RN Adult Medical Surgical Online Practice 2023 B

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching?

"I will take my temperature once a day." Rational: A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will use my hands rather than a washcloth to clean the radiation area." Rational: The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

"I am taking this medication to increase my energy level." Rational: The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

A nurse is providing discharge teaching about infection prevention to a client who is receiving chemotherapy. Which of the following statements by the client indicates understanding of the teaching?

"I can ask a friend to change my cats litter box." Rational: Changing a pet's litter box increases the client's risk of being exposed to toxoplasmosis. Therefore, the client should wear gloves or avoid changing the pet's litter box.

The nurse is providing care for the client.A nurse is providing discharge teaching with the client. Which of the following statements made by the client indicates an understanding of the teaching? (Select all that apply.)

"I should schedule several rest periods throughout the day." "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit." Rational: When evaluating outcomes, the nurse should identify that the client understands discharge teaching after stating "I will schedule several rest periods throughout the day" and "I will notify my provider if temperature is greater than 101 F." The client had an exploratory laparotomy procedure and has a closed incision; therefore, the client will require rest throughout the day and should monitor for manifestations of infection such as an elevated temperature and drainage from surgical wound.

A nurse is evaluating a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following client statements indicates the client is successfully coping with the change?

"I used to never worry about my feet. Now, I inspect my feet every day with a mirror." Rational: This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more high-fiber foods." Rational: The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

A nurse is caring for a client who is scheduled for a right knee arthroplasty.The nurse provided preoperative teaching to the client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

"I will need to do the breathing exercises every 1 to 2 hours after the surgery" "I will be sure to ask for pain medication before my knee starts to hurt too bad" "I will probably be going home with a walker" Rational: "Well, I guess there's no changing my mind about having surgery now" is incorrect. The nurse and the client reviewed the consents; therefore, the nurse has instructed the client that they have the right to refuse surgery at any time. "I will need to do the breathing exercises every 1 to 2 hours after the surgery" is correct. The client should cough and deep breathe and use the incentive spirometer every 1 to 2 hr to reduce the risk of postoperative complications, such as pneumonia. "I will be sure to ask for pain medication before my knee starts to hurt too bad" is correct. For optimal control of postoperative pain, the client should request analgesic medication before the pain becomes severe. "My physical therapy will start after I leave the hospital" is incorrect. Early ambulation leads to improved postoperative outcomes and reduces the risk of complications of immobility, such as pneumonia and atelectasis. The client should be informed that physical therapy will begin the day of, or the day following, surgery. "I will probably be going home with a walker" is correct. It can take 6 weeks for complete recovery from knee arthroplasty. Clients are often discharged with the use of a walker and will advance to a cane or crutch 4 to 6 weeks following surgery.

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will wear clean graduated compression stockings every day." Rational: The client should apply a clean pair of graduated compression stockings each day and clean soiled stockings with mild detergent and warm water by hand.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching?

"My joints ache because I have Lyme disease." Rational: Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in their diet?

12 almonds Rational: The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching?

"This identifies if the pacemaker cells of my heart are working properly." Rational: Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy.Which of the following statements should the nurse include in the teaching?

"You should cut the opening of the skin barrier one-eighth inch wider than the stoma." Rational: The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

The nurse is providing care for the client. The nurse has completed the assessment and is reviewing the findings in the EMR. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

12 % weight loss over 2 months Muscle guarding and tenderness in right lower quadrant of abdomen Abdominal firmness and rigidity Abdominal pain rate of 8 Hypoactive bowel sounds Report of anorexia Temperature of 38.5 C (101.4 F) Rational: When recognizing cues, the nurse should identify the assessment findings that require follow-up include 12 % weight loss over 2 months, muscle guarding and tenderness in right lower quadrant of abdomen, abdominal firmness and rigidity, abdominal pain rate of 8, hypoactive bowel sounds, report of anorexia and temperature of 38.5 C (101.4 F) require follow up by the nurse. These are unexpected findings that should be assessed further by the nurse and may require further intervention.

A nurse is caring for a client who has a new prescription for total parenteral nutrition (TPN). The client is to receive 2,000 kcal per day. The TPN solution has 500 kcal/L. The IV pump should be set at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

167 mL/hr Rational: mL/hr = 4000/24 = 166.6 = 167

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL shouldthe nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

24 mL

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?

A client who is receiving preoperative teaching for a right knee arthroplasty. Rational: The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. Thenurse should explain that applying a TENS unit to the painful area has which of the following effects?

A tingling sensation replacing the pain Rational: A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain.

A nurse is caring for a client in the emergency department (ED). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Administer Morphine IV - Ensure client is NPO Cholecystitis Monitor for rectal bleeding - Monitor for dark urine Rational: The nurse should plan to administer an opioid analgesic, such as morphine, for acute pain. Since the client is experiencing nausea and vomiting, the nurse should also ensure they are NPO. The client is likely experiencing cholecystitis, which typically presents with nausea, vomiting, upper abdominal pain that radiates to the right shoulder, fever, and dyspepsia. The client also has elevated liver enzymes and a WBC count, which is consistent with cholecystitis. Surgical management for cholecystitis might be indicated. The nurse should monitor the client's stool and urine color because a biliary obstruction from gallstones may cause clay-colored stools and dark urine.

A nurse in an emergency department is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect?

Administer an opioid analgesic to the client. Rational: The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

The nurse is providing care for the client. A nurse is reviewing the client's electronic medical record (EMR) and the provider's prescriptions. Which of the following actions should the nurse take? Select the 3 actions that the nurse should take.

Administer gentamicin 100 mg IV. Administer client's PO medication with a sip of water. Ensure that the client has provided informed consent. Rational: When taking actions after reviewing the client's EMR and provider prescriptions, the nurse should prepare the client for an exploratory laparotomy by ensuring that the client has provided informed consent, administer gentamicin 100 mg IV, and the client's prescribed PO phenytoin. The client has findings of peritonitis in which the provider evaluating further.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurseshould take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Administer oxygen via a nonrebreather mask. Initiate IV therapy with a large-bore catheter. Insert an NG tube. Administer famotidine. Rational: Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to administer oxygen. The nurse should then initiate IV therapy to support circulation by expanding the client's intravascular fluid volume. Next, the nurse should insert an NG tube to monitor the rate of bleeding and prevent gastric dilatation. Finally, to prevent a stress ulcer, the nurse can administer famotidine when the client is no longer bleeding.

A nurse is caring for a client. Complete the following sentence by using the lists of options.

After reviewing the findings in the client's medical record, the nurse should first address the client's ABDOMINAL FINDINGS followed by the client's PAIN RATING Rational: When prioritizing hypotheses and using the priority framework of urgent vs non-urgent approach to client care, the nurse first should address the client's abdominal findings followed by the client's pain rating. Abdominal distention is a manifestation of an inflammatory intestinal disorder. The nurse should address this finding first to reduce the risk of life-threatening complications, such as obstruction or infection. The nurse should next address the client's pain rate of 8 which indicates moderate pain which requires intervention by the nurse.

The nurse is providing care for the client. The nurse is planning care for the client.(For each potential provider's prescription, click to specify if each potential prescription is anticipated or contraindicated for the client.)

Anticipate - Obtain blood cultures, insert NG, obtain vitals Contraindicated - Bolus fluids Rational: When generating solutions when planning the client's care, the nurse should anticipate that the provider prescriptions for obtaining blood cultures, obtaining vital signs ever hour and insert a nasogastric tube are prescriptions that could be indicated to manage the client's current condition. The anticipated provider prescription for administering a bolus of IV fluid is contraindicated for the client because the client's vital signs are within the expected reference range and the client is not experiencing findings that indicate a decrease in their fluid volume.

A nurse is caring for a client. The nurse is planning care for the client.For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Anticipated - Obtain sputum, acetaminophen, cough and deep breathe, administer O2 Nonessential - Neuro checks, famotidine Contraindicated - Limit fluid intake Rational: Cough and deep breathe every 2 hr is anticipated. The nurse should anticipate a prescription for coughing and deep breathing to promote lung expansion and improve impaired gas exchange. Obtain a sputum culture and sensitivity is anticipated. The nurse should anticipate a prescription for a sputum culture and sensitivity to determine the type of bacteria present and to identify antibiotics to be prescribed. Perform neurological checks every 2 hr is nonessential. The client is alert and oriented to person, place, and time. Therefore, the nurse does not need to perform neurological checks every 2 hr. Administer oxygen at 3 L/min via nasal cannula is anticipated. The client's oxygen saturation level is 88% on room air, which indicates hypoxemia. Therefore, the nurse should administer oxygen at 3 L/min via nasal cannula. Limit the client's fluid intake to 1,500 mL per day is contraindicated. The client has manifestations of dehydration. Therefore, fluid restriction is contraindicated. Acetaminophen 500 mg PO every 6 hr as needed is anticipated. The nurse should anticipate a prescription for acetaminophen to reduce the client's temperature and promote comfort. Famotidine 40 mg PO daily is nonessential. Famotidine is a histamine2 antagonist that is used in short-term therapy for the treatment of peptic ulcers. Therefore, the nurse does not need to administer famotidine 40 mg PO daily.

A nurse is caring for a client.The nurse has completed their performing an assessment of the client and reviewing the client's EMR. (For each of the client's assessment finding, click to specify if the finding is consistent with appendicitis or Crohn's disease. Each finding may support more than one disease process.)

Appendicitis - Pain location, temperature, GI concerns Crohn's Disease - Stool color, pain location, temperature, GI concerns

A nurse is assessing a client who has had a plaster cast applied to their left leg 2 hr ago. Which of the following actions should the nurse take?

Check that one finger fits between the cast and the leg. Rational: To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy?

Avocados Rational: Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity.

A nurse at a provider's office is caring for a client who is 2 weeks postoperative following a gastrectomy. A nurse is providing teaching for the client. Which of the following instructions should the nurse include?Select all that apply.

Avoid drinking fluids with meals Eat several small meals Consume high-protein snacks Avoid highly seasoned foods Rational: Maintain a high carbohydrate intake is incorrect. Dumping syndrome requires a low carbohydrate diet because of reactive hypoglycemia. Eat five servings of fresh fruit per day is incorrect. The client should limit intake to three servings of unsweetened cooked or canned fruit per day. Avoid drinking fluids with meals is correct. The nurse should instruct the client to drink fluids 30 min before or after meals. Eat several small meals per day is correct. The nurse should instruct the client to eat several small, frequent meals instead of three large meals per day. Consume high-protein snacks is correct. The client should eat snacks that are high in protein and low in carbohydrates to prevent the gastric food boluses and reactive hypoglycemia in dumping syndrome. Avoid highly seasoned foods is correct. The nurse should instruct the client to avoid excessive amounts of spices and salt.

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should thenurse include in the plan of care to prevent a Pseudomonas aeruginosa infection?

Avoid placing plants or flowers in the client's room. Rational: Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

A nurse is caring for a client. The nurse is reviewing the client's diagnostic results. Which of the following findings requires follow-up by the nurse?Select all that apply.

BUN level Chest x-ray Oxygen saturation level WBC count PCO₂ level Rational: PCO2 level is correct. The client has an elevated PCO2 level, which indicates the retention of carbon dioxide. Therefore, this finding requires follow-up by the nurse. WBC count is correct. The client has an elevated WBC count, which indicates an infection. Therefore, this finding requires follow-up by the nurse. Chest x-ray is correct. The client's chest x-ray indicates increased opacity in the bilateral posterior lobes, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Oxygen saturation level is correct. The client's oxygen saturation is decreased, which is a manifestation of pneumonia. Therefore, this finding requires follow-up by the nurse. Calcium level is incorrect. The client's calcium level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. HCO3- level is incorrect. The client's HCO3- level is within the expected reference range. Therefore, this finding does not require follow-up by the nurse. BUN level is correct. The client's BUN is elevated, which is a manifestation of dehydration or kidney disease. Therefore, this finding requires follow-up by the nurse.

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Bathe the client using chlorhexidine solution. Rational: The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80 mm Hg Rational: Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a componentof Cushing's triad?

Bradycardia Rational: A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion?

Bubbling in the water seal chamber has ceased. Rational: Bubbling in the water seal chamber ceases when the lung re-expands.

A nurse is providing teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which ofthe following supplements can interfere with the effectiveness of the medication?

Calcium Rational: Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A nurse is caring for a client. The nurse is reviewing the client's medical record.Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Client is short of breath and has a productive cough with yellow mucus "I could barely breathe when I got up this morning and I had a throbbing headache" Crackles heard in posterior lungs Client is diaphoretic Rational: Client is short of breath and has a productive cough with yellow mucus is correct. Shortness of breath, along with a productive cough with yellow mucus, indicates a potential problem. "I could barely breathe when I got up this morning and I had a throbbing headache" is correct. Difficulty breathing and a throbbing headache indicates a potential problem. Crackles heard in posterior lungs is correct. Crackles heard in the posterior lower lobes indicate a potential problem. Capillary refill less than 2 seconds is incorrect. A capillary refill less than 2 seconds is within the expected reference range and indicates adequate perfusion. Client is diaphoretic is correct. Diaphoresis is a manifestation of an elevated temperature or hypoglycemia and indicates a potential problem. Pedal pulses +2 bilaterally is incorrect. Pedal pulses +2 bilaterally is within the expected reference range and indicates adequate perfusion.

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information shouldthe nurse include in the teaching?

Create complete outfits and allow the client to select one each day. Rational: The family should place completed outfits on hangers and allow the client to select which one to wear each day.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? (Click on the "Exhibit"button for additional information about the client. There are three tabs that contain separate categories of data.)

Current medications Rational: The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?

Decreased viral load Rational: Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Scan the bladder with a portable ultrasound. Rational: The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

Document that depolarization has occurred. Rational: When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching?

Drink 240 mL (8 oz) of water after administration. Rational: The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

A nurse is caring for a client. For each assessment finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Emphysema - ABG results, Respiratory rate, Heart rate, Breath sounds, Cough Asthma - Resp rate, breath sounds, cough Pneumonia - ABG, RR, temp, HR, breath, cough Rational: Temperature is consistent with pneumonia. Fever is a manifestation of pneumonia and is related to inflammation or infection. Breath sounds are consistent with emphysema, asthma, and pneumonia. The client's wheezing is a manifestation of emphysema, asthma, and pneumonia. It is the result of narrowed airways and alveoli. ABG results are consistent with emphysema and pneumonia. The client's ABG results indicate respiratory acidosis, which is a manifestation of emphysema and pneumonia. Respiratory rate is consistent with emphysema, asthma, and pneumonia. The client's respiratory rate is a manifestation of emphysema, asthma, and pneumonia. Heart rate is consistent with emphysema and pneumonia. The client is experiencing tachycardia, which is a manifestation of emphysema and pneumonia. Cough is consistent with emphysema, asthma, and pneumonia. The client's cough is a manifestation of emphysema, asthma, and pneumonia.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Hair loss on the lower legs Rational: The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

History of asthma Rational: A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging?

Heart rate 110/min. Rational: One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.

A nurse is caring for a client who presents to a clinic for a 1-week follow-up visit after hospitalization for heart failure. Based on the information in the client's chart, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Heart rate 55/min Rational: The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

A nurse is caring for a client. The nurse is reviewing the client's medical record from Day 5.Click to highlight the findings below that indicate the client is improving.To deselect a finding, click on the finding again.

Heart rate 72/min Respiratory rate 20/min Blood pressure 128/56 mm Hg Oxygen saturation 95% on room air Rational: Heart rate is 72/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Respiratory rate is 20/min is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Blood pressure is 128/56 mm Hg is correct. The client's heart rate, respiratory rate, and blood pressure are within the expected reference ranges. Therefore, this finding indicates the client's pulmonary and cardiovascular statuses are improving. Oxygen saturation is 95% on room air is correct. The client's oxygen saturation is within the expected reference range and no longer requires supplemental oxygen. Therefore, this finding indicates the client's pulmonary status is improving. Lung sounds are diminished in the bilateral posterior bases with occasional crackles heard upon auscultation is incorrect. The nurse should identify that the client's lungs sounds are still diminished in the bilateral posterior bases with occasional crackles heard upon auscultation due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving. Cough is productive with yellow mucus is incorrect. The client's cough is still productive with yellow mucus due to the client's acute respiratory infection. Therefore, this finding indicates the client's respiratory status is not improving.

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should thenurse identify as a desired outcome for this therapy?

INR 2.5 Rational: Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

A nurse is providing teaching to a client who has irritable bowel syndrome (IBS). Which of the following instructions should the nurse include in the teaching?

Increase fiber intake to at least 30 g per day. Rational: Dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

Increased BUN Rational: Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

Instruct the client to allow the machine to breathe for them. Rational: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take?

Inject the medication into the anterolateral abdominal wall. Rational: The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take?

Instruct the client on alternative therapies for pain reduction. Rational: The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. Rational: The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

Irrigate the indwelling urinary catheter. Rational: The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client's room. Rational: The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is caring for an client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting toremove their IV catheter. Which of the following actions should nurse take to avoid restraining the client?

Keep the client occupied with a manual activity. Rational: The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity Rational: An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?

Naproxen Rational: Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Nonrebreather mask Rational: The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition?

Pain that increases with passive movement Rational: The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?

Perform synchronized cardioversion. Rational: The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

A nurse is caring for a client who is 4 hr postoperative following a totalvaginal hysterectomy.Click to highlight the findings the nurse should report to the provider immediately.

Perineal pad saturated with blood, large clots present Change of blood pressure, heart rate of 102/min Rational: Perineal pad saturated with blood, large clots present, blood pressure trend, and heart rate of 102/min are correct. The client has manifestations of vaginal hemorrhage, including vaginal bleeding, blood clots, reduced blood pressure, and tachycardia. The nurse should report these findings to the provider.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority?

Place a tracheostomy tray at the bedside. Rational: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.

A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Place personal items, such as pictures, at the client's bedside. Rational: The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.

A nurse is caring for a client. The nurse is reviewing the client's medical record.Select the 3 findings that require nursing intervention.

Potassium level WBC count Temperature Rational: Temperature is correct. The nurse should identify that the client continues to have a fever as a result of the body's immune system fighting the infection. Therefore, this finding requires nursing intervention. WBC count is correct. The nurse should identify that the client's WBC count remains elevated, which indicates an infection. Therefore, this finding requires nursing intervention. Heart rate is incorrect. The nurse should identify the client's heart rate is within the expected reference range. Therefore, this finding does not require nursing intervention. Potassium level is correct. The nurse should identify that the client's potassium level is elevated, which places them at risk for cardiac dysrhythmias. Therefore, this finding requires nursing intervention. Oxygen saturation is incorrect. The nurse should identify the client's oxygen saturation has improved and is within the expected reference range. Therefore, this finding does not require nursing intervention.

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

Rational: This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer?

Regular insulin 20 units IV bolus Rational: DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

Remain with the client for the first 15 min of the infusion. Rational: The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?

Remind the client to scan their complete range of vision during ambulation. Rational: The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?

Report of sore throat Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?

Respiratory paralysis Rