NURS 304 Assessment 2 MC questions

When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching? A. "I take my ibuprofen every morning as soon as I get up." B. "My daughter removed all of the throw rugs in my home." C. "My husband helps me every afternoon with range of motion exercises." D. "I rest in my reclining chair every day for at least an hour."

A Ibuprofen can cause abdominal discomfort or pain and ulceration of the GI tract. In such cases, it should be taken with meals or milk. Removal of throw rugs help prevent falls. Range-of-motion exercises and rest are important strategies for coping with osteoporosis

The nurse is reviewing medication lists for patients who are being treated for peptic ulcer disease (PUD). The nurse is most likely to question the use of which medication? A. Ibuprofen B. Omeprazole C. Amoxicillin D. Clarithromycin

A Ibuprofen is a NSAID, and NSAIDs are thought to be one of the aggravating factors of PUD. Omeprazole, amoxicillin, and clarithromycin are used as a triple combination therapy for the treatment of PUD

The nurse is completing a neurologic assessment and finds that the client is easily arousable but goes back to sleep. How will the nurse document the client's level of consciousness? A. Lethargic B. Stuporous C. Comatose D. Alert

A Lethargic means that the patient can be aroused, but may go back to sleep. Comatose patients will not be aroused even by painful stimuli.

The nurse is caring for a client who is post-operative 3 hours after having abdominal surgery for peritonitis complications. What task is appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)? A. Obtain a urine analysis sample B. Evaluation of wound drainage C. Perform Foley catheter care D. Explain wound care to the client

A The UAP can safely obtain a urine analysis sample from the client. Evaluation is part of the nursing process's long with any teaching. The nurse should perform Foley catheter care as part of the head-to-toe assessment process so that they can evaluate the skin, catheter drainage, condition of the strap securing the catheter, amount of urine, color etc.

A nurse is teaching a client who has a duodenal ulcer and a new prescription for esomeprazole. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Take the medication 1 hr before a meal B. Limit NSAIDs when taking this medication C. Expect skin flushing when taking this medication D. Increase fiber intake when taking this medication E. Chew the medication thoroughly before swallowing

A, B The rationale just restates that these are the right choices and that the wrong choices are wrong. So that's cool.

The nurse is providing teaching to a group of people of all ages regarding modifiable risk factors for osteoporosis. What teaching will the nurse provide to this group? (Select all that apply) A. High alcohol intake B. High impact exercise C. Race and age D. Lack of exercise E. Broken leg after 50 years old

A, B, D These are all modifiable risk factors as they can be changed. What can't be changed is race, age and risk for osteoporosis after breaking a bone after the age of 50 years old. This increases the risk for osteoporosis

The ED nurse has just received a client who has had nausea and vomiting for two days. The ABG is pH 7.46, CO2 38, HCO3 28, PaO2 90. What is the priority nursing action(s)? (Select all that apply) A. Start NS 0.9% at 125 mLs/hour B. Notify the HCP about the results C. Obtain another ABG in an hour D. Start a 20 gauge intravenous line E. Document and monitor the client

A, B, D This client is in metabolic alkalosis from vomiting all the acid out of their stomach. The client is also dehydrated. The nurse should start an IV, administer fluids and notify the HCP of the ABG results. There is no need to redo the ABG in an hour and remember that each answer in a SATA stands alone, which means that documenting and monitoring only implies no intervention.

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

A

Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism? A. Measuring heart rate and rhthym B. Checking core body temperature C. Asking about previous allergic drug reactions D. Listening to bowel sounds in all four abdominal quadrants

A

A nurse in a provider's office is assessing a client who recently began taking levothyroxine to treat hypothyroidism. Which of the following findings should indicate to the nurse that the client might need a decrease in the dosage of the medication? A. Hand tremors B. Bradycardia C. Pallor D. Slow speech

A A just says it's a sign of too much med B, C, and D are all expected findings for hypothyroidism and the patient might need an increase in dosage

The nurse delegates the measurement of vital signs to an experienced assistive personnel (AP). Osteomyelitis has been diagnosed in a patient. Which vital sign value would the nurse instruct the AP to report immediately for this patient? A. Temperature of 101 F B. Blood pressure of 136/80 mmHg C. Heart rate of 96 beats/min D. Respiratory rate of 24 breaths/min

A An elevated temperature indicates infection and inflammation. This patient needs IV antibiotic therapy. The other vital sign values are normal or high normal

Which assessment finding of a client 8 hours after a subtotal thyroidectomy does the nurse consider most relevant as an indication of a possible complication? A. The client's hand spasms during blood pressure measurement B. The respiratory rate has dropped from 18 to 14 breaths per minute C. The dressing has a moderate amount of serosanguinous drainage D. The client responds to questions correctly but does not open the eyes while talking

A Hand spasms in the presence of decreased oxygen (as would happen while a blood pressure cuff was inflated above systolic pressure) is an indication of hypocalcemia, a possible complication of reduced parathyroid function that can result from thyroid surgery. The respiratory rate is within normal limits of a healthy adult. A moderate amount of drainage may be more than expected but is not an indication of obstruction. After general anesthesia, most clients are sleepy. Not opening his or her eyes during a response to a question is not an indication of a complication.

The nurse is caring for a client who returned from abdominal surgery three hours ago. When auscultating the client's abdomen, the nurse hears hypoactive bowel sounds. What is the most appropriate nursing action? A. Document and continue to monitor B. Notify the healthcare provider immediately C. Insert a nasogastric tube D. Perform deep palpation to the abdomen

A Hypoactive bowel sounds are an expected assessment finding within a few hours after abdominal surgery. This finding should be noted in the patient's chart. The HCP does not need to be notified at this time. The nurse would insert a nasogastric tube if the paralytic ileum persists, but with the HCP order only, deep palpation would not be performed, would be uncomfortable for the patient and would not reveal the cause of the ileus.

The nurse in the emergency department receives a client from EMS who started having dysphagia, left-sided weakness and confusion one hour ago. The clients' Glasgow Coma Score is of 11. What is the nursing priority? A. Assess the client for any anticoagulant medications B. Prepare for immediate endotracheal intubation C. Obtain a full medical, surgical and medical history D. Perform an EKG and blood glucose immediately

A The client should be assessed immediately to determine if they take any anticoagulants such as aspirin, NSAIDs or others in case they have an ischemic stroke going on and need thrombolytic therapy. Obtaining a complete medical, surgical and medication history can be obtained after any treatment or testing and should not be done initially as this may slow down the process of testing and thrombolytic therapy if needed. Although, checking the blood glucose would be appropriate as a hypoglycemic event can mimic a stroke, the EKG should be done at another time, so as not to interrupt thrombolytic therapy. The clients GCS is fine to support their airway and does not need intubation at this time.

When developing a postoperative plan of care for a client after a total thyroidectomy, which intervention will the nurse include? A. Avoidance of extending the client's neck B. Assessing the client's voice once per shift C. Encouraging the client to stay on bedrest D. Avoid oxygen via nasal cannula if needed

A The nurse should avoid extending the client's neck to decrease tension on the suture line. The air in the client's room should be humidified to promote easier respirations and thin respiratory secretions. Apply oxygen therapy as needed. The client's voice should be assessed for changes every 2 hours. Sandbags or pillows should be used to support the client's head or neck, and the client should be placed in a semi-Fowler's position

A nurse is assessing a client who is 24 hr postoperative following an above-the-elbow amputation. Which of the following findings should the nurse identify as the priority? A. Report of muscle spasms B. Inability to get dressed without assistance C. Report of feelings of anger D. Refusal to look at the affected limb

A The nurse should consider Maslow's hierarchy of needs, which includes five levels of priority. Physiological needs are the priority client finding, which are muscle spasms.

