast medium because it increases the risk of kactic acidosis, which leads to renal problems

The client diagnosed with Parkinson's disease is being admitted with a fever and patchy infiltrates in the lung fields on the chest exray. Which clinical manifestations of PD would explain these assessment data? A. masklike facies and shuffling gait? B. Difficulty swallowing and immobility C.Pill rolling of fingers and flat affect D. lack of arm swing and bradykinesia

B. Difficulty swallowing places the client at risk for aspiration. Immobility predisposes the client to pneumonia. Both clinical manifestations place the client at risk for pulmonary complications. hint; nurse must recognize clinical manifestations of disease and resulting bodily comprimise.

the client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data WARRANT IMMEDIATE intervention by the nurse? A. serum blood glucose level of 74 mg/dL B. pulse oximeter reading of 90% C. telemetry reading showing sinus bradycardia D. the client is lethargic and sleeps all the time

B. a pulse oximeter reading of less than 93% is significant. A 90% pulse oximeter reading indicates a Pao2 of approximately 60 on an arterial blood gas test; this is severe hypoxemia and requires immediate intervention

the client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client NEEDS MORE teaching concerning the ileostomy? A. my stoma should be pink and moist B. i will irrigate my ileostomy every morning C. if I get a red, bumpy, itchy rash I will call my HCP D. i will change my pouch if it starts leaking

B. an ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces hint; this is an except question, and the test taker must identify which option is not a correct action for the nurse to implement. Sometimes flip the queston - which interventions indicate the client understands the teaching?

the nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is IMPROVING? A. the client is using the maximum amount allowed by the PCA pump B. the client's bladder spasms are relieved by medication C. the client's scrotum is swollen and tender with movement D. the client has passed a large, hard, brown stool this morning

B. bladder spasms are common, but being relieved with medication indicates the condition is improving

the dietician and the nurse in a long-term care facility are planning the menu for the day. Which foods should be recommended for the immobile clients for whom swallowing IS NOT an issue? A. cheeseburger and milk shake B. canned peaches and a snadwich on whole-wheat bread C. mashed potatoes and mechanically ground red meat D. biscuits and gravy with bacon

B. canned peaches are soft and can be chewed and swallowed easily while providing some fiber; whole-wheat bread is higher in fiber than white bread. These foods will be helpful for clients whose gastric motility is slowed as a result of lack of exercise or immobility

the nurse at freestanding health-care clinic is caring for a 56 yr old male client who is homeless and is type 2 diabetic controlled with insulin. Which action is an example of client advocacy? A. ask the client if he has somewhere he can go and live B. arrange for someone to give him insulin at a local homeless shelter C. notify Adult Protective Services about the client's situation D. Ask the HCP to take the client off insulin because he is homeless

B. client advocacy focuses support on the client's autonomy. Even if the nurse disagrees with his living on the street, it is the client's right. Arranging for someone to give him his insulin provides for his needs and allows his choices.

the client is one day postoperative TURP. Which task should the nurse delegate to the UAP? A. increase the irrigation fluid to clear clots from the tubing B. elevate the scrotum on a towle roll for support C. change the dressing on the first postoperative day D. teach the client how to care for the continuous irrigation catheter

B. elevating the scrotum on a towel for support is a task that can be delegated to the UAP

which statement made by the client indicates to the nurse the client may be experiencing GERD? A. my chest hurts when I walk up the stairs in my home B. I take antacid tablets with me wherever I go C. my spouse tells me I snore very loudly at night D. I drink six to seven soft drinks every day

B. frequent use of antacids indicates an acid reflux problem

which signs/symptoms should make the nurse suspect the client is experiencing a thyroid storm? A. obstipation and hypoactive bowel sounds B. hyperpyrexia and extreme tachycardia C. hypotension and bradycardia D. decreased respirations and hypoxia

B. hyperpyrexia (high fever) and rate above 130 beats per minute are signs of thyroid storm, a severely exaggerated hyperthyroidism

the nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one day postoperative TURP. Which intervention should the nurse implement? A. remove the indwelling catheter B. titrate the NS irrigation to run faster C. administer protamine sulfate IVP D. administer vitamin K slowly

B. increasing the irrigation fluid will flush out the clots and blood

the client with a history of peptic ulcer disease is admitted into the intensivecare department with frank gastric bleeding. Which PRIORITY intervention should the nurse implement? A. maintain a strict record of intake and output B. insert a nasogastric (N/G) tube and begin saline lavage C. assist the client with keeping a detailed calorie count D. provide a quiet environmet to promote rest

B. inserting a nasogastric tube and lavaging the stomach with saline is the most important intervention because this directly stops the bleeding

the nurse is caring for a client who uses cathartics frequently. which statement made by the client indicates an UNDERSTANDING of the discharge teaching? A. in the future I will eat a banana every time I take the medication B. I don't have to have a bowel movement every day C. I should limit the fluids I drink with my meals D If I feel sluggish, I will eat a lot of cheese and dairy products

B. it is not necessaryto have a bowel movement every day to have normal bowel functioning

which expected outcome should the nurse include for a client diagnosed with peptic ulccer disease? A. the client's pain is controlled with the use of NSAIDs B. the client maintains lifestyle modifications C. the client has no signs and symptoms of hemoptysis D. the client has antacids with each meal

B. maintaining lifestyle changes such as following an appropriate diet and reducing stress indicate the client is complying with the medical regimen. Compliance is the goal of treatment to prevent complications

the male client tells the nurse he has been experiencing "heartburn" at night that awakens him. Which assessment question should the nurse ask? A. how much weight have you gained recently? B what have you done to alleviate the heartburn? C. do you consume many milk and dairy products? D. have you been around anyone with a stomach virus?

B. most client's with GERD have been self-medicating with over-the-counter medications prior to seeking advice from a health-care provider.It is important to know what the client has been using to treat the problem.

the client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement FIRST? A. notify the health-care providre (HCP) B. assess the client for muscle weakness C. request telemetry for the client D. prepare to administer potassium IV

B. muscle weakness must be a sign of hypokalemia; hypokalemia can lead to dysrhythmias and can be life threatening. assessment is a priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L

the clinic is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibuotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication? A. the antibiotic will trat the bladder spasms that accompany a urinary tract infection B. if the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth C. in three months, the client should be rid of all bacteria in the urinary tract D. the HCP is providing the client with enough medication to treat future infection

B. some clients develop a chronic infection and must receive antibiotic theraoy as a routine daily medication to suppress the bacterial growth. The prescription will be refilled afte 90 days and continued

the charge nurse has just received the shift report. Which client should the nurse see FIRST? A. the client diagnosed with Crohn's disease who had two semiformed stools on the previous shift B. the eldery client admitted from another facility who is complaining of constipation C. the client diagnosed with AIDS who had a 200-mL diarrhea stool and has elastic skin tissue rigor D. the client diagnosed with hemorrhoids who had some spotting of bright red blood on the toilet tissue

B. the client has just arrived, so the nurse does not know if the complaint is valid and needs intervention unless assessed. The elderly have difficulty with constipation as a result of decreased gastric motility, medications, poor diet, and immobility

the UAP on the medical floor tells the nurse the client diagnosed with DKA wants something else to eat for lunch. Which interventions should the nurse implement? A. instruct the UAP to get the client additional food B. notify the dietician about the client's response C. request the HCP increase the client's caloric intake D. tell the UAP the client cannot have anything else

B. the client will not be compliant with the diet if he or she is still hungry. Therefore, the nurse should request the dietitian talk to the client to try to adjust the meals so the client will adhere to the diet hint; test take should select option attempting to ensure the client maintain compliance.

which assessment data indicate the client diagnosed with diabetic ketoacidosis is RESPONDING to the medical treatment? A. the client has tented skin turgor and dry mucous membranes B. the client is alert and oriented to date, time, and place C. the client's ABG results are pH 7.29, Paco2 44, HCO3 15 D. the client's serum potassium level is 3.3 mEq/L

B. the client's level of consciousness can be altered because of dehydration and acidosis. If the client's sensorium is intact, the client is getting better and responding to the medical treatment

The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which intervention should the nurse implement? A. notify the health-care provider if the potassium level is 3.8 mEq B. question administering medication if the BP is less than 90/60 mm Hg C. Do not administer the medication if the client's radial pulse is greater than 100 D. Monitor the client's BP while he or she is lying, standing, and sitting

B. the nurse should question administering the beta blocker if the BP is low because this medication will cause the blood pressure to drop even lower, leading to hypotension. Hint; must know normal laboratory data and assessment findings

Which client goal is MOST APPROPRIATE for a client diagnose with OA? A. perform passive range-of-motion exercises B.Maintain optimal functionality C. Client will walk 3 miles every day D client will join a health club

B. the two main goals of treatment for OA are pain management and optimizing functional ability of the joints to ensure movements of the joints hint; goal is measurable outcome

the HCP prescribes glucosamine and chondroitin for a client diagnosed with OA. What is the scientific rationale for prescribing this medication? A. it will help decrease the inflammation in the joints B. it improves tissue function and retards breakdown of cartilage C. it is a potent medication which decreases the client's joint pain D. it increases the production of synovial fluid in the joint

B. this is the rationale for administering these medications

which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease? A. history of side effects experienced from all medications B. use of nonsteroidal anti-inflammatory drugs (NSAIDs) C. any known allergies to drugs and environmental factors D. medical histories of at least three generations

