PN Med Surg Prac. 2017 A

A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the followinh statements indicates that the client understands the teaching?

" I will have my HbA1c checked twice per year."

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the statements should the nurse make?

"Avoid bending your hips more than 90°."

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements indicates an understanding of the teaching?

"I should wait at least two hours after eating before going to bed."

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?

"Limit contact with large groups of people." Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include teaching?

"This type of insulin should be given at the same time every day."

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?

*"You should have a pneumococcal immunization every 10 years."* The nurse should remind the client to have a pneumococcal immunization at age *65 and every 10 years* thereafter to protect her from acquiring pneumonia. *Wrong: "You should have a screening for glaucoma every 5 years."* The nurse should remind the client to have a screening for glaucoma every *2 to 3 years* along with an annual visual accuity exam. *Wrong: "You should have a physical examination every other year."* The nurse should remind the client to have a physical examination *every year.* *Wrong: "You should have your hearing checked every 2 years."* The nurse should remind the client to have her hearing checked *every year*.

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?

*Bradycardia* The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate. *Wrong: Weight loss* The nurse should identify that weight loss is a manifestation of *hyperthyroidism* caused by an increase in the client's metabolic rate. *Wrong: Blurred vision* The nurse should identify that blurred vision is a manifestation of *hyperthyroidism.* *Wrong: Insomnia* The nurse should identify that insomnia is a manifestation of *hyperthyroidism* that is caused by an increase in the client's metabolic rate.

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?

*Give the client liquids with increased viscosity.* Thickened liquids are easier for the client to swallow and can prevent aspiration. *Wrong: Provide small, frequent meals:* Providing small, frequent meals can improve the client's nutritional intake, but it does not decrease the risk for aspiration. *Wrong: Tell the client to extend his neck when swallowing.* The client should tilt his neck forward while swallowing to decrease the risk for aspiration. *Wrong: Provide mouth care before meals.* Mouth care can enhance the client's sense of taste, but it does not decrease the risk for aspiration.

A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group?

*Herpes zoster*: The nurse should recommend the herpes zoster immunization for adults 60 years of age and older.

A nurse is preparing to administer phytonadione 7 mg subeutaneously to a dlient who has an INR of 4. Available is phytonadione 10 mg/ml How many mL should the nurse administer? (Round the answer to the nearest tenth, Use a leading zero if it applies Do not use a trailing zero.)

.7 mL

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of this medication?

Abdominal cramps

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine. The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?

Allow for 30 minutes of rest before meals

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions shoud the nurse include when contributing to the plan of care?

Apply am asking the client if transport is needed

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Apply cold packs to the inflamed joints

A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching?

Avoid liquids at meal times

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the follow should the nurse include in the teaching?

Avoid stopping this medication suddenly

A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should review prior to the procedure?

BUN

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia?

Bradycardia

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the place the V1 electrode? (You will find hot spots to select in the artwork below Select only the hot spot that corresponds to your answer.)

C

A nurse is reinforcing teaching with the family of a client with a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?

Change the sheepskin liner weekly *change when spikes or at least once per week to prevent skin irritation

A nurse is assisting with the care of a client who is receiving 9% sodium chloride by continuous iv infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps?

Check the IV site Stop the infusion With drawl the IV catheter Elevate the affected arm Notify the charge nurse

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?

Combination oral contraceptives

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

Consume foods low in sodium

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL

A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the the following interventions should the nurse include?

Dangle the extremities off the side of the bed. The nurse should include in the plan of care to have the client dangle the lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report bef administering the medication?

Decreased potassium

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect

Decreased shortness of breath

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

Decreases pain during urination

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should t identify as the priority?

Determine the clients understanding of the procedure.

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of the radiation implants in a lead container

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as thr priority?

Dyspnea

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse Identify as the Priority?

Dysrhythmia

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

Eat several, small portion meals daily.

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan?

Encourage abdominal breathing

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of following interventions should the nurse include?

Encourage the client to complete ADLs. The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications?