The home health nurse is assessing a client with osteoarthritis. What is the most important assessment for the nurse to perform on this client? A. Assess the client's ability to perform ADLs B. Assess if the client has any broken bones C. Assess the client's pain level on a 0-10 scale D. Assess if the client has any outside family help

A The priority assessment for this client is to determine if they are able to perform their ADLs as the home health nurse is responsible for setting up outside help if necessary. The client's pain should be assessed and health with, but is not the priority because pain, although uncomfortable, will not kill them. Outside help should be assessed and if none is available the home health nurse should set up outside help to come and assist the client. There has been no indication that this client has fallen, thus no immediate need to assess for broken bones.

A nurse is completing discharge teaching to a client who had a wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months B. Relief of pain indicates the infection is eradicated C. Airborne precautions are used during wound care D. Expect paresthesia distal to the wound

A The rationale just repeats the answer, so like just know that's true I guess and everything else is false I guess B. lol no C. Contact precautions, that wound be nasty D. That's a manifestation of neuromuscular compromise, so like yeah that's def not a thing to expect

A client had an open partial colectomy and colostomy placement 6 hours ago. Which assessment would concern the nurse? A. Purple, moist stoma B. Stoma edema C. Liquid stool collecting in the drainage bag D. Serosanguinous fluid draining from the drain(s)

A There's no rationale for this one so I guess you just gotta believe me ¯\_(ツ)_/¯

The nurse is caring for a diabetic client with a Hgb A1C of >12% and is complaining of tingling to bilateral legs, feet and hands. The client states that he needs to get up to the bathroom. What is the priority nursing action? A. Ensure the bed is locked, in the low position, and assist them to walk B. Ensure the bed is locked and let the client go to the bathroom C. Ask the unlicensed assistive personnel to help them to the bathroom D. Tell the client that it is ok for the to get up and go to the bathroom

A This client has diabetic neuropathy and is a fall risk. Although the UAP can assist the client to the bathroom, the. nurse is already there in the room and should help the client themselves. Telling the client that it is ok for them to go to the bathroom by themselves, places the client at risk for a fall and possible complications from that fall. Safety is the priority in this scenario. Just ensuring that the bed is locked and letting the client go to the bathroom is again a risk for falls. The nurse should make sure the bed is locked, int he lowest position and assist the client to and from the bathroom

A patient with a right above-the-knee amputation asks the nurse why he has phantom limb pain. What is the nurse's best response? A. "Phantom limb pain is not explained or predicted by any one theory" B. "Phantom limb pain occurs because your body thinks your leg is still present" C. "Phantom limb pain will not interfere with your activities of daily living." D. "Phantom limb pain is not real pain but is remembered pain."

A Three theories are being researched with regard to phantom limb pain. The peripheral nervous system theory suggests that sensations remain as a result of the severing of peripheral nerves during the amputation. The CNS theory states that phantom limb pain results from a loss of inhibitory signals that were generated through afferent impulses from the amputated limb. The psychological theory helps predict and explain phantom limb pain because stress, anxiety, and depression often trigger or worsen a pain episode

Which client assessment finding alerts the nurse to perform a detailed endocrine system assessment? Select all that apply A. Fatigue B. Weight gain C. Reports being cold all the time D. Decrease in peripheral pulses E. Changes in hair texture and appearance

A B, C, E Changes in physical appearance can reflect an endocrine problem. Obvious changes identified during the physical assessment include hair texture and distribution, facial contours and eye protrusion, voice quality, body proportions, and secondary sexual characteristics. Changes in weight and fatigue may also be associated with endocrine disorders as well as other conditions. Poor peripheral pulses are more likely associated with cardiovascular diseases

A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply) A. Observe cardiac monitor for cardiac dysrhythmias B. Observe for evidence of UTI C. Initiate IV fluids using 0.9% sodium chloride D. Administer a levothyroxine IV bolus E. Provide warmth using a heating pad

A, B, C D A client who has myxedema can have a flat or inverted T wave as well as ST deviations. An infection (in the urinary tract) can precipitate myxedema coma. Observe the client for manifestations of infection so that the underlying illness can be treated. Hyponatremia is an expected finding in the presence of myxedema coma. IV therapy is administered using 0.9% sodium chloride. Myxedema coma is a severe complication of hypothyroidism that if left untreated can lead to coma or death. Levothyroxine is administered IV bolus to treat the condition. E is incorrect because you should use blankets. They might burn with the use of a heating pad

The nurse is caring for a client with osteoporosis and is preparing discharge instructions. What its he most important for the nurse to include in these instructions? (Select all that apply) A. "Your furosemide is most likely contributing to your osteoporosis condition." B. "You should be careful at home with small area rugs so that you don't fall." C. "The corticosteroids you take may very well be contributing to the osteoporosis." D. "Be sure to take your calcium with vitamin D to help absorption of calcium." E. "Be sure to take your calcium pills daily, but you won't need the vitamin D"

A, B, C, D Osteoporosis can cause serious, debilitating lifestyle changes for a client. They should be careful of small area rugs as these are a tripping hazard and can cause the client to fall and break a bone. Calcium needs vitamin D for absorption and furosemide and corticosteroids are a cause of osteoporosis

The nurse is educating the newly diagnosed diabetic client on the importance of self-monitoring blood glucose. What statement(s) will the nurse include in the teaching plan? (Select all that apply) A. "Self-monitoring your blood glucose helps you to adjust your medication therapy." B. "Self-monitoring glucose levels help to prevent hypoglycemia or hyperglycemia." C. "You should eat carbohydrates that avoid empty calories among with 25 grams of carbs." D. "Self-monitoring glucose helps to evaluate the effectiveness of drug therapies." E. "You should be able to drink more than two alcoholic beverages daily, but avoid sugary drinks."

A, B, C, D The nurse should provide teaching to the newly diagnosed client regarding frequent monitoring of blood glucose levels as this will help prevent hypo/hyperglycemia and can help with adjusting medication regimens. The client can have two alcoholic drinks daily, but should avoid sugary drinks to help maintain glucose levels. The client should be encouraged to eat 25 grams of fiber daily for fruits, vegetables, whole grains, legumes and dairy products and not empty calories such as foods containing sugar-sweetened beverages, high fructose corn syrup and sucrose to prevent weight gain and adverse effects on metabolism. Self-monitoring glucose levels helps prevent high and low swings of glucose levels and helps the HCP with adjusting medications if needed.

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (Select all that apply) A. "I will clean the pins more often if drainage from the pins increases." B. "I will use a separate cotton swab for each pin." C. "I will report loosening of the pins to my doctor." D. "I will move my leg by lifting the device in the middle." E. "I will report increased redness at the pin sites."