B. use of NSAIDs places the client at risk for peptic ulcer disease and hemorrhage. NSAIDs suppress the production of prostaglandin in the stomach, which is a protective mechanism to prevent damage from hydrochloric acid

the client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? A. provide a low-rediue diet B. rest the client's bowel C. assess vital signs daily D. administer antacids daily

B. whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity? A. It is alright for me to drink coffee for breakfast B. My menstrual cycle will not effect my seizure disorder C. I am going to take a class in stress management D. I should wear dark glasses when I am out in the sun

C . Tension states, such as anxiety and frustration, induce seizures in some clients, so stress management may be helpful in preventing seizures hint: caffeine stimulant not recommended. mestrual cycle can affect seizure disorders

the nurse is assessing the feet of a client with long -term type 2 diabetes. Which assessment data WARRANT IMMEDIATE intervention by the nurse? A. the client has crumbling toenails B.the client has athletes foot C. the client has a necrotic big toe D. the client has thickened toenails

C a necrotic big toe indicates "dead" tissue. The client does not feel pain., does not realize the injury, and does not seek treatment. Increased blood glucose levels decrease the oxygen supply needed to heal the wound and increase the risk for developing an infection

the client diagnosed with type I diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result? A, this result is below normal levels B. this result is within acceptable levels C. this result is above recommended levels D. the result is dangerously high

C the result parallels a serum blood glucose level of approximately 180 to 200 mg/dl. See more info...

The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly? A. Alzheimer's disease B.Parkinson's disease (PD) C. Cerebral Vascular Accident (CVA,stroke) D. Brain atrophy due to aging

C. A CVA (stroke) is the leading ause of seizures in the elderly: increased intracranial pressure associated with the stroke can lead to seizures

The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate. A. Asses the client's neurological status every hour. B. Monitor the clients heart rhythm via telemetry. C. Administer an anticonvulsant medication by intravenous push. D.Prepare to administer a glucocorticosteroid orally

C. Administering an anticonvulsant medication by intravenous push requires the nurse to have an order or confer with another member of the healthcare team.

which disease is the client diagnosed with GERD at GREATER RISK for developing? A. hiatal hernia B. gastroenteritis C. esophagealcancer D. gastric cancer

C. Barrett's esophagus results from long-term erosion of the esophagus as a result of reflux of the stomach contents secondary to GERD. This is a precursor to esophageal cancer

the client being admitted from the emergency department is diagnosed with fecal impaction. WHich nursing intervention should be implemented? A. administer an antidiarrheal medication every day and prn B. perform bowel training every two hrs C. administer an oil retention enema D. prepare for an upper gastrointestinal (UAG) series x-ray

C. Oil retention enemas will help to soften the feces and evacuate the stool

the client diagnosed with OA is resident in a long-term care facolity. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed assistive personnel(UAP) ? A. allow client to stay in bed until the pain becomes bearable B. Tell UAP to give client a bed bath this morning C. Try to encourage the client to get up and go to the shower D. Notify the family the client is refusing to be bathed

C. Pain will decrease with movement, and warm or hot water will help decrease the pain. The worst thing the client can do is not move

the nurse has been assigned to care for a client diagnosed with peptic ulcer disease. Which assessment data REQUIRE FURTHER intervention? A. bowel sounds ausculated 15 times in one minute B. belcing after eating a heavy and fatty meal late at night C. a decrease in sysolic blood pressure (BP) of 20 mm Hg from lying to sitting D. a decreased frequency of distress located in the epigastric region

C. a decrease of 20 mm Hg in blood pressure after changing position from lying, to sitting, to standing is orthostatic hypotension. This could indicate the client is bleeding

the nurse preparing a plan of care for the client diagnosed with acute glomerulonephritis. Which statement is an APPROPRIATE long-term goal? A. the client will have a blood pressure within normal limits B. the client will show no protein in the urine C. the client will maintain normal renal function D. the client will have clear lung sounds

C. a long-term complication of glomerulonephritis is it can becomechronic if unresponsive to treatment, and this can lead to end-stage renal disease. Maintaining renal function is an appropriate long-term goal

the client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client UNDERSTANDS the diet teaching? A. grilled hamburger on a wheat bun and fried potatoes B. a chicken salad sandwich and lettuce and tomato salad C. roast pork, white rice, and plain custard D. fried fish, whole grain pasta, and fruit salad

C. a low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended

The charge nurse is making assignments on a cardiac unit. Which client should the charge nurse assign to a NEW GRADUATE nurse? A. the 44 yr old client diagnosed with a mycardial infarction B. the 65 yr old client admitted with unstable angina C. the 75 yr old client scheduled for a cardiac catheterization D. the 50 yr old client complaining of chest pain

