Nurs 201 final

a nurse is teaching a client who has chronic kidney failure planning a low-protein diet. The client states, "why do I have to be concerned about protein?" Which of the following responses should the nurse make? "A low-protein diet reduces the risk for uremia." "A low-protein diet reduces the risk for edema." "A low -protein diet will reduce the risk for hyperkalemia." "A low-protein diet will increase the nitrogenous wastes in the blood."

"A low-protein diet reduces the risk for uremia."

a nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? "Don't worry; most clients dislike the prep more than the procedure itself." "Before the examination, your provider will give you a sedative that will make you sleepy." "I know you're anxious, but this procedure is recommended for people your age." "After you have signed the consent form, we can talk more about this."

"Before the examination, your provider will give you a sedative that will make you sleepy."

a nurse is assessing a client who has a suspected diagnosis of GBS. Which of the following questions should the nurse ask the client? "Do have a history of chronic alcohol abuse?" "Have you had a recent influenza infection?" "Have traveled overseas recently?" "Are you taking a multivitamin?"

"Have you had a recent influenza infection?"

a nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."

"I don't eat shellfish because it gives me hives."

a nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse reports to the client's provider? "My eye really itches, but I'm trying not to rub it." "I need something for the pain in my eye. I can't stand it." "It's hard to see with a patch on one eye. I'm afraid of falling." "The bright light in this room is really bothering me."

"I need something for the pain in my eye. I can't stand it." Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

a nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching? "I can expect to have swelling in my face." "I will lose protein in my urine." "I should expect my provider to prescribe a kidney biopsy." "I should increase my sodium intake."

"I should increase my sodium intake."

a nurse is presenting discharge instructions to a client who has MS. The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate? "Wear an eye patch on the right eye at all times." "Plan to relax in a hot tub spa each day." "Engage in a vigorous exercise program." "Implement a schedule to include periods of rest."

"Implement a schedule to include periods of rest."

a nurse is providing teaching to a client about interventions to reduce the risk of developing cardiovascular disease. Which of the following statements by the client should indicate to the nurse the need for further teaching? "A weight loss program can decrease my LDL cholesterol level." "Exercising regularly will increase HDL cholesterol levels." "Adding foods containing omega-3 fatty acids to my diet can lower my risk." "Increasing my intake of foods containing trans-fatty acids can lower my risk."

"Increasing my intake of foods containing trans-fatty acids can lower my risk." Increasing dietary intake of trans-fatty acids can cause an increase in LDL cholesterol, which increases the risk for developing cardiovascular disease.

a staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make? "It is caused by the lack of production of insulin by the pancreas.." "It is caused by the lack of production of aldosterone by the adrenal gland." "It is caused by the overproduction of growth hormone by the pituitary gland." "It is caused by the overproduction of parathormone by the parathyroid gland."

"It is caused by the lack of production of aldosterone by the adrenal gland."

a nurse is caring for a client who is 9 day postop following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? "Tuck your chin when you swallow so you won't choke." "It is no longer possible for you to choke on or aspirate food." "You should have no trouble swallowing fluids." "I will add a thickener to your liquids to prevent aspiration."

"It is no longer possible for you to choke on or aspirate food."

a home health nurse is teaching an older adult client who just had cataract surgery. Which of the following instructions should the nurse include? "Rest in bed for at least 2 days." "Keep your head up and straight." "Deep breathe and cough four times a day." "Lie on the side of the surgery when in bed."

"Keep your head up and straight."

a nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? "I am gaining weight." "I am constipated." "My vision seems yellow." "My tongue is red and beefy."

"My vision seems yellow."

a nurse is caring for the client who has Meniere disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? "Yes, you are free to move around as you wish." "No, you are on strict bedrest and must not be up." "Please ring for assistance when you wish to get out of bed." "We will have to get a prescription from your provider."

"Please ring for assistance when you wish to get out of bed." This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.

a nurse is providing discharge instructions to a client who has RA and a prescription for oral bethamethasone. Which of the following statements should the nurse make about how to take this medication? "Take the medication between meals." "Take the medication with orange juice." "Take the medication with milk." "Take the medication on an empty stomach."

"Take the medication with milk." Betamethasone should be administered with milk or food to prevent gastric irritation.

a client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make? "The laxative will prevent the absorption of magnesium." "The laxative helps eliminate the barium." "The laxative is the protocol at this facility." "The laxative makes the barium turn brown."

"The laxative helps eliminate the barium."

a nurse is caring for a client who will have blood sampling for a serum creatinine level and asks what this test shows. Which of the following responses should the nurse make? "This test will tell your doctor how your kidneys are functioning." "You'll have to ask your doctor." "This test will tell if you have severe renal impairment or a disease." "We'll find out if any medications, such as steroids, are interfering with your kidney function."

"This test will tell your doctor how your kidneys are functioning."

a nurse is providing postop teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include? "Bloodshot eyes on the day of surgery should be reported to the provider." "Warm compresses should be applied to the eye three times daily." "Photophobia is expected for 2 to 3 days." "Vision will be greatly improved on the day of surgery."

"Vision will be greatly improved on the day of surgery."

a nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? "Without treatment, glaucoma can cause blindness." "Double vision is a common symptom of glaucoma." "Glaucoma is caused by inadequate production of fluid within the eye." "Use of eye drops will improve vision over time."

"Without treatment, glaucoma can cause blindness."

a nurse is providing discharge teaching for a client who is to perform peritoneal dialysis as home. which of the following information should the nurse include? "You should avoid foods high in fiber." "You should expect redness at the catheter exit site." "You should anticipate pain the first week during the inflow of dialysate." "You should warm the dialysate in a microwave oven before instillation."

"You should anticipate pain the first week during the inflow of dialysate."

a nurse is preparing to administer atenolol 25 mg PO every 12 hr. The amount available is atenolol 50 mg/tab. How many tablets should the nurse administer per dose?

0.5 tablets x tablets => 1 tablet/50 mg x 25 mg/ 1 tablet(s) = Step 4: Solve for X. X tablet(s) = 0.5 tablet

A nurse is admitting a client who has acute heart failure following MI. The nurse recognizes that which of the following prescriptions by the provider requires clarification? Morphine sulfate 2 mg IV bolus every 2 hr PRN pain Laboratory testing of serum potassium upon admission 0.9% normal saline IV at 50 mL/hr continuous Bumetanide 1 mg IV bolus every 12 hr

0.9% normal saline IV at 50 mL/hr continuous

a nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A client who has diarrhea A client who is vomiting A client who is taking a thiazide diuretic A client who has salicylate intoxication

A client who has diarrhea

a nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? Abnormally prominent U wave Elevated ST segment Wide QRS Inverted P wave

Abnormally prominent U wave Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.

a nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? Tell the client to expect dark stools following chemotherapy. Have the client floss 4 times daily. Have the client swish with commercial mouthwash before therapy. Administer an antiemetic prior to the procedure.

Administer an antiemetic prior to the procedure.

a nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan? Administer antibiotics. Encourage increased fluid intake. Obtain weight weekly. Encourage frequent ambulation.

Administer antibiotics.

a nurse is caring for a female client in the ED who reports SOB and pain in the lung area. She states that she started taking BC pills 3 weeks ago and that she smokes. Her heart rate is 110/min, Resp 40/min, BP 140/80 mm Hg. Her ABG are pH 7.50, PaCOs 29, PaO2 60, HCO3 20 mEq, and SaO2 86%. Which of the following is the priority nursing intervention? Prepare for mechanical ventilation. Administer oxygen via face mask. Prepare to administer a sedative. Assess for indications of pulmonary embolism.

Administer oxygen via face mask. The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.

a nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority? Initiating oxygen therapy Providing immediate rest for the client Positioning the client in high-Fowler's Administering a nebulized beta-adrenergic

Administering a nebulized beta-adrenergic The greatest risk to the client's safety is airway obstruction. Beta-adrenergic medications act as bronchodilators. They provide prompt relief of airflow obstruction by relaxing bronchiolar smooth muscle and are the initial priority intervention when a client has an acute asthma exacerbation.

a nurse is discussing kidney transplant with a client who has ESRD. Which of the following should the nurse identify as a contraindication for this treatment? Breast cancer survivor for 8 years Pacemaker 65-years of age Alcohol use disorder

Alcohol use disorder

a nurse is reviewing the lab results of an adolescent female client and notes a WBC count of 16,000/mm3 with increased immature neutrophils (bands) and normal monocytes. Which of the following is the appropriate analysis of the results? An acute infectious process Neutropenia Allergic reaction A resolving inflammatory process

An acute infectious process The white blood cell (WBC) count is greatly elevated; however, even more telling is the elevated neutrophil count, sometimes referred to as a "shift to the left." So, with the combined information from the elevated WBC count indicating infection or inflammation and the elevated neutrophil count indicating an acute process, the appropriate analysis is that the client has an acute infectious process.

a nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? Ventricular depolarization Slow repolarization of ventricular Purkinje fibers Atrial depolarization Early ventricular repolarization

Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node.

a nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft? Measure the client's blood pressure to ensure it is higher in the left arm than the right. Check the brachial and radial pulses of the left arm simultaneously. Auscultate the site for a bruit. Auscultate the antecubital fossa using a Doppler stethoscope.

Auscultate the site for a bruit.

a nurse is providing teaching to a client who has emphysema and a new prescription for theophylline. Which of the following instructions should the nurse provide? Consume a high-protein diet. Administer the medication with food. Avoid caffeine while taking this medication. Increase fluids to 1L/per day.

Avoid caffeine while taking this medication.

a nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? Sleep on the abdomen to facilitate wound healing. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. Bend at the waist to pick objects up from the floor. Notify the surgeon if white drainage develops on the eyelids.

Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery.

a nurse is reviewing the BUN and creatinine levels of an older adult client who has CKD. The nurse should expect which of the following findings? BUN 10 mg/dL and creatinine 0.3 mg/dL BUN 23 mg/dL and creatinine 1.0 mg/dL BUN 8 mg/dL and creatinine 0.7 mg/dL BUN 45 mg/dL and creatinine 8 mg/dL

BUN 45 mg/dL and creatinine 8 mg/dL

a nurse is preparing a client for a kidney biopsy. Which of the following client conditions should the nurse identify as a contraindication for this diagnostic test? Elevated creatinine level Flank pain Urinary retention Bleeding tendencies

Bleeding tendencies

a nurse is assessing a client who has PD. Which of the following manifestations should the nurse expect? Pruritus Hypertension Bradykinesia Xerostomia

Bradykinesia

a nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse the client is developing this condition? Anorexia Weight gain Breathlessness Distended abdomen

Breathlessness

a nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following? Cabbage Cantaloupe Green beans White beans

Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K

The nurse is caring for a client who has heart failure and a history of asthma. The nurse reviews the provider's orders and recognizes that clarification is needed for which of the following medications? Carvedilol Fluticasone Captopril Isosorbide dinitrate

Carvedilol

A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? Check the results of the client's most recent CBC. Assess the client for a hypersensitivity reaction. Evaluate the client for hypercalcemia. Examine the client for hepatomegaly.

Check the results of the client's most recent CBC.

a nurse is caring for a client who is 5 hr postop following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.

Check the tubing for kinks.

a nurse is modifying the diet of a client who has PD and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate? Fresh fish Cheddar cheese Cherries Chicken

Cheddar cheese

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include? Women should start yearly mammograms at age 30. Clients should have a colonoscopy at age 40 and every 10 years thereafter. Clients should have a yearly test for fecal occult blood. Women should have a yearly clinical breast examination starting at age 45.

Clients should have a yearly test for fecal occult blood. According to the American Cancer Society, all clients should have a yearly test to check for fecal occult blood. According to the American Cancer Society, women should start yearly mammography at age 40. According to the American Cancer Society, clients should have their first colonoscopy at age 50 and then every 10 years thereafter. According to the American Cancer Society, women should start to have a yearly clinical breast examination at age 40.

a nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? A raised red rash around the fistula site Pain in the right arm proximal to the fistula site Cold and numb numbness distal to the fistula site Foul-smelling drainage from the fistula site

Cold and numb numbness distal to the fistula site

a nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? Potassium levels are increased in clients who have polyuria. Specific gravity is decreased in clients who have hypovolemia. BUN is decreased in clients who have dehydration. Creatinine levels are increased in clients who have acute kidney injury.

Creatinine levels are increased in clients who have acute kidney injury.

a nurse is caring for a client who has suspected cholecystitis. The nurse should expect the client's urine to appear which of the following colors? Pale yellow Greenish-brown Red Dark and foamy

Dark and foamy

a nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication? Decreased blood pressure Increase of HDL cholesterol Prevention of bipolar manic episodes Improved sexual function

Decreased blood pressure

a nurse is caring for a client following his first hemodialysis treatment. The client reports a headache, nausea, and restlessness. The nurse should identify these findings as manifestations of which of the following complications? Dialysis disequilibrium Air embolism Peritonitis Septicemia

Dialysis disequilibrium

a nurse is caring for a client who is postop following vascular surgery. Which of the following signs should indicate to the nurse that the client has developed a thrombus? Positive Kernig's sign Positive Homan's sign Dull, aching calf pain Soft, pliable calf muscle

Dull, aching calf pain

a nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to asses in this client? SATA Dyspnea Bradycardia Barrel chest Clubbing of the fingers Deep respirations

Dyspnea Barrel chest Clubbing of the fingers

a nurse is planning care for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following manifestations is most appropriate for the nurse to monitor? Elevated WBC Fever Ecchymosis Fatigue

Ecchymosis

a nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? Decreased brain natriuretic peptide (BNP). Elevated central venous pressure (CVP). Increased pulmonary artery wedge pressure (PAWP). Decreased specific gravity

Elevated central venous pressure (CVP).

a nurse is providing care for a client who has laparoscopic cholecystectomy. Which of the following is appropriate nursing action? Place the client in a supine position postoperatively. Encourage ambulation once fully awake. Offer the client ice cream postoperatively. Instruct the client not to lift over 4.5 kg (10 lb).

Encourage ambulation once fully awake.

a nurse is caring for a client who has COPD. The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? Maintaining a semi-Fowler's position as often as possible Administering oxygen via nasal cannula at 2 L/min Helping the client select a low-salt diet Encouraging the client to drink 2 to 3 L of water daily

Encouraging the client to drink 2 to 3 L of water daily

a nurse is caring for an older adult client who has RA and is taking aspirin 650 mg every 4 hrs. which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication? White blood cell (WBC) count Rheumatoid factor (RF) Antinuclear antibody (ANA) Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate (ESR) Rheumatoid arthritis is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.

a nurse is caring for a client who is post-op following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for? Hemorrhage Infection Urinary retention Pain

Hemorrhage Using the airway breathing circulation (ABC) approach to client care the nurse determines that the priority complication to monitor for is the client hemorrhaging; therefore, the nurse should monitor the client's urinary output for blood clots and bright red blood tinged urine following surgery.

a nurse is assessing a client who has right ventricular failure. which of the following findings should the nurse expect? Dry, hacking cough Hepatomegaly Dizziness Crackles in the lungs

Hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

a nurse is providing an education program about dietary interventions to reduce the risk for prostate cancer. Which of the following information should the nurse include? Increase animal fat in the diet. Increase fatty fish in the diet. Reduce dietary fiber intake. Increase complex carbohydrates in the diet.

Increase fatty fish in the diet.

a nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? SATA Increased heart rate Increased blood pressure Increased respiratory rate Increase hematocrit Increased temperature

Increased heart rate Increased blood pressure Increased respiratory rate

a nurse is teaching a client who has asthma how to use a metered-dose-inhaler (MDI). the nurse identifies the sequence of steps the client should follow.

Inhaling deeply and then exhaling completely. The client should place her lips firmly around the mouthpiece to direct the spray to the airways. Breathe in deeply over 2 to 3 seconds while pushing down on the canister. This slow, deep inhalation directs the medication down into the lower respiratory tract. Holding her breath for 10 seconds, it allows time for absorption of the medication. Pursed-lip breathing keeps the small airways open during slow exhalation. Waiting 60 seconds between puffs allows for deeper penetration of the medication into the respiratory tract.

a nurse in the ER is caring for a client who presents with manifestations that indicates a MI. Which of the following prescriptions should the nurse take first? Attach the leads for a 12-lead ECG. Obtain a blood sample. Initiate oxygen therapy. Insert the IV catheter.

Initiate oxygen therapy.

a nurse is planning care for a client who has an absolute neutrophil count (ANC) less than 1,000/mm3. Which of the following interventions should the nurse include in the plan? Take the client's rectal temperature each day. Increase raw produce in the client's diet. Limit visitors to healthy adults. Instruct the client to floss his teeth daily.

Limit visitors to healthy adults.

a nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? SATA Lubricate lips with water-soluble ointment. Brush teeth with a soft toothbrush. Blow nose gently. Limit fruit consumption. Use a straight edge razor to shave.

Lubricate lips with water-soluble ointment. Brush teeth with a soft toothbrush. Blow nose gently.

a nurse in an ED is planning care for a client who is having an acute MI. The nurse should plan to administer which of the following medications after the initial acute phase to mange the clients pain and anxiety? Nitroglycerin Aspirin Oxygen Morphine

Morphine

a nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? SATA Muscle distortion Pain behind the ear Hearing loss Facial twitching Impaired taste

Muscle distortion Pain behind the ear Impaired taste

a nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? Hyperactive bowel sounds Nausea and vomiting Bradycardia Increased urinary output

N/V

a nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take? Review laboratory test results for low hemoglobin. Observe for signs of infection. Monitor the mouth for signs of xerostomia. Examine the skin for generalized urticaria.

Observe for signs of infection.

a nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take? Suggest that the client use a salt substitute. Obtain a 12-lead ECG. Advise the client to add citrus juices and bananas to her diet. Obtain a blood sample for a serum sodium level.

Obtain a 12-lead ECG. This client's potassium level is above the expected reference range of 3.5-5.0 mEq/L and is at risk for dysrhythmias as well as cardiac arrest. Therefore, the nurse should obtain a 12-lead ECG to monitor for cardiac changes.

a nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care? Monitor the client's intake and output every 6 hr. Offer the client 240 mL (8 oz) of oral fluids every 4 hr. Check the client's IV infusion every 8 hr. Administer furosemide to the client.

Offer the client 240 mL (8 oz) of oral fluids every 4 hr.

a nurse is assessing a client who is 2 weeks postop following a kidney transplant. Which fo the following manifestations should the nurse identify as possible organ rejection? Temperature 36.1° C (97.0° F) Insomnia Oliguria Weight loss

Oliguria

a nurse is caring for a client who is 2 hr postop following a TURP gland. Which of the following assessments should the nurse view to be an indication of a postop complication? Output of burgundy colored urine Pulse rate of 88/min Oral temperature of 38.2° C (100.76° F) An urge to void despite having an indwelling urinary catheter

Output of burgundy colored urine

a nurse is reviewing the lab data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following lab values? RBC count Protein Calcium Potassium

Potassium

a nurse suspects a client who has MG is experiencing a myasthenic crisis. Which of the following interventions should the nurse take? Prepare the client for mechanical ventilation. Administer an anticholinesterase medication. Instruct the client to perform the pursed lip breathing. Prepare to administer a vasoconstrictor.

Prepare the client for mechanical ventilation.

a nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications? Propranolol Theophylline Montelukast Prednisone

Propranolol

a nurse is providing teaching to the family of a client who has PD. Which fo the following information should the nurse include in the teaching? Provide client supervision. Limit client physical activity. Speak loudly to the client. Leave the television on continuously.

Provide client supervision.

a nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization? PR interval QT interval ST segment QRS complex

QT interval

a nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? Reduction of T-wave amplitude Shortening of P-wave duration Widening of the QRS complex Restoration of QRS complex amplitude

Reduction of T-wave amplitude Polystyrene sulfonate should bring the potassium level back to the expected reference range of 3.5-5.0 mEq/L. Hyperkalemia causes peaked T waves and sometimes a widened QRS on ECG, so resolution of the potassium imbalance should restore these ECG changes to baseline.

a client is admitted to the ER with a respiratory rate of 7/min. ABG reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% bicarbonate 26 mEq/L Respiratory acidosis Metabolic acidosis Metabolic alkalosis Respiratory alkalosis

Respiratory acidosis

a nurse is reviewing lab values for a client who has SLE. Which fo the following values should give the nurse the best indication of the client's renal function? Serum creatinine Blood urea nitrogen (BUN) Serum sodium Urine-specific gravity

Serum creatinine

a nurse is caring for a client who has CKD and states she has heartburn. The provider prescribes aluminum hydroxide. The client asks, "Why can't I just take the antacid magaldrate my husband has at home?" The nurse explains to the client that aluminum hydroxide is the preferred antacid because it lowers which of the following? Serum phosphorus levels Serum potassium levels Serum magnesium levels Serum calcium levels

Serum phosphorus levels

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? Shallow respirations Hypertensive crisis Diarrhea Hyperreflexia

Shallow respirations A client's shallow respirations are a sign of weakness in the accessory muscles of breathing, due to hypokalemia.

A nurse is caring for a client who has End-stage renal disease (ESRD). Which of the following are expected findings? Slurred speech Bone pain Bradypnea. Pruritus Hypotension

Slurred speech Bone pain Pruritus

a nurse is monitoring a client who is on telemetry. Which of the following findings on the ECG strip should the nurse recognize as normal sinus rhythm? The P wave falls before the QRS complex. The T wave is in the inverted position. The P-R interval measures 0.22 seconds. The QRS duration is 0.20 seconds.

The P wave falls before the QRS complex.

a nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? The client has a 5 lb weight gain since yesterday. Flattened neck veins Oxygen saturation 93% Return of skin to previous position when the client's shin is palpated

The client has a 5 lb weight gain since yesterday.

a nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? Take ibuprofen for eye discomfort. Creamy white drainage is an indication of infection. Notify the provider immediately if the operative eye itches. The client should wear dark glasses while outdoors.

The client should wear dark glasses while outdoors.

a nurse is caring for a female client who has RA and a new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instructions should the nurse give the client? Dietary modifications occur during pregnancy when taking this medication. The medication should be discontinued 3 months prior to a planned pregnancy. Dosage of the medication will be reduced during pregnancy. The client can breast feed when taking this medication.

The medication should be discontinued 3 months prior to a planned pregnancy.

a nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis? Anticoagulants NSAIDs Cardiac glycosides Thyroid hormones

Thyroid hormones Long-term use of synthetic thyroid hormone, such as levothyroxine, can accelerate bone loss.

a nurse is teaching a client who has CKD about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? SATA Green Beans Tomatoes Bananas Asparagus Raisins

Tomatoes Bananas Raisins

a nurse is caring for a client who came to the ED reporting chest pain. The provider suspects a MI. While waiting for the troponin levels report, the client asks what this blood test will show. Which of the following explanations should the nurse provide the client? Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. Troponin is a lipid whose levels reflect the risk for coronary artery disease. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. Troponin is a protein that helps transport oxygen throughout the body.

Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart.

a nurse is preparing to obtain a daily weight from a client who has CKD. Which of the following actions should the nurse implement? Use any available scale to weigh the client. Balance the scale at minus two before weighing the client. Obtain the weight each day at a time most convenient for the client. Weigh the client after he has voided.

Weigh the client after he has voided.

a client who has a history of MI is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? analgesic anti-inflammatory antiplatelet aggregate antipyretic

antiplatelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.

a nurse is assessing a client who has CKD for fluid volume increase. Which of the following provides a reliable measure of fluid retention? Daily weight Sodium level Tissue turgor Intake and output

daily weight

a home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? Pitting edema Fatigue Dyspnea Oliguria

fatigue

A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect? Flank pain Hypotension Confusion Urinary retention

flank pain

a nurse in an ophthalmology clinic is interviewing a client who has referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report loss of central vision. having a loss of peripheral vision. seeing bright flashes of light and floaters. having a decreased ability to perceive colors.

having a decreased ability to perceive colors.

a nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was dysphagia. hoarseness. dyspnea. weight loss.

hoarseness.

A nurse is reviewing the ABG value of a client who has CKD. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.

A nurse is caring for a client who has AKI. Which of the following ABG values would the nurse expect this client to have? pH 7.49, HCO3 24, PaCO2 30 pH 7.49, HCO3 30, PaCO2 40 pH 7.26, HCO3 24, PaCO2 46 pH 7.26, HCO3 14, PaCO2 30

pH 7.26, HCO3 14, PaCO2 30

a nurse is caring for a client 1 hr following a subtotal thyroidectomy. In which of the following positions should the nurse place the client? Semi-Fowler's Dorsal recumbent Supine Sims'

semi-fowlers