A, B, C, E Clean the external fixation pins more frequently than prescribed if the amount of drainage increases or infection is suspected. Using a separate cotton swab on each pin will decrease the risk of cross-contamination, which could cause pin site infection. Notify the provider if a pin is loose because the provider will know how much to tighten the pin and prevent damage to the tissue and bone. They should report redness, that, and drainage at the pin sites, which can indicate an infection that can lead to osteomyelitis. D is incorrect because the external fixation device should never be used to lift or move the affected leg, due to the risk of injuring and dislocating the fractured bone

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply) A. Eat at regular intervals B. Decrease intake of saturated fats C. Increase daily fiber intake D. Limit saturated fat intake to 15% of daily caloric intake E. Include omega-3 fatty acids in the diet

A, B, C, E The client should eat at regular intervals throughout the day to maintain blood glucose levels. Healthy nutrition should include lowering LDL by decreasing intake of saturated fats, which can prevent diabetes and hyperlipidemia. Healthy nutrition should include increasing dietary fiber to control weight gain and decrease the risk of diabetes and hyperlipidemia. Healthy nutrition should include omega-3 fatty acids for secondary prevention of diabetes and heart disease D is incorrect because you shouldn't eat more than 7% saturated fat

A nurse is planning discharge teaching on home safety for an adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Remove throw rugs in walkways B. Use prescribed assistive devices C. Remove clutter from the environment D. Wear soft bottomed shoes E. Maintain lighting of doorway areas

A, B, C, E The rationale on all of these just repeat the answer and say "can prevent a fall and bone fracture" so I ain't writing all that out 4 times D is incorrect because they should wear rubber-bottomed shoes to prevent slipping

Which assessment data are factors that increase the risk for osteoporosis for an older Euro-American female? (Select all that apply) A. Drinks 3 to 4 glasses of wine each day B. Sits at a desk all day at her job C. Smokes a pack of cigarettes a day D. Takes a mile-long walk 5 days a week E. Takes 1000 mg acetaminophen for arthritis daily F. Weighs 110 lbs (50 kg)

A, B, C, F These are all modifiable risk factors

A client presents to the ED nurse complaining of chest palpitations, double vision, and states "My temper has been really short the last few days." The nurse observes that the client is really skinny and sweating even though it is cold outside. What is the priority nursing action(s)? (Select all that apply) A. Call the HCP for a prescription for thyroid scan B. Draw a thyroxine (T4) serum blood level C. Perform a finger stick blood glucose level D. Draw a triiodothyronine (T3) serum blood level E. Perform an electrocardiogram (ECG) immeidately

A, B, D, E This client is experiencing hyperthyroidism as evidenced by the chest palpitations, irritability, weight loss and intolerance to heat. The nurse should draw T3, T4 and TSH, along with preparing for a thyroid scan, and should immediately perform an ECG checking the rhythm of the heart. Hyperthyroidism can cause dysrhythmias, excessive sweating, palpitations, tachycardia, heat intolerance amongst other things

A nurse in the emergency department is completing an assessment of a client who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (Select all that apply) A. Rigid abdomen B. Tachycardia C. Elevated blood pressure D. Circumoral cyanosis E. Rebound tenderness

A, B, E Manifestations of perforation include a rigid, board-like abdomen. Tachycardia occurs due to GI bleeding that accompanies a perforation. Rebound tenderness is an expected finding in a client who has a perforation. C is incorrect because hypotension is an expected finding in a client who has a perforation and bleeding. D is wrong because that's not a manifestation of perforation.

The nurse is providing discharge teaching to a client who has suffered a transient ischemic attack (TIA). What teaching will the nurse provide this client about modifiable risk factors that can reduce the chance of a stroke? (Select all that apply) A. "You should always maintain a healthy blood pressure." B. "There are medications available to totally prevent strokes." C. "Make sure that you exercise at least 3-5 times weekly." D. "Be sure to eat a diet with lots of fruits & vegetables." E. "Your ethnicity or race does not increase your risk for stroke."

A, C, D Modifiable risk factors are something the client can change such as controlling HTN,e eating healthy and exercising regularly. There are no medications to prevent strokes and ethnicity and race can contribute to the risk factor of strokes. Also, ethnicity and race cannot be modified.

A nurse is performing health screenings at a health fair. Which of the following clients have a risk factor for osteoporosis? (Select all that apply) A. A 40 year old client who has been taking prednisone for 4 months B. A 30 year old client who jogs 3 miles daily C. A 45 year old client who takes phenytoin for seizures D. A 65 year old client who has a sedentary lifestyle E. A 70 year old client who has smoked for 50 years

A, C, D, E Prednisone affects the absorption and metabolism of calcium and places the client at risk for osteoporosis when taken for an extended time (at least 3 months). Same with phenytoin. A sedentary lifestyle places the client at risk for osteoporosis because bones need the stress of weight bearing activity for bone rebuilding and maintenance. Smoking decreases osteogenesis Weight-bearing activities, such as jogging, promotes bone rebuilding and maintenance

The nurse is caring for a patient who had a dual-energy x-ray absorptiometry scan and is now prescribed calcium with vitamin D twice a day. The patient asks the nurse the purpose of this drug. What is the nurse's best response? (Select all that apply) A. "When your calcium and vitamin D levels are low, your risk for osteoporosis and osteomalacia increases." B. "When your vitamin D level is high, your bones release calcium to keep your blood calcium level in the normal range." C. "When your blood calcium is low, calcium is released from your bones increasing your risk for fractures." D. "When blood calcium is normal, long bones are formed, increasing a person's height." E. "The extra calcium and vitamin D will help protect your bones from damage such as fractures" F. "You can also get extra vitamin D by increasing your intake of beef and pork sources."

A, C, E Vitamin D and its metabolites are produced in the body and transported in the blood to promote the absorption of calcium and phosphorus from the small intestine. There is a relationship between calcium and phosphorus so that if a patient's phosphorus level is higher than normal, the calcium level will drop, and vice versa. A decrease in the body's vitamin D level can result in osteomalacia (softening of bone) in an adult. When serum calcium levels are lowered, parathyroid hormone (PTH) secretion increases and stimulates bone to promote osteoclastic activity and release calcium to the blood. PTH reduces the renal excretion of calcium and facilitates its absorption from eh intestine. Sources of vitamin D include sunlight, fatty fish, and vitamin D-enriched foods

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (Select all that apply) A. Engage in regular exercise including walking B. Sit for up to 10 hours each day to rest the back C. Maintain weight within 25% of ideal body weight D. Create a smoking cessation plan E. Wear low-heeled shoes

A, D, E B is incorrect because long periods of sitting or standing can cause low-back pain. Advise the client to use footstools or ergonomic chairs when sitting is necessary C is incorrect because the client should maintain weight within 10% of ideal body weight as obesity can cause low back pain

A nurse in a clinic is teaching a client who has ulcerative colitis. Which of the following statements by the client indicates understanding of the teaching? A. "I will plan to limit fiber in my diet." B. "I will restrict fluid intake during meals." C. "I will switch to black tea instead of drinking coffee." D. "I will try to eat cold foods rather than warm when my stomach feels upset."

A. A low-fiber diet is recommended for the clietn who has ulcerative colitis to reduce inflammation B is incorrect because a client who has dumping syndrome should avoid fluids with meals. Caffeine can increase diarrhea and cramping. The client should avoid caffeinated beverages, such as black tea. The client should avoid cold foods because these can increase intestinal motility and cause exacerbation of manifestations.

The charge nurse is making assignments and has a licensed vocational nurse (LVN) who has floated to the unit. Which client will the charge nurse assign to the LVN? A. The client who will be discharged today after hip replacement surgery B. The client who just came back from spinal surgery 3 hours ago C. The client who just came back from surgery after a broken arm repair D. The client who just came back from surgery for a hip replacement

A. This is the least critical client and should be assigned to the LVN who floated from another floor and may not be experienced with newly returned surgery clients. Nurses who have these clients all the time and work that floor as permanent staff should take the fresh surgery clients

A nurse is assessing a client who is 48 hr postoperative following open reduction and internal fixation of a fractured tibia. Which of the following findings should the nurse report to the provider? A. Toes cold to the touch B. Serous drainage from the pin sites C. Blanching of the toenail beds with pressure D. Pink tissue around the fixator insertion sites

A. The nurse should monitor for and report manifestations of compartment syndrome following enteral fixation. Therefore, the nurse should contact the provider immediately if the client's toes are cold to the touch B. Expected finding during the first 2 to 3 days following the procedure C. This is good D. Expected finding during the first 2 to 3 days following the procedure

A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and crushing pain in the toes of the right foot. Which of the following statements should the nurse make? A. "This type of pain usually decreases over time as the limb becomes less sensitive." B. "Try to look at the surgical wound as a reminder the limb is gone." C. "Use a cold compress intermittently to decrease these pain sensations." D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."

A. The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following amputation. The nurse should instruct the client that the sedation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain. B. Doesn't address the concern C. They should use heat and massage, along with pharmacological interventions, to mange this type of pain D. The nurse should validate the client's report of pain and treat it accordingly. The client is not exhibiting denial; therefore, this statement by the nurse is not appropriate

A nurse is reviewing the laboratory data of a client who has an acute exacerbation of Chron's disease. Which of the following blood laboratory results should the nurse expect to be elevated? (Select all that apply) A. Hematocrit B. Erythrocyte sedimentation rate C. WBC D. Folic acid E. Albumin

B, C Increased ESR is an expected finding in a client who has Chron's disease as a result of inflammation. Elevated WBC is also an expected finding. Hematocrit would be decreased as a result of chronic blood loss. A decrease in folic acid level is indicative of malabsorption due to the disease. A decrease in albumin is indicative of malabsorption due to Chron's disease.

A nurse is completing discharge teaching with a client who has Crohn's disease. Which of the following instructions should the nurse include in the teaching? A. Decrease intake of calorie-dense foods B. Drink canned protein supplements C. Increase intake of high fiber foods D. Eat high residue foods

B A high-protein diet is recommended. Canned protein supplements are encouraged. C is incorrect because a low fiber diet is also recommended. D is incorrect because low-residue foods reduce inflammation.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Whihc of the following actions should the nurse take? A. Check blood glucose immediately after breakfast B. Administer insulin when breakfast arrives C. Hold breakfast for 1 hour after insulin administration D. Clarify the prescription because insulin should not be administered at this time

B Administer insulin aspart when breakfast arrives to avoid a hypoglycemic episode. Insulin aspart is rapid-acting and should be administered 5 to 10 minutes before breakfast

What question is the home health nurse most likely to ask the patient to evaluate the efficacy of cimetidine? A. "Are you still having problems with constipation?" B. "Has the medication helped to relieve the acid indigestion?" C. "Did the medication relieve the nausea and vomiting?" D. "Do you feel like your appetite has improved?"

B Cimetidine is available over the counter and is used to relieve heartburn, acid indigestion, and sour stomach

When caring for a client having a hypoglycemic episode, which symptom requires immediate nursing intervention? A. Hunger B. Confusion C. Headache D. Incontinence

B Glucose is necessary for brain function. Confusion is a marker of severe hypoglycemia requiring immediate intervention. Irritability/anxiety, hunger, tachycardia, headaches eating, and seizures are additional signs of hypoglycemia

A nurse is providing dietary teaching about calcium-rich foods to a client who has osteoporosis. Which of the following food should the nurse include in the instructions? A. White bread B. Kale C. Apples D. Brown rice

B Green leafy vegetables (broccoli, kale, mustard greens) are good sources of calcium.

A nurse is caring for a client who has a pelvic fracture. The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. The nurse should identify that the client is experiencing which of the following complications? A. Pneumonia B. Pulmonary embolus C. Tension pneumothorax D. Tuberculosis

B Immobility following musculoskeletal trauma places the client at an increased risk for pulmonary embolus. The client might also exhibit tachycardia, chest petechiae, and have a decreased SaO2. The nurse should notify the rapid response team immediately

The charge nurse is assigning the nursing care of a patient who had a left below-the-knee amputation 1 day ago to an experienced LPN/LVN, who will function under an RN's supervision. What will the RN tell the LPN/LVN is the major focus for the patient's care today? A. To attain pain control over phantom pain B. To monitor for signs of sufficient tissue perfusion C. To assist the patient to ambulate as soon as possible D. To elevate the residual limb when the patient is supine

B Monitoring for sufficient tissue perfusion is the priority at this time. Phantom pain is a concern but is more common in patients with above-the-knee amputations. Early ambulation is a goal, but at this time, the patient is more likely to be engaged in muscle-strengthening exercises. Elevating the residual limb on a pillow is controversial because it may promote knee flexion contracture

The nurse is caring for 4 clients who all had hip replacement during surgery yesterday. What task will the nurse delegate to the unlicensed assistive personnel (UAP)? A. Gauging the clients' pain level every 2 hours B. Emptying all Foley catheters at the end of shift C. Evaluating intake and output at the end of shift D. Getting the client out of bed for the first time

B The UAP can empty the catheters and put the output into the computer, but the nurse must assess the end intake and output record. Evaluating and gauging are different words for assessing, and getting the client up for the first time should be done by the nurse or physical therapy

The ED nurse is caring for a client with an ulcer to the right foot that has sinus tract formation, drainage and localized pain. What is the priority nursing action? A. Assess circulation to the opposite extremity B. Assess the circulation above the affected extremity C. Assess circulation above the opposite extremity D. Assess the circulation below the affected area

B The nurse should assess the circulation above the affected extremity to determine if there is adequate blood flow throughout the leg. Trying to assess circulation below the foot... there ain't nothing below the foot to assess. Although the nurse will assess the opposite extremity for circulation, this is not the priority

A client who was treated for seizures in the emergency department is now being transferred to the medical/surgical floor. What equipment is the most important for the med/surg nurse to place in this clients' room? A. Penlight & neurological flow sheet B. Oxygen and suction equipment C. Cardiac and pulse oximetry monitors D. Padded tongue blade and side rails

B The nurse should have suction and oxygen equipment in the room of every seizure client. This is to help with oxygenation during a seizure and allow suctioning of the mouth if needed during a seizure. This will help prevent aspiration, and although a cardiac monitor and pulse oximetry monitor are important, they do not come before "airway" which suction equipment would fall under. The nurse would never use a padded tongue blade, making this answer incorrect, even though the side rails may get padded. Again, a penlight and neurological sheet, though important to have in the room do not take priority over oxygen and suction (airway, breathing) equipment.

A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following lab findings is expected? A. Elevated T4 B. Decreased T3 C. Elevated thyroid stimulating hormone D. Decreased cholesterol

B The rationale just makes you feel bad if you were wrong

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Record the client's intake and output B. Suction saliva from the client's mouth C. Perform passive range of motion on each extremity D. Monitor the client's electrolyte levels

B The unconscious client is unable to independently maintain a clear airway and is at risk of ineffective airway clearance. According to the safety and risk reduction priority setting framework, maintaining the client's airway, breathing and circulation is the highest priority

The ED nurse is caring for a diabetic client who has a sore and erythema on the left foot and is rating their pain 10/10 on 0-10 scale. The client has a fever of 102.1 F, HR 103 bpm, BP 125/71, RR 22 bpm; O2 sat 98% on RA. What is the priority nursing action? A. Obtain an EKG STAT and draw laboratory specimens B. Start an IV and fluids 0.9% NS at 125 mLs/hour C. Obtain a urine analysis and send for culture & sensitivity D. Document all findings and continue to monitor

B This client most likely has osteomyelitis as evidenced by the fever, left foot pain, erythema (redness), tachycardia and increased respiratory rate. The EKG is not implicated here, nor a UA and C&S. The nurse should not just document and monitor in this situation as it implies that no interventions should be done

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? A. Hold the client's arms and legs to prevent injury B. Place the client on their side C. Insert a tongue blade in the client's mouth D. Place the client back in bed

B This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed

A nurse is caring for a client who is 3 days postoperative following a right total hip arthroplasty. While transferring to a chair, the client cries out in pain. The nurse should assess the client for which of the following manifestations of dislocation of the hip prosthesis? A. Bulging in the area over the surgical incision B. Shortening of the right leg C. Sensation of warmth over the surgical incision D. Pallor following elevation of the right leg

B The nurse should monitor the client for shortening of the affected leg as an indication of dislocation of the prosthesis. Other findings include increased hip pain, inability to move the extremity, and rotation of the hip internally or externally.