C. a new graduate should be able to complete a preprocedure checklist and get this client to the catheterization laboratory

the nurse is planning the care of a client diagnosed with lower esophageal sphincter dysfenction. Which dietary modifications should be included in the plan of care? A. allow any of the client's favorite foods as long as the amount in limited B. have the client perform eructation excersises several times a day C. eat four to six small meals a day and limit fluids during mealtimes D. encourage the client to consume a glass of red wine with one meal a day

C. clients should eat small, frequent meals and limit fluids with the meals to prevent reflux into the esophagus from a distended stomach

the client diagnosed with type 2 diabetes is admitted to the intensive care unit (ICU) with hyperosmolar hyperglycemic nonketonic syndrome (HHNS) coma. Which assessment data should the nurse expect the client to exhibit? A. Kussmaul's respirations B. Diarrhea and epigastric pain C. Dry mucous membranes D. Ketone breath odor

C. dry mucous membranes are a result of hyperglycemia and occur with both HHNS and DKA

the nurse finds small, fluid-filled lesions on the margins of the client's surgical dressing. Which statement is the MOST APPROPRIATE scientific rationalenfor this occurrence? A. these were caused by the cautery unit in the operating room B. these are papular wheals from herpes zoster C. these are blisters from the tape used to anchor the dressing D. these macular lesions are from the latex allergy

C. fluid-filled blisters are from a reaction to the tape and usually occur along the margins of the dressing where the tape was applied

the client is taking calcium carbonate (Tums) to help PREVENT further development of osteoporosis. Which teaching should the nurse implement? A. encourage the client to take tums with at least 8 ounces of water B. teach the client to take tums with the breakfast meal only C. instruct the client to take tums 30 to 60 min before a meal D. discuss the need to get a monthly serum calcium level

C. free hydrochloric acid is needed for calcium absorption;mtherefore tums should be taken on an empty stomach

the elderly client is diagnosed with chronic glomerulonephritis. Which laboratory value indicates to the nurse the condition has BECOME WORSE? A. the blood urea nitrogen is 15 mg/dL B. the creatine level is 1.2 mg/dL C. the glomerular filtration rate is 40 mL/min. D. the 24 hr creatine clearance is 100 mL/min.

C. glomerular filtration rate (GFR) is approximately 120 mL/min. If the GFR is decreased to 40 mL/min., the kidneys are funtioning at about one-third filtration capacity

the nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type I diabetes. Which instruction is MOST IMPORTANT to discuss with the client? A. refer the client to the American Diabetes Association B. do not take any over-the-counter (OCT) medications C. take the prescribed insulin even when unable to eat because of illness D. explain the need to get the annual flu and pneumonia vaccines

C. illness increases blood glucose levels; therefore, the client must take insulin and consume high-carbohydrate foods such as regular jell-o, regular popsicles, and orange juice

Which is a common COGNITIVE problem associated with Parkinson's disease? A. emotional lability B. depression C. memory deficis D. Paranoia

C. memory deficits are cognitive impairments. The client may also develop dementia.

the charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the MOST EXPERIENCED nurse? A. the client with type 2 diabetes who has a blood glucose level of 348 mg/dL B. the client diagnosed with type I diabetes who is experiencing hypoglycemia C. the client with DKA who has multifocal premature ventricular contractions D. the client with HHNS who has a plasma osmolarity of 290 m)sm/L

C. multifocal PVCs, which are secondary to hypokalemia and can occur in clients with DKA, are a potentially life-threatening emergency. This client needs an experienced nurse.

the nurse is discussing osteoporosis with a group of women. Which factor will the nurse identify as a NONMODIFIABLE risk factor? A. calcium deficiency B tabacco use C. female gender D. high alcohol intake

C. nonmodifiable risk factor is factor client cannot change. 50% women will experience osteoporosis -related fracture in their lifetime

the client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assisstive personnel (UAP) tells the nurse the client has a headache and is really acting "funny". Which intervention should the nurse implement FIRST? A. instruct the UAP to obtain the blood glucose level B. have the client drink eight ounces of orange juice C. Go to the client's room and assess the client for hypoglycemia D. prepare to administer one (1) ampule 50% dextrose intravenously

C. regular insulin peaks in two (2) to four (4) hrs. Therefore, the nurse should think about the possibility the client is having a hypoglycemic reaction and should assess the client. The nurse should not delegate nursing tasks to UAP if a client is unstable

A 78-year old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority? A. prepare to administer rt-PA B. discuss precipitating factors that caused the symptoms C. schedule for a STAT CT scan of the head D. notify the speech pathologist for an emergency consult

C. schedule for a STAT CT scan of the head

the nurse, a licensed practical nurse (LPN), and an unlicesned assitive personnel (UAP) are caring for the clients on a medical floor. Which nursing task would be MOST APPROPRIATE to assign an LPN? A. assist the UAP to learn to perform blood glucose checks B. monitor the potassium levels of a client with diarrhea C. administer a bulk laxative to a client diagnosed with constipation D. assess the abdomen of a client who has had complaints of pain

C. the LPN can administer medications such as a laxative hint; nurses cannot delegate any activity requiring professional judgement, assessment, teaching, or evauation

the client diagnosed with crohn's disease is crying and tells the nurse, " i can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's BEST RESPONSE? A. i understand how frustrating this must be for you B. you mustbkeep thinking about the good things in your life C. i can see your very upset. ill sit down and we can talk D. are you thinking about doing anything like commiting suicide?