Encourage the client to use and incentive spirometer every hour while awake

A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoitin alpha. The nurse should identify that which of the laboratory values and indicates the treatment is effective?

HGB 11 g/dL

A nurse is contributing to the plan of care for a client who has a methicillin-resistant staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take?

Have a designated stethoscope in the clients room. Not sure this is correct but I know you want to Remove the gloves before you leave the room and you're going to wear goggles for splashes but masks aren't necessary- he's on contact... But you don't want to bring your stethoscope in there because then you'll get him RSA on it and then transmit it to the next person you touch with your stethoscope...

A nurse is collecting data from a ss-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT) Which of the following should the nurse recognize as a contraindication to HRT

History of treatment for blood clots

A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening to the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.)

Hyperactive bowel sounds

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?

I don't cross my legs anymore

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of budesonide and albuterol inhalers? (Select all that apply)

I never forget to rinse my mouth after using my inhaler Between office visits I keep a record of how many times I use my albuterol inhaler Are use my albuterol inhaler before I go swimming

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client i understanding of the disease process?

I should call my doctor if my ankles swell

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by t demonstrates an understanding of the teaching?

I understand it testicular cancer is painless

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should th include in the teaching?

Increase intake of fiber rich foods

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis following interventions should the nurse include in the plan?

Instruct the client to swish the medication in her mouth

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?

Intra-abdominal bleeding

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as melanoma?

Irregular borders

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a contin passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the clients extremity and the CPM

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 he ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side lying position *The greatest risk to the client following a stroke is aspiration. Laying on side will allow secretions to drain out of the mouth.

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin Break down?

Keep the skin dry and free of perspiration

A nurse is reinforcing teaching with a client who is on low sodium diet and asked about how to improve the taste of bland food. Which of the following should the nurse recommend?

Lemon juice

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep?

Listen to soft music before sleeping

A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck. [The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.]

placed on the right lower extremity for a bone fracture. Which of the following findings A nurse is monitoring a client who recently had a cast should the nurse recognize as abnormal?

Loss of sensation between the first and second toes

A nurse is caring for a client who is three days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?

Maintain abduction of the clients right leg while in bed

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Maintain the clients body alignment

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?

Mask

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take?

Minimize the time the head of the bed is elevated

A nurse is collecting data from a ss-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT) Which of the following should the nurse recognize as a contraindication to HRT

Mohs surgery is a horizontal shaving of thin layers of the tumor.

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all that apply.)

Monitor the insertion site for bleeding. Maintain the pressure dressing. Check the clients peripheral pulses.

A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates type of cooking fat the nurse should recommend the client use when preparing meals?

Olive oil

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider?

Onset of nausea

A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the folowing actions should the nurse take first?

Palpate the abdomen

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days age of the following actions should the nurse take?

Perform pin site care daily

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration?

Pinch the NG tube. The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take?

Position pillows between the bony prominences.

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Pre-albumin 12 mg/dL

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first?

Recommend a referral for a speech language pathologist. The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to recommend a referral for a speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids.

A nurse is caring for a client who has bacterial meningitis. Upon monitering the client which of the following findings should the nurse expect?

Red macular rash

A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching her feet when walking

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse communicating with the client?

Rephrase the client instructions when not understood

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching?

Report purulent drainage to the provider

Following a blood draw precedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because i'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take?

Reschedule the FBS test for early the next morning

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Whi following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools

A nurse enters the room of a client whose transfusion of packed RBCs what is initiated 15 minutes ago by the RN. Which of the following actions should the nurse perform first?

Stop the infusion

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make?

Tell me more about the way you are feeling

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication

A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of iv therapy?

Thrombophlebitis

A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider?

Urinary retention

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?

Use a raised toilet seat

A nurse is preparing to suction a client who has a tracheostomy, Which of the following actions should the nurse take first?

Ventilate with 100% oxygen

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the information should the nurse plan to share with visitors

Visitors must don gown and gloves before entering the room

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include?

You are at risk for infertility with this infection, regardless of the treatment.

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider?

ceftriaxone