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Weight gain is expected while taking this medication B. Medication should not be discontinued without the advice of the provider C. Follow up blood TSH levels should be obtained D. Take the medication on an empty stomach E. Use fiber laxatives for constipation

B, C, D Correct answers: The provider carefully titrates the dosage of this medication. It should be increased slowly until the client reaches a euthyroid state. The client should not discontinue the medication unless directed to do so by the provider. Blood TSH levels are used to monitor the effectiveness of the medication. The medication should be taken on an empty stomach to promote absorption. Incorrect: Levothryoxine speeds up metabolism. Weight loss is an expected effect. Fiber laxatives reduce absorption of the medication and should be avoided

The medical/surgical nurse is caring for a client who is receiving an intravenous infusion of antibiotics. The client suddenly sits up, starts wheezing and states, "I itch all over and feel like I'm going to die." What is the priority nursing action(s)? (Select all that apply) A. Document and continue to monitor the client B. Administer 0.3mLs - 0.5mLs of 1:1000 epinephrine IM C. Stop the antibiotic infusion immediately D. Call the Rapid Response Team STAT

B, C, D The nurse should immediately stop the transfusion of the antibiotics s this is most likely an anaphylactic reaction to the ABX. The nurse should call Rapid Response to help secure an airway and administer the epi. Each answer stands alone on a SATA question, which implies that documenting and monitoring is the only action. All documentation would happen after the crisis is over.

A nurse is admitting an adult client who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis (Select all that apply) A. History of consuming one glass of wine daily B. Loss in height of 2 in (5.1 cm) C. Body mass index (BMI) of 18 D. Kyphotic curve at upper thoracic spine E. History of lactose intolerance

B, C, D, E A is incorrect because a client who consumes more than 3 glasses of alcohol each day is a risk factor for developing osteoporosis because alcohol increases bone loss B is correct because the loss of 2 inches of height is suggestive of osteoporosis due to fractures of the vertebral column C is correct because they're at risk due to low body weight and thin body build, suggesting decreased bone mass D. Kyphosis is highly suggestive of osteoporosis due to fractures of the vertebrae causing the curve E. is correct because of possible lack of calcium intake

The nurse is caring for a client diagnosed with peptic ulcer disease (PUD). For which potential complications will the nurse monitor? (Select all that apply) A. Pneumonia B. Peritonitis C. Anemia D. Stroke E. Hypotension F. Cirrhosis

B, C, E There's no rationale for this one so I guess you just gotta believe me ¯\_(ツ)_/¯

A nurse is collecting an admission history from a client who has hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply) A. Diarrhea B. Menorrhagia C. Dry skin D. Increased libido E. Hoarseness

B, C, E These are expected findings A isn't right because constipation is a manifestation of hypothyroidism D. is incorrect because decreased libido is a manifestation of hypothyroidism

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

B, D, E These are all S/S of hyperthyroidism A. the client who has hyperthyroidism has an increased metabolic rate, resulting in increased hunger C. Diarrhea is an expected finding for the client who has hyperthyroidism F. Hyperthyroidism increase's the client's metabolism, causing tachycardia

Which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger of thyroid storm? (Select all that apply) A. Increased salivation B. Client report of increased palmar sweating C. Decreased pulse pressure from 40 mmHg to 36 mmHg D. Diminished bowel sounds in all four abdominal quadrants E. An increase in temperature from 99.5 F (37.5 C) to 101.3 F (38.5 C) F. Serum sodium level increase from 136 mEq/L (mmol/L) to 139 mEq/L (mmol/L) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

B, E, G

The nurse is completing a neurologic assessment and finds that the client is arousable only with vigorous or painful stimulation. How will the nurse document the client's level of consciousness? A. Lethargic B. Stuporous C. Comatose D. Alert

B. Stupurous means they're only responding to noxious or painful stimuli.

A nurse is caring for a client who is in skeletal traction following a femur fracture. The nurse finds the client has slid down toward the foot of the bed and the traction weight is resting on the floor. Which of the following actions should the nurse take? A. Remove the weight temporarily to reposition the client to the correct alignment in bed B. Have the client use a trapeze to pull himself up while ensuring the weight hangs freely C. Lift the rope off the pulley while the client rocks back and forth to reposition D. Lift the weight manually while another staff member moves the client up in bed

B. The nurse should ensure that traction weight is hanging freely. The client can use an overhead trapeze bar to move up in bed or the nurse can assist the client up, making sure to maintain proper alignment of the extremity A. The nurse should not remove the weight without a prescription, because this could interfere with the correct alignment of the extremity C. The nurse should ensure the traction ropes are on the pulley. Lifting the rope displaces the weight and can interfere with the correct alignment of the extremity. D. See A

A nurse in the emergency department is assessing a client who was in a motor-vehicle crash 2 days ago and sustained fractures to his tibia, ulna, and several ribs. The client is now disoriented to time and place, has a SaO2 of 87%, and the nurse notes generalized petechiae on the client's skin. Which of the following complications should the nurse suspect? A. Hypovolemic shock B. Fat embolism syndrome C. Thrombophlebitis D. Avascular bone necrosis

B. The nurse should identify the triad of neurologic changes, petechial rash, and hypoxemia as findings of fat embolism syndrome. Risk factors include multiple fractures and fracture of a long bone. Male clients are also at greater risk. The manifestations occur when fat globules occlude small blood vessels. A. The nurse should suspect hypovolemic shock for a client who experiences hypotension following extreme fluid loss, as with uncontrolled bleeding, dehydration, or severe edema C. The nurse should suspect thrombophlebitis for a client who reports redness and warmth over the involved vein, along with extremity pain D. The nurse should suspect avascular bone necrosis as a long term complication for a client who reports pain and limited movement. Radiographs of the extremity will reveal loss of bone structure

The nurse reviewing the laboratory values of a client with hypoparathyroidism finds a serum calcium level of 7.9 mg/dL (1.76 mmol/L). Which parameter is most important for the nurse to assess to prevent harm? A. Temperature B. Heart rate and rhythym C. Deep tendon reflexes D. Level of consciousness

C

A nurse is completing discharge teaching for a client who has an infection due to Helicobacter pylori (H. pylori). Which of the following statements by the client indicates understanding of the teaching? A. "I will continue my prescription for corticosteroids" B. "I will schedule a CT scan to monitor improvement." C. "I will take a combination of medications for treatment." D. "I will have my throat swabbed to recheck for this bacteria."

C A combination of antibiotics and a histamine2 receptor antagonist is used to treat an infection caused by H. pylori

The nurse is caring for a client with a bowel obstruction. Before using a newly placed nasogastric (NG) tube for the first time to administer tube feeding, what is the most appropriate action by the nurse? A. Inject air into the NG tube while auscultating the client's epigastric area B. Start the tube feeding as ordered and check the residual in 30 minutes C. Obtain x-ray order to confirm tube placement before starting the feedings D. Raise the head of the bed to 30 degree position and start the feedings

C Before feeding is started after a newly inserted NG tube, the placement must be confirmed by x-ray. Raise the head of the bed to a 30 degree positions and start feedings would be correct if we had x-ray confirmation. Injecting air into the NG tube and listening over the epigastric area can help identify placement, the gold standard and only way to use it for feeding is with x-ray confirmation. The nurse should never start tube feeding before

After a nasograstic tube is inserted, which assessment finding is cause for greatest concern? A. The patient reports that the tube is irritating nose and throat feels sore B. Gastric contents have a coffee-ground appearance C. The patient demonstrates coughing and cannot speak clearly D. Gastric fluid is bright red and has small clots

C Coughing and an inability to speak or difficulty in speaking clearly suggests that the tube has been inserted into the trachea. The tube should be removed immediately. Bright red blood with clots indicates active bleeding; this should be immediately reported to the health care provider. Coffee-ground appearance of gastric contents indicates old blood; this finding should also be reported but is less urgent. Irritation of the throat and around the nares is commonly reported. Perform hygiene around the nares as needed; irritation of the throat usually subsides, but an anesthetic throat spray may offer some temporary relief.

A client at continuing risk for hyperparathyroidism is prescribed to take furosemide 40 mg and to drink at least 3 to 4 L of fluid daily. He tells the nurse he believes taking a "water pill" and then drinking so much seems wrong. How will the nurse respond? A. "This combination of a water pill and drinking more protects you from buildup of excessive sodium in the kidney." B. "The furosemide makes you lose water and you need to increase your intake to keep from becoming dehydrated." C. "The drug helps you to get rid of calcium and drinking more helps dilute your blood calcium so the level doesn't get too high." D. "You are correct. I will check with your primary health care provider to determine whether you should restrict your fluid intake."

C Furosemide, a diuretic that increases kidney excretion of calcium, is used along with IV saline in large volumes to promote calcium excretion

The nurse working on the floor is helping the unlicensed assistive personnel (UAP) pull a client up in bed and feels a pinch along with pain to the lower back area. What action will the nurse take first? A. Apply ice to the affected area B. Ask the ED for opioid pain medication C. Apply heat to the affected area D. Ask the ED for acetaminophen 650mg

C Heat for acute lower back pain helps blood flow to the area and helps reduce pain. The nurse, after an injury like this should immediately stop, notify the supervisor and be seen in the ED. The nurse should not just go to the ED and ask for opioid pain medication and acetaminophen is not helpful with lower back pain, the nurse should take ibuprofen, an anti-inflammatory. Applying ice to the affected area will cause vasoconstriction, thus not allowing blood flow to the area, possible making the pain and injury worse. With chronic back pain, the fluctuation of hot and cold therapy can be helpful, with 15-20 minutes off. The hot and cold can be rotated. This is an acute injury, so heat will help better with this injury

The nurse is providing teaching to a newly diagnosed client with Rheumatoid arthritis regarding ibuprofen use. What is the most appropriate teaching for the nurse to provide to this client regarding NSAIDs? A. "You should notify the healthcare provider if you notice changes with your skin." B. "Don't worry about taking your ibuprofen with food, you can take it on an empty stomach. C. "You should take your ibuprofen every morning with food to avoid stomach upset." D. "You should notify the healthcare provider if you start having any neurological problems."

C NSAIDS can cause GI upset if not taken with food. They can also cause renal problems along with bleeding. The skin or neurological system is not effected by NSAIDS

In the care of a patient with gastroesophageal reflux disease, which task would be appropriate to delegate to assistive personnel (AP)? A. Sharing successful strategies for weight reduction B. Encouraging the patient to express concerns about lifestyle modification C. Reminding the patient not to lie down for 2 to 3 hours after eating D. Explaining the rationale for eating small frequent meals

C Reminding the patient to follow through on advice given by the nurse is an appropriate task for the AP. The RN should take responsibility for teaching rationale, discussing strategies for the treatment plan, and assessing patient concerns

For patients with peptic ulcer disease (PUD), what is the most important lifestyle modification? A. Avoiding caffeine B. Decreasing alcohol intake C. Smoking cessation D. Controlling stress

C Smoking is associated with PUD. The other lifestyle modifications may be desirable, but the current evidence does not show strong linkage to the development of or recovery from PUD

The type 1 diabetic client has the flu and asks the nurse why they need to drink juice and check their blood glucose levels every four hours. What is the most appropriate response by the nurse? A. "You can substitute water for juices to prevent dehydration, and check your glucose daily." B. "You need to monitor your glucose, vomiting could cause hypoglycemia and dehydration." C. "You need to prevent dehydration, monitor for hyperglycemia and excessive breakdown of fats." D. "Your body uses protein for energy during illness, causing increased ketones, hypoglycemia."

C Starvation induced ketosis can be prevented by drinking juice that is equal to the prescribed carbohydrate meal pattern. Fluids are needed to prevent dehydration and hyperosmolarity, which could result from large amount of fluid loss and persistent vomiting. The liver breaks down fats, not protein, to form glucose for energy and ketones as a byproduct leading to DKA and hyperglycemia. Substitution on water will not meet the caloric needs of a diabetic client during illness. The client should be taught to drink plenty of fluids containing both glucose and electrolytes to prevent diabetic keto acidosis. The client, if vomiting, should drink 8-12 ounces of calorie free, caffeine free liquids every hour. If the client cannot keep down fluids or foods, they should go to their healthcare provider within 24 hours

The nurse is teaching an older patient about risks for fractures and osteoporosis. Which diagnostic test should the nurse teach about when the goal is to establish he patient's bone strength and determine if osteoporosis is present? A. Computed tomography scan B. Magnetic resonance imaging scan C. Dual-energy x-ray absorptiometry (DXA or DEXA) scan D. Joint x-rays

C Testing bone density (how strong the bones are) is the only way o know for sure whether or not a patient has osteoporosis. A diagnostic test commonly prescribed by health care providers is DXA or DEXA. This type of scan focuses on two main areas, the hip and the spine. The forearm can be tested. The other tests may be prescribed but are not as commonly used to test bone strength.

A client presents to the ED nurse complaining of abdominal pain for the last three days and states that they have been really hungry and thirsty and feeling really "weird." What is most appropriate response by the nurse? A. "I'm sure that this is not a big problem." B. "I am going to draw laboratory values." C. "Do you mind if I perform an accucheck?" D. "Have a seat and the nurse will call you."

C The client has signs and symptoms indicating hyperglycemia as evidenced by the hunger and thirsty statements, abdominal pain and feeling weird and the nurse should perform an accucheck to see what the client's blood glucose level is. S/S of hyperglycemia also include fruity or acetone smelling breath, Kussmaul's respirations, extreme hunger, thirst and urination. The three "P's" along with abdominal pain caused by impaired gastric motility. Although the nurse may draw laboratory values, this is done after an accucheck to verify the results. This client may very well be sent to the waiting room if they are stable, but the nurse must do an accucheck first. Telling the client that this is not a big problem would not be an appropriate statement as learning that you are diabetic is life altering

A nurse is caring for a client who has a blood glucose of 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 minutes B. Provide a carbohydrate and protein food C. Provide 15g of simple carbohydrates D. Report findings to the provider

C The greatest risk to the client is injury from hypoglycemia; therefore, the priority action to take is to administer 15 to 20 g of a rapidly absorbed carbohydrate (grape juice)

A nurse is completing an assessment of a client who has a gastric ulcer. Which of the following findings should the nurse expect? (Select all that apply) A. Client reports pain relieved by eating B. Client states that pain often occurs at night C. Client reports a sensation of bloating D. Client states that pain occurs 30 min to 1 hr after a meal E. Client experiences pain upon palpation of the epigastric region

C, D, E A is incorrect because pain is relieved by eating if it's a duodenal ulcer. B is incorrect because pain rarely occurs at night.

The nurse is preparing discharge paperwork for a client who was admitted for diverticulitis. The client asks the nurse what type of diet they should eat to help avoid another episode of diverticulitis. What is the most appropriate teaching for the nurse o provide to this client? A. "You should only eat foods that have vitamin B12." B. "You should be able to eat anything you want now." C. "You should eat foods high in fiber and low in fat." D. "You should eat foods high in fiber and high in fat."

C The high fiber helps food move more quickly through the gut, thus reducing the chance that particles may become lodged and cause an abscess, thus diverticulitis. Those foods that are high in fiber include wheat bran, whole-grain breads and cereals. They should eat 25-35 grams of these fibers daily. Clients should always be taught to eat lower caloric foods to help maintain a healthy weight. Although vitamin B12 is important to get in our for source, the client doesn't need to eat only foods with B12. The client should avoid foods.

The nurse is caring for a client who has just come back to the medical/surgical floor after a kidney transplant. The client is rating their pain 10/10 on a 0-10 scale and is vomiting. What is the priority nursing action? A. Administer hydrocodone 5/800 ibuprofen by mouth B. Administer hydrocodone 5/500 acetaminophen PO C. Administer morphine sulfate 4mg IV and ondansetron D. Administer hydromorphone 4mg IV and ondansetron

C The nurse would not want to administer PO medications as this client is vomiting, which eliminate the hydrocodone/ibuprofen, which is also irritating to the stomach along with being possibly damaging to the kidneys. Again, because the client is vomiting we would not want to give anything by mouth as it could be vomited up and the client gets no pain relief. The hydromorphone 4mg IV and ondansetron can be given, but the hydromorphone is in too large of a dose. It should be 0.5mg - 1mg IV. The dosage of morphine is a safe dosage and would be the best choice for this client for pain control

The nurse is caring for a client who has just returned from an EGD procedure. What is the priority nursing action for this client? A. Give sips of water only for 60 minutes B. Monitor vital signs for only 60 minutes C. Keep the client NPO until gag reflex returns D. Administer morphine for pain after the EGD

C The patients' vital signs should be monitored every 15-30 minutes until awake, not just every 60 minutes. Analgesia may relieve the pain in the throat, but may cause respiratory depression. They should be kept NPO until the gag reflex returns. Morphine or other pain medication is usually used during the procedure, not after. The client should not be given anything by mouth until the gag reflex returns and they are awake enough to safely swallow without aspirating.

The ED nurse is caring for a client who is complaining of nausea, vomiting and coffee ground looking emesis. While reviewing laboratory values the nurse sees WBC 12.8mm^3, K+ 3.4 mEq/L, Hct 20% and Na+ 134 mEq/L. What is the priority nursing action? A. Notify the healthcare provider about the WBC count B. Notify the healthcare provider about the Na+ level C. Type and cross client for a possible blood transfusion D. Notify the healthcare provider about the K+ level

C This client has a Hct of 20% which if divided by 3 makes the Hgb 7.0. The nurse should type and cross this client for a transfusion and then notify the HCP about the abnormal lab values. None of the labs other than the Hct are grossly abnormal

The nurse is caring for a client and walking into the room to find the client diaphoretic, confused and their skin is cold and clammy. What is the priority nursing action? A. Obtain an accucheck immediately and give 3 ounces of apple juice orally B. Obtain an accucheck immediately and give 4 units insulin subcutaneously C. Obtain an accucheck immediately and give glucagon 1mg subcutaneously D. Obtain an accucheck immediately and give 3 ounces of orange juice orally

C This client is confused and altered, thus nothing by mouth should be given. They are having a hypoglycemic event as evidence by confusion, diaphoresis, cold and clammy skin. The nurse should obtain an accucheck, treat the hypoglycemia with glucagon 1mg IM or SQ. Giving additional insulin will cause the clients' blood glucose levels to drop further

The emergency department (ED) nurse is caring for a client who is complaining of nausea, vomiting and right lower abdominal pain. The nurse reviews the laboratory values and sees a WBC count of 15,000mm^3, Hgb 13.2 g/dL, Hct 40%, K+ 4.2 mEq/dL. What is the priority nursing action? A. Call the healthcare provider about the WBC count. B. Call the healthcare provider about the Hct level C. Assess when the client last had something to eat D. Document all findings and continue to monitor

C This client most likely has appendicitis and will go to surgery. The nurse must maintain the NPO status to ensure that the client can go to surgery in a timely manner and should also ask the client when they last had anything to eat or drink and note this in the medical record. Although the WBC is high and the nurse will notify the healthcare provider, the first thing is to keep the client NPO. All the information can then be given to the HCP at the same time. The nurse will document and monitor after all interventions are completed. The Hct level is within normal range.

A patient with a fractured fibula is receiving skeletal traction and has skeletal pins in place. What would the nurse instruct the assistive personnel to report immediately? A. The patient wants to change position in bed B. There is a small amount of clear fluid at the pin sites C. The traction weights are resting on the floor D. The patient reports pain and muscle spasms

C When the weights are resting on the floor, they are not exerting pulling force to provide reduction and alignment or to prevent muscle spasm. The weights should always hang freely. Attending to the weights may reduce the patient's pain and spasms. With skeletal pins, a small amount of clear fluid drainage is expected. It is important to inspect the traction system after a patient changes position because position changes may alter the traction

An assistive personnel reports that a nursing home client who has hypothryoidism has a pulse of 48 beats/min this morning. Which assessments have the highest priority for the nurse to perform immediately? (Select all that apply) A. Checking body temperature B. Testing deep tendon reflex responses C. Measuring oxygen saturation by pulse oximetry D. Checking blood pressure, heart rate, and rhythm E. Determining level of consciousness and cognition F. Identifying presence or absence of the swallowing reflex G. Examining feet and ankles for indications of peripheral edema

C, D

A nurse is caring for a client who is postoperative following a total knee arthroplasty and is prescribed a continuous passive motion (CPM) machine and PCA. The client tells the nurse, "I am in so much pain." Which of the following actions should the nurse take first? A. Remind the client to push the button for the PCA device B. Discuss activities the client may use to distract from the pain C. Ask the client to describe the characteristics of the pain D. Pause the CPM machine briefly to apply a cold pack to the client's knee.

C. Answering this item requires application of the nursing process priority - setting framework. The first action the nurse should take is to acquire further data by asking the client to describe characteristics of the pain. The rationales for the wrong answers just says "you should do C first." ¯\_(ツ)_/¯

The nurse is caring for a client who has been brought to the ED with upper gastrointestinal (GI) bleeding. The client is vomiting large amounts of bright red blood. What is the priority nursing action? A. Assess the client for pain on a 0-10 scale B. Draw serum laboratory specimens C. Gather equipment for a colonoscopy D. Ensure that the client has a patent airway

D The client must have a patent airway, which may be compromised from bloody emesis. The client does not need laboratory specimens drawn immediately, or need a colonoscopy; these actions are not as important as maintaining the airway. Pain and assessing for causative factors will be important after the client has stabilized.

The nurse is caring for a patient with osteoporosis who is at an increased risk for falls. Which intervention should the nurse delegate to the assistive personnel (AP)? A. Identifying environmental factors that increase the risk for falls B. Monitoring gait, balance, and fatigue level with ambulation C. Collaborating with the physical therapist to provide the patient with a walker D. Assisting the patient with ambulation to the bathroom and in the halls

D

The nurse reviewing the preadmission testing laboratory values for a 62 year old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal B. The client has type 1 diabetes mellitus C. The client has type 2 diabetes mellitus D. The client has prediabetes mellitus

D

The nurse is caring for a patient with peptic ulcer disease (PUD). Which assessment finding is the most serious? A. Projectile vomiting B. Burning sensation 2 hours after eating C. Coffee-ground emesis D. Board-like abdomen with shoulder pain

D A board-like abdomen with shoulder pain is a symptom of perforation, which is the most lethal complication of PUD. A burning sensation is a typical report and can be controlled with medications. Projectile vomiting can signal an obstruction. Coffee ground emesis is typical of slower bleeding and the patient will require diagnostic testing.

The nurse is caring for a client who frequently experiences an aura of flashing lights, double vision and they say that things "smell funny" when this happens. Which task is the most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP) for this client? A. Draw the shades, dim the lights and close the door B. Immediately evaluate for any signs of seizure activity C. Teach the client to always wear their eyeglasses D. Help the client to ambulate to prevent trips and falls

D Help the client to ambulate to prevent trips and falls. The UAP is trained to assist clients to ambulate and delegating this task is perfectly ok. Drawing the shades, turning down the lights and closing the door would be for a migraine, not a seizure which may very well have an aura of flashing lights, double vision and funny smells. Evaluation is a form of assessment and should only be done by the nurse, not the UAP.

The nurse is caring for a client who just returned to the floor after having a thyroidectomy. What is the priority nursing action? A. Assess the clients' blood glucose levels every 30 to 60 minutes B. Apply monitors to check the blood pressure every hour for 4 hours C. Administer iodine preparations to reduce vascularity of thyroid D. Instruct the client to use incentive spirometry every 30-60 minutes

D The client should be instructed to use an incentive spirometer every 30-60 minutes to reduce the risk of respiratory complications post-surgery. The vital signs should be taken every 15 minutes for an hour, every half hour for an hour, and then hourly for 2 hours or per facility protocol. There is no reason to check the clients' blood glucose levels, especially this frequently. This would only be done the frequently for a client on an insulin drip or has had ha hypo/hyperglycemic event. Iodine preparations are given preoperative to reduce the size and vascularity of the thyroid prior to surgery

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

D 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 4.5kg (10 lb) for 1 week following surgery

During morning care, a patient with a below-the-knee amputation asks the assistive personnel (AP) about prosthesis. How will the nurse instruct the AP to respond? A. "You should get a prosthesis so that you can walk again." B. "Wait and ask your health care provider (HCP) that question the next time he comes in." C. "It's too soon to be worrying about getting a prosthesis." D. "I'll ask the nurse to come in and discuss this with you."

D The patient is indicating an interest in learning about prostheses. The experienced nurse can initiate discussion and begin educating the patient. Certainly, the HCP can also discuss prostheses with the patient, but the patient's wish to learn should receive a quick response. The nurse can then notify the HCP about the patient's request

The clinic nurse is assessing a client who had a kidney transplant 2 months ago. While reviewing the laboratory values the nurse sees a BUN of 40 and creatinine of 2.0mg/dL. After notifying the healthcare provider of the results, what is the first nursing action? A. Explain to the client that the kidney has been rejected and they need another transplant B. Explain to the client that everything looks really good and there are no problems C. Explain to the client that they only need to come to see the provider every 6 months D. Explain to the client that they need to increase their anti-rejection medications

D This is an acute rejection which happens with 1 week to 3 months after transplant. This transplant can possibly be saved with increasing the anti-rejection medication. The client will be closely monitored, most likely weekly to see if this strategy is working. Telling the client that everything looks good or that they don't need to come back for 6 months is completely inaccurate.

The nurse is caring for a post-operative client. The client states that they notice an aura and have a headache rating their pain 8/10 on 0-10 scale, and states that it is throbbing on the right side. What is the priority nursing intervention? A. Administer Dilaudid 4mg intravenous B. Document and continue to monitor C. Administer 1000mg Ibuprofen PO D. Turn the lighting down in the room

D Turn the lighting down in the room. Most common migraines come with photosensitivity, so the nurse should turn down the lights. The dosage of Ibuprofen is too much, the maximum dose is 800mg every 8 hours. Dilaudid should be given IVP at no more than 0.5 - 1.0mg in a dose. This medication is 10x more powerful than morphine and when administering the nurse should be very careful of dosage and client reaction. To document and monitor without the interventions first would be inappropriate as this client needs nursing intervention.

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply) A. Remove calluses using OTC remedies B. Apply lotion between toes C. Test water temperature with fingers before bathing D. Trim toenails straight across E. Wear closed-toe shoes

D, E Correct: Trim toenails straight across to prevent injury to soft tissue of the toes. Wear closed-toe shoes to prevent injury to soft tissue of the toes and feet Incorrect: A podiatrist should remove calluses or corns. OTC remedies can increase the risk for soft tissue injury and an infection. Applying lotion between the toes increases moisture for growth of micro-organisms, which can lead to infection. The client should check bathwater with the wrist or a thermometer to ensure it is a safe temperature. The fingers might not be as sensitive.

A nurse is teaching a client who has a new prescription for alendronate for treatment of osteoporosis. Which of the following statements by the client indicates understanding of the teaching? A. "I will take the medication in the evening." B. "I will drink a full glass of milk with the medication." C. "I will take the medication at mealtime." D. "I will sit upright after taking the medication."

D. A client taking alendronate should sit upright for 30 min after administration to prevent esophageal irritation and ulceration. Therefore, the nurse should identify this statement as indicating an understanding of the teaching A. They should take it in the morning B. High-calcium foods can reduce the absorption of alendronate. Alendronate can cause hypocalcemia; therefore, the client might require a calcium supplement taken at a different time of day C. Should be taken 30 minutes before food

A nurse is reviewing the medical record of a female client. Which of the following findings should the nurse identify as a risk factor for osteoporosis? A. Decreased intake of phosphate-containing foods B. Spending several hours in the sun daily C. Increased estrogen levels D. History of anorexia nervosa

D. Inadequate protein intake can lead to a decreased bone density, increasing the risk for fractures A. The nurse should identify increased intake of phosphate-containing foods, such as carbonated beverages, as a risk factor for osteoporosis B. The nurse should identify lack of time outdoors in sunlight as a risk factor for osteoporosis C. Decreased estrogen or testosterone are risk factors

A nurse is discussing the plan of care with a client who has osteomyelitis of an open wound on his heel. Which of the following information should the nurse include? A. "You will need to apply a cold pack to the site three times a day." B. "Your provider might ask you to walk frequently to increase circulation of the area." C. "You will need to limit consumption of high protein foods." D. "Your provider might prescribe a central catheter line for long-term antibiotic therapy."

D. Osteomyelitis is an acute or chronic bone infection. The client will require weeks to months of IV antibiotic therapy for treatment. Therefore, the nurse should discuss the need for long-term IV access for antibiotic therapy. A. Cold therapy is contraindicated for a client who has an open wound. B. The client is at an increased risk for fracture of the weakened bone. Therefore, limit weight bearing exercises C. Protein is good for healing