C. the client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk

the charge nurse is making assignments, staffing includes a registered nurse with five years of medical experience, a newly graduated registered nurse, and two unlicensed assitive personnel. Which client should be assigned to the MOST EXPERIENCED nurse? A. the 39 yr old client diagnosed with lower esophageal dysfunction who is complaining of pyrosis B. the 54 yr old client diagnosed with Barrett's esophagus who is scheduled to have an endoscopy this morning C. the 46 yr old client diagnosed with GERD who wheezes in all five lobes D. the 68 yr old client who is three days postoperative for hiatal hernia and needs to be ambulated four times a dA.

C. the client is exhibiting symptoms of asthma, a complication of GERD. this client should be assignes to the most experienced nurse

the client diagnosed with hypothyroidism is prescribed the thyroid hormone levothyroxine (Synthroid). WHich assessment data indicate the medication has been EFFECTIVE? A. the client has a 3 lb weight gain B. the client has a decreased pilse rate C. the client's temperature is WNL D. the client denies any diaphoresis

C. the client with hypothyroidism frequently has a subnormal temperature, so a temperature WNL indicates the medication is effective

the nurse is preparing a client diagnosed with GERD for surgery> Which information WARRANTS NOTIFYING the HCP? A. the client's Berstein esophageal test was positive B. the client's abdominal x-ray shows a hiatal hernia C. the client's WBC count is 14,000/mm3 D. the client's hemoglobin is 13.8g/dL

C. the client's WBC count is elevated, indicating a possible infection, which warrants notifying the HCP

the emergency department nurse is caring for a client diagnosed with HHNS who has a blood glucose of 680 mg/dl. Which question should the nurse ask the client to determine the cause of this acute complication? A. when is the last time you took your insulin? B. when did you have your last meal? C. have you had some type of infection lately? D. how long have you had diabetes?

C. the most common precipitating factor is infection. the manifestations may be slow to appear, with onset ranging from 24 hrs to two weeks

the nurse is caring for an 80 yr old client admitted with a fractured right feomoral neck who is oriented x1 . Which intervention should the nurse implement FIRST? A. check for a positive Homan's sign B. encourage the client to take deep breaths and cough C. determine the client's normal orientation staus D. Monitor the client's Buck traction

C. the nurse is not aware of the client's usual mental status so, before taking any further action, the nurse shoud determine what is normal or usual for this client hint; test taker needs to ynderstand what the question is askeing. Although the clien has a fractured hip, the orientation status is the unexpected symptom which requires assessment

the client is diagnosed with an acute exacerbation of IBD. Which PRIORITY intervention should the nurse implement? A. weigh the client daily and document in the client's chart B. teach coping strategies such as dietary modifications C. record the frequency, amount, and color of stools D. monitor the client's oral fluid intake every shift

C. the severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output

the nurse examining a 15 yr old female who is complaining of pain, frequency, and urgency when urinating. After asking the parent to leave the room, which question should the nurse ask the client? A. when was your last mensrtual cycle B. have you noticed any change in the color of your urine C. are you sexually active D. What have you taken for the pain

C. these are symptoms of cystitis, a bladder infection, which may be caused by sexual intercourse as a result of the introduction of bacteria into the urethea during the physical act. A teenager may not want to divulge this information in fron of the parent

The nurse is caring for clients on the orthopedic floor. Which client should be assessed FIRST? A. the client diagnosed with back pain who is complaining of a "4" on a 1-10 scale B. the client who has undergone a myelogram who is complaining of a slight headache C. the client two days post-disk fusion who has T 100.4, P 96, R 24, and BP 138/78 D. the client diagnosed with back pain who is being discharged and whose ride is here

C. this client is postoperative and now has a fever. This client should be assessed and the health-care provider should be notified

the nurse in caring for a client diagnosed with hemorrhaging duodenal ulcer. Which collaborative interventions should the nurse implement? SELECT ALL THAT APPLY A. perform a complete pain assessment B. Assess the client's vital signs frequently C. Administer a proton pump inhibitor intravenously D. obtain permission and administer blood products E. monitor intake of a soft, bland diet

C. this is a collaberative intervention the nurse should implement. It requires an order from the HCP D. administering blood products is collaberative, requiring an order form the HCP hint; COLLABORATIVE INTERVENTIONS

the client who is postoperative TURP asks the nurse, " when will I know if I will be able to have sex after my TURP?" Which response is MOST APPROPRIATE by the nurse? A. you seem anxious about your surgery B. tell me about your fears of impotency C. potency can return in six to eight weeks D. did you ask your doctor about your concern

C. this is usually the length of time clients need to wait prior to having sexual inercourse; this is the information the client wants to know

the client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease (IBD). Which intervention should the nurse discuss with the client? A. take this medication on an empty stomach B. notify the HCP is experiencing a moon face C. take the steroid medication as prescribed D. Notify the HCP if the blood glucose is over 160

C. this medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed

the nurse is preparing to administer the following medications. Which medication should the nurse QUESTION administering? A. the thyroid hormone to the client who does not have a T3, T4 level B. the regular insulin to the client with a blood glucose level of 210 mg/dL C. the loop diuretic to the client with a potassium level of 3.3 mEq/L D. the cardiac glycoside to the client who has a digoxin level of 1.4 mg/dL

C. this potassium level is below normal, which is 3.5 to 5.5 mEq/L. Therefore, the nurse should question administering this medication because loop diuretics cause potassium loss in urine

which medication order should the nurse question in the client diagnosed with untreated hypothyroidism? A. thyroid hormones B. oxygen C. sedatives D. laxatives

C. untreated hypothyroidism is characterized by an increased susceptibility to the effects of most hypnotic and sedative agents; therefore, the nurse should question this medication

The nurse is discussing the importance of exercise with the client diagnosed with coronary artery disease. Which intervention should the nurse implement? A. perform isometric exercises daily B. walk for 15 min three times a week C. do not walk outside if it is less than 40 F D. wear open-toed shoes when ambulating

C. when it is cold outside, vascoconstriction occurs, and this will decrease oxygen to the heart muscle. Therefore the client should not exercise when it is cold outside.

which statement by the client diagnosed with a fractured ulna indicates to the nurse the client NEEDS FURTHER teaching? A. I need to eat a high-protein diet to ensure healing B. I need to wiggle my fingers every hr to increase circulation C. I need to take my pain medication before my pain is too bad D. I need to keep this immobilizer on when lying down only

D The immobilizer should be kept on at all times. this indicates the client does not understand the teaching and nneds the nurse to provide more instruction

the client diagnosed with IBD is prescribed sulfalazine (Asulfidine), a sulfonamide antibiotic. Which statment best describes the rationale for administering this medication? A. it is administered rectally to help decrease colon inflammation B. this medication slows gastrointestinal (GI) motility and reduces diarrhea C. this medication kills the bacteria causing the exacerbation D. it acts topically on the colon mucosa to decrease inflammation

D asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process

the female client in an outpatient clinic is being sent home with a diagnosis of urinary tract infection (UTI). Which instruction should the nurse teach to PREVENT a recurrence of a UTI? A. clean the perineum from back to front after a bowel movement B. take warm tub baths instead of hot showers daily C. void immediately preceeding sexual intercourse D. avoid coffee, tea, colas, and alcoholic beverages

D. Coffee, tea, cola and alcoholic beverages are urinary tract irritants

The 85-yr old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first? A. administer a nonnarcotic analgesics B. Prepare for STAT MRI C. start an IV infusion with D5W at 100 mL/hr D. Complete a neurological assessment

D. Complete a neurological assessment (must determine the cause of the headache first)

The client diagnosed with OA is prescribed an oral nonsteroidal ant-inflammatory drug (NSAID). Which instruction should the nurse teach the client? A. take medication on an empty stomach B. Make sure to taper the medication when discontinuing C. Apply the medication topically over the affected joints D. Notify health-care provider if vomiting blood

D. NSAID are well known for causing gastric upset and increasing risk for peptic ulcer disease, which could cause the client to vomit blood

the client has been experiencing difficulty and straining when expelling feces. Which intervention should the nurse discuss with the client? A. explain some blood in the stool will be normal for the client B. instruct the client in manual removal of feces C. encourage the client to use a cathartic laxative on a daily basis D. place the client on a high-fiber diet

D. a high-fiber (residue) diet provides bulk for the colon to use in removing the waste products of metabolism. Bulk laxatives and fiber from vegetables and bran assist the colon to work more effectively

the nurse is administering morning medications at 0730. Which medication should have PRIORITY? A. a proton pump inhibitor B. a nonarcotic analgesic C. a histamine receptor antagonist D. a mucosal barrier agent

D. a mucosal barrier agent must be administered on an empty stomach for the medication to coat the stomach

the nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? A. eat a simple carbohydrate snack before exercising B. carry peanut butter crackers when exercising C. encourage the client to walk 20 min three times a week D. perform warm-up and cool-down exercises

D. all clients who exercise should perform warm-up and cool-down exercises to help prevent muscle strain and injury. see hint

the nurse is providing an in-service on thyroid disorders. One of the attendees asks the nurse, why don't the people in the United States get goiters as often? Which statement by the nurse is the BEST RESPONSE? A. it is because of the creening techniques used in the United States B. it is a genetic predisposition rare in north Americans C. the medications available in the United States decrease goiters D. iodized salt helps prevent the development of goiters in the United States

D. almost all of the iodine entering the body is retained in the thyroid gland. A deficiency in iodine will cause the thyroid gland to work hard and enlarge, whish is called a goiter. Goiters are commonly seen in geographical regions having an iodine deficiency. Most table salt in the US has iodine added.

the nurse has administered an antbiotic, a proton pump inhibitor, and Pepto-Bismol for peptic ulcer disease secondary to H. Pylori. Which data would indicate to the nurse the medications are EFFECTIVE? A. a decrease in alcohol intake B. maintaining a bland diet C. a return to previous activities D. a decrease in gastric distress

D. antibiotics, proton pump inhibitors, and Pepto-Bisol are administered to decrease the irriatation of the ulcerative area and cure the ulcer. A decrease in gastric distress indicates the medicine is effctive

which data support to the nurse the client's diagnosis of acute bacterial prostatitis? A. terminal dribbling B. urinary frequency C. stress incontinence D. sudden fever and chills

D. client's with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Client's with chronic prostatitis have milder symptoms

which assessment data support the client's diagnosis of gastric ulcer to the nurse? A. presence of blood in the client's stool for the past month B. reports of a burning sensation moving like a wave C. sharp pain in the upper abdoment after eating a heavy meal D. complaints of epigastric pain 30 to 60 min after ingesting food

D. in a client diagnosed with a gastric ulcer, pain usually occurs 30 to 60 min after eating but not at night. In contrast, a client with a duodenal ulcer has pain during the night often relieved by eating food. Pain occurs one to three hrs after meals.

the client diagnosed with osteoporosis asks the nurse, why does smoking cigarettes cause my bones to be brittle? which response by the nurse is MOST APPROPRIATE? A. smoking causes nutritional deficiencies, which contribute to osteoporosis B. Tobacco causes an increase in blood supply to the bones, causing osteoporosis C. Smoking low-tar cigarettes will not cause your bones to become brittle D. Nicotine impairs the absorption of calcium, causing decreased bone strength

D. nicotine slows production of osteoblasts and impairs the absorption of calcium

The client has been diagnosed with a stroke. The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge? A. obtain a rubber mat to place under the dinner plate B. purchase a long-handed bath sponge for showering C. purchase clothes with Velcro closure devices D. obtain a raised toilet seat for the clients bathroom

D. obtain a raised toilet seat for the clients bathroom (addresses clients weakness in being able to sit down and get up without straining muscles or requiring assistance)

the nurse is preparing a client diagnosed with GERD for discharge following an esophagogastroduodenoscopy (EGD). Which statement includes the client UNDERSTANDS the discharge instructions? A. i should not eat for at least one day following this procedure B. I can lie down whnever I want after a meal. it won't make a difference C. the stomach contents won't bother my esophagus but will make me nauseous D. i should avoid orange juice and eating tomatoesuntil my esophagus heals

D. orange juice and tomatoes are acidic, and the client diagnosed with GERD should avoid acidic foods until the esophagus has had a chance to heal

which problems should the nurse include in the plan of care for the client diagnosed with peptic ulcer disease to observe for physiological complications A. alteration in bowel elimination patterns B. knowledge deficit in the cause of ulcers C. inability to cope with changing family roles D. potential for alteration in gastric emptying

D. potential for alteration in gastric emptying is caused by edema or scarring associated with an ulcer, which may cause a feeling of "fullness", vomiting of undigested food, or abdominal distention

The client has been diagnosed with OA for the last 7 yrs and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which PSYCHSOCIAL client problem should the nurse identify? A. severe pain B. Body image disturbance C.Knowledge deficit D. Depression

D. the client experiencing chronic pain often experiences depression and hopelessness

which nursing intervention should be included in the plan of care for the client diagnosed with hyperthyroidism? A. increase the amount of fiber in the diet B. encourage a low-calorie, low-proyein diet C. decrease the client's fluid intake to 1,000 mL/day D. provide six small, well-balanced meals a day

D. the client with hyperthyroidism has an increased appetite; therefore, well-balanced meals served several time throughout the day will help with the client's constant hunger

The nurse is caring for a client diagnosed withnGERD. Which nursing interventions should be implemented? A. place the client prone in bed and administer nonsteroidal anti-inflammatory medications B.have the client remain upright at all times and walk for 30 min three times a week C. Instruct the client to maintain a right lateral side-lying position and take antacids before meals D. elevate the head of the bed (HOB) 30 degrees and discuss lifestyle modifications with the client

D. the head of the bed should be elevated to allow gravity to help in preventing reflux. Lifestyle modifications of losing weight, making dietary modifications, attempting smoking cessation, discontinuing the use of alcohol, and not stooping or bending at the waist all help to decrease reflux

The nurse is planning the care for a client diagnosed with Parkinson's disease. Which would be a therapeutic goal of treatment for the disease process? A. the client will experience periods of akinesia throughout the day B. the client will take the prescribed medications correctly C. the client will be able to enjoy a family outing with the spouse D. the client will be able to carry out activities of daily living

D. the major goal of treating PD is to maintain the ability to function. Clients with PD experience slow, jerky movements and have difficulty performing routine daily task. hint: test taker should match the goal to the problem. a Therapeutic goal is the key to answering this question.

the client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement FIRST? A. call the surgeon to inform the HCP of the client's complaint B. administer the client a narcotic medication for pain C. explain to the client this sensation happens frequantly D. assess the continuous irrigation catheter for patency

D. the nurse should always assess any complaint before dismissing it as a commonly ocurring problem

which statement made by the client makes the nurse suspect the client is experiencing hyperthyroidism? A. i just don't seem to have any appetite anymore B. i have a bowel movement about every three to four days C. my skin is really becomming dry and coarse D. i have noticed all my collars are getting tighter

D. the thyroid gland (in the neck) enlarges as a result of the increased need for thyroid hormone production; an enlarged gland is called a goiter

which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis? A. pH 7.34, Pao2 99, Paco2 48, HCO3 24 B. pH 7.38, Pao2 95, Paco2 40, HCO3 22 C. pH 7.46, Pao2 85, Paco2 30, HCO3 26 D. pH 7.30, Pao2 90, Paco2 30, HCO3 18

D. this ABG indicates metabolic acidosis, which is expected in a client diagnosed with diabetic ketoacidosis hint; test taker must know normal ABGs to be able to correctly answer this question

the client is placed on percutaneous endoscopic gastrotomy (PEG) tube feedings. Which occurrence WARRANTS IMMEDIATE intervention by the nurse? A. the client tolerates the feedings being infused at 50 mL/hr B. the client pulls the nasogastric feeding tube out C. the client complains of being thirsty D. the client has green, watery stool

D. this client needs to be cleaned immediately, the abdomen must be assessed, and a determination must be made regarding the type of feeding and the additives and medications being administered and skin damage occurring. This occurrence is priority

which nursing diagnosis is priority for the client who has undergone a TURP? A. potential for sexual dysfunction B. potential for altered body image C. potential for chronic infection] D. potential for hemorrhage

D. this is a potentially life-threatening problem hint: for most surgeries, the highest priority problem is hemorrhaging.

the client from a long-term care facility is admitted to the medical unit with a fever, hot flushed skin, and clumps of white sediment in the indwelling catheter. Which intervention should the nurse implement FIRST? A. start IV with a 20-gauge catheter B. initiate antibiotic therapy IVPB C. collect urine specimen for culture D. change the indwelling catheter

D. unless the nurse can determine the catheter has been inserted within a few days, the nurse should replace the catheter and then get a specimen. This will provide the most accurate specimen for analysis note: 4, 3, 1, 2 order of interventions

the client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dl. The client's blood glucose level is now 300 mg/dl. Which intervention should the nurse implement? A. Increase the regular insulin IV drip B. Check the client's urine for ketones C. provide the client with a therapeutic diabetic meal D. Notify the HCP to obtain an order to decrease insulin

D. when the glucose level is decreased to around 300 mg/dl, the regular insulin infusion therapy is decreased. Subcutaneous insulin will be administered per sliding scale

the nurse is admitting the client with OA to the medical floor. Which statement by the client indicates an ALTERNATIVE form of treatment for OA? A. i take medication every 2 hrs for my pain B. I use a heating pad when I go to bed at night C. I wear a copper bracelet to help with my OA D. I always wear my ankle splints when I sleep

c. alternative forms of treatment have not been proved efficacious in the treatment of a disease. the nurse should be nonjudgemental and open to discussions about alternative treatment, unless it interferes with medical regimen.

the clinic nurse is talking on the phone to a client who has diarrhea. Which intervention should the nurse discuss with the client? A. tell the client to measure the amount of stool B. recommend the client come to the clinic immediately C. explain the client should follow the BRAT diet D. discuss taking an over-the-counter histamine-2 blocker

c. the BRAT (bananas, rice, applesauce, and toast) diet is recommended for a client with diarrhea because it is a low residue and produces nutrition while not irritating the GI system

the client must take 3 grams of calcium supplements a day. the medication comes in 500 mg tablets. How many tablets will the client need to take daily? ___________________

six (read math given for reason)

the client diagnosed with type I diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (60 units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client? _________________

three (3) units. See more info....