PN med surg B FND II
A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?
Elevated serum amylase level
A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify which of the following statements by the client indicates an understanding of the teaching?
"I drink bottled water."
a nurse in a health clinic is reinforcing teaching a client who has tuberculosis (TB) about transmission of the disease. which of the following client statements indicates an understanding of the teaching?
"I inhaled the infected droplets that were in the air." *TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching.
A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?
"My food tastes bland even after I add seasoning."
A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?
"Pursed-lip breathing works best for activities like walking up stairs"
A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make?
"The tumor causes obstruction of urine from the urethra."
A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?
"You should place your toothbrush in hydrogen peroxide overnight."
a nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb). Which of the following statements by the client indicates an understanding of the teaching?
"i should give my shot in my belly tissue"
A nurse is caring for a client who has a new cast on her forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?
Compartment Syndrome
A nurse is caring for a cliennt who has restricted movement of the chest due to a burn injury. The nurse should anticipated preparing the client for which of the following procedures?
Escharotomy
a nurse is reviewing the medication record of a client who is taking digoxin. which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?
Furosemide
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?
HbA1c results measure glucose control for the prior 3 months.
A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider?
Heart rate 120/min
A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication?
I have gained 3 pounds since my last appointment.
A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?
Keep an abduction pillow beneath the client's legs.
A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?
Muscle spasticity is a manifestation of multiple sclerosis.
A nurse is caring for a client following thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?
Muscle twitching
A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?
Perform testicular self-examination after taking a warm shower
A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following?
Wheezes
a nurse is planning care for a group of clients after receiving change-of-shift report. which of the following clients should the nurse plan to see first?
a client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night
a nurse is reviewing the medication administration record of a client who has ostteoarthritis. which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain
acetaminophen
a nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. which of the following instructions should the nurse include in the teaching
add oily fish to your diet twice weekly
a nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. which of the following actions should the nurse take
administer oxygen via nasal cannula
a nurse is delegating the task of repositioning a client who is in the skeletal traction to an assistive personnel (AP). which of the following instructions should the nurse give the AP
allow the weights to hang freely
a nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from PACU following a right total knee arthroplasty. which of the following interventions should the nurse include in the plan
assist the client to change positions at least every 2 hr - client use the incentive spirometer once per hr while awake during the first 24 hr postoperative to prevent respiratory complications.
a nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?
blow cool air into the case using a blow dryer on a cool setting *Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin. -->The nurse should plan to have the provider bivalve a cast to relieve pressure caused by impaired blood flow. The cast is split down both sides and held together with hook and loop fastener straps to maintain immobilization.
a nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis
calcitonin will slow the breakdown of bone in your body *Calcitonin inhibits osteoclast activity, therefore minimizing bone loss. The medication helps to preserve bone for a client who has osteoporosis.
a nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. the client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first
check for kinks in the NG tube *The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the priority action is to check the NG tube to determine if the tube is kinked, which can interfere with the suctioning function and result in nausea.
a nurse is caring for a client who is suspected of having a myocardial infarction. which of the following actions should the nurse take to prepare the client for an ECG.
cleans the client's skin prior to electrode placement
a nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take?
cleanse the drainage plug with alcohol swabs
a nurse is caring for a client who is postoperative and has a Jackson-pratt drain. which of the following actions should the nurse take
compress the bulb reservoir and then close the drainage valve
a nurse is caring for a client who has been taking enalapril. the nurse should monitor the client for which of the following adverse effects?
cough
a nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?
decrease in exertional dyspnea
a nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?
diminished breath sounds
a nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?
diminished headache
a nurse is caring for an adult client who has age-related macular degeneration. which of the following findings should the nurse expect?
distorted central vision of the eyes
a nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. which of the following actions should the nurse take
educate the client about choosing low-fat, low-cholesterol foods *The nurse should educate the client about a low-fat, low-cholesterol diet, which is prescribed for clients who have atherosclerosis. This diet can also aid in weight reduction, which can improve activity tolerance. Other considerations: -avoid flexing the hips and knees because it can further impede the peripheral blood flow. -avoid the use of elastic support hose because they can reduce circulation to the skin -avoid the use of electric heating pads due to an increased risk of burns from decreased sensation of the extremities.
a nurse is reviewing the laboratory reports of a client who reports chest pain. which of the following laboratory results indicates the client is experiencing a myocardial infarction
elevated troponin
a nurse is caring for a client who has dementia due to Alzheimer's disease. which of the following actions should the nurse take to reduce the client's confusion
encourage reminiscence of past experiences
a nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. which of the following findings should the nurse include as an adverse effect of the medication
frequent colds *corticosteroids can increase susceptibility to infection by suppressing the immune response. The nurse should instruct the client about infection prevention measures to implement while taking a corticosteroid.
a nurse is assisting with the care of a client who had a stroke and is unable to speak. the nurse should identify that the client's injury occurred in which of the following lobes of the brain?
frontal lobe
a nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. which of the following information should the nurse include in the teaching
household family members should be tested for TB
a nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. the nurse tells the client to consume foods containing cit C when taking the supplement to enhance iron absorption. which of the following client food choices indicates an understanding of the teaching?
i cup boiled broccoli
nurse is preparing to administer an influenza vaccine to a client. which of the following statements by the client should cause the nurse to postpone administration of the vaccine
i had a low fever this morning
a nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. which of the following statements by the client indicates an understanding of the teaching
i will limit my daily intake of protein * client should decrease his intake of protein to slow the progression of kidney failure. Other considerations: -caution the client to avoid salt substitutes, which are high in potassium, because kidney impairment causes hyperkalemia - reinforce that the client should maintain adequate carbohydrates as part of a balanced diet to maintain tissue integrity. Restriction of fluids and phosphorus are necessary -avoid eating foods high in potassium, such as bananas, because kidney impairment causes hyperkalemia.
a nurse is admitting a client who is suspected of having active tuberculosis (TB). which of the following actions should the nurse take first
institute airborne precautions
a nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. which of the following provider prescriptions should the nurse expect?
irrigate the urethral catheter with 0.9% sodium chloride
a nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. which of the following interventions should the nurse include in the plan of care?
keep bed linens ff of the affected areas
a nurse is caring for a client who has neutropenia. which of the following nursing interventions should the nurse implement?
limit visitors to healthy adults
a nurse is reinforcing teaching with the parent of a toddler who has type I diabetes mellitus and whose prescription has been changed from regular insulin to lispro insulin. which of the following information should the nurse include in the teaching
lispro should be given before eating
a nurse is caring for a client who begins to have a seizure while ambulating in the hall. identify the sequence of actions the nurse should follow.
lower the client to the floor place a pad beneath the client's head to protect the client from injury loosen the clothing around the client's neck time the length of the client's seizure reorient and reassure the client
a nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include?
maintain hip flexion to 90 degrees or less when sitting
a nurse is reviewing the medical record for an older adult who is experiencing nausea and vomiting. based on the client data, which of the following actions should the nurse take?
notify the charge nurse of the client's BUN level
a nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. which of the following actions should the nurse take first
obtain the client's blood pressure
a nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. which of the following interventions should the nurse include in the plan
offer a small snack at bedtime
a nurse is assisting with an educational program for clients who has been newly diagnosed with diabetes mellitus. which of the following instructions should the nurse include in the program regarding insulin
opened insulin can be stored on a cool countertop away from light
a nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. which of the following findings requires immediate attention from the nurse
oxygen saturation of 88%
a nurse is caring for a client following a gastrectomy. which of the following actions should the nurse take to decrease episodes of dumping syndrome
place the client in the supine position after meals
a nurse is providing information regarding transmission-based precautions for a client who has clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (select all)
provide the client with disposable utensils and dishes for meals leave blood pressure equipment in the client's room clean contaminated surfaces with a bleach solution
a nurse is repositioning a client who has lower back pain. which of the following positions is appropriate for the client
semi-Fowler's with knees flexed
a nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. which of the following instructions should the nurse include to promote comfort
sleep on a firm mattress
a nurse is reinforcing teaching with an older adult client who has osteoporosis. which of the following instructions should the nurse include in the teaching?
take calcium supplements with meals *take calcium carbonate supplements with or following meals to increase absorption and effectiveness. Other considerations: -weight-bearing exercises-recommend that the client perform weight-bearing exercises, such as walking, or low-impact aerobic exercises, three to four times per week to promote bone formation. Swimming is not a weight-bearing exercise. -Take Vit D - to improve calcium absorption
a nurse is reinforcing teaching with a client who is taking levothyroxine. which of the following statements by the client indicates an understanding of the teaching
the medication should be taken before i eat breakfast every morning
a nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. which of the following information should the nurse include in the teaching
the virus can be transmitted without lesions present
a nurse is caring for a client who has cushing's syndrome and expresses concern regarding body image changes. which of the following should the nurse recognize as a physical change caused by this disease?
truncal obesity
a nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). which of the following actions should the nurse include in the plan?
use a turn sheet to reposition the client
a nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. which of the following actions should the nurse include in the plan?
use simple verbal cues when directing tasks
a nurse in a clinic is assisting with the development of a pamphlet about STIs. which of the following information should the nurse recommend to include in the pamphlet?
women have a higher risk of contracting STIs than men
a nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. which of the following information should the nurse include in the teaching (select all)
your knee is flexed and extended as prescribed by your provider the machine is padded with sheep skin-Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity. Other: -The client can elevate the head of the bed up to 20° while the CPM machine is in motion. -The client should exert force on the CPM machine but allow the machine to perform passive range-of-motion exercises. -The nurse should avoid placing the CPM on the floor to protect it from contamination.
A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?
"I will feel vibrations on my leg from the cast cutter." --- ---------The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain. ^Other considerations: - client should resume activities gradually to avoid placing unnecessary stress on the healing bone. -The nurse should instruct the client that the leg might appear atrophied following cast removal due to disuse of the muscles. -client should use a gentle technique, such as soaking the skin or applying moisturizing lotion, to remove dry, scaly flakes.
A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?
"I will limit my coffee intake"
A nurse is reinforcing discharge teaching a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?
"Maintain a low-residue diet"
a nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching
"i will notify my dentist about this procedure"
a nurse is reinforcing teaching with a client about increasing dietary fiber. the nurse should recommend which of the following foods as the best source of fiber?
1/2 cup cooked kidney beans
a nurse is preparing to insert a double-lumen gastric (salem) sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select?
A
A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?
Check incisional dressing *The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding. Other things to consider: -Obtain pt temp-temperature to monitor for hyperthermia, which can indicate an infection, or hypothermia following anesthesia administration. -Observe for phantom pain- observe the client for phantom pain to promote prompt pain treatment and relief -measure Urine output- measure the client's urinary output to monitor for fluid imbalance
A nurse is caring for 4 clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?
Diabetes mellitus
A nurse caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?
Decreased blood pressure
A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?
Place the client in a negative-pressure airflow room *The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms. Other Considerations: -place a surgical mask on the client when transporting her outside of the room to prevent the transmission of micro-organisms.
A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her mediation for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?
Prednisone
A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?
Reposition the client
A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team members should the nurse recommend a referral prior to initiating oral intake for the client?
Speech-language pathologist
A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hrs? (Round the answer to the nearest whole number)
Step 1: What is the unit of measurement the nurse should calculate? Calories Step 2: What is the volume the nurse should infuse? 60 mL/hr x 12 hr = 720 mL Step 3: What is the total infusion time? 12 hrs Step 4: Should the nurse convert the units of measurement? No Step 5: Set up an equation and solve for x. 720 mL x 1.2 cal/mL = calories x = 864 cal Step 6: Round if necessary. Step 7: Reassess to determine if the amount to administer makes sense.
A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?
Upright, leaning forward
A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?
Urine output is 50 mL/hr.
a home health nurse is caring for a client who has COPD. the client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. which of the following instructions should the nurse include?
drink beverages at the end of meals
a nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first
verify the client has given informed consent
a nurse is reviewing the medical record of a client who is postoperative. which of the following findings should the nurse identify as a complication of surgery
wbc count of 15,000/mm3
a nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. which of the following instructions on preparing the insulins should the nurse include
withdraw the regular insulin before withdrawing the NPH insulin
a nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. which of the following actions should the nurse take?
withhold the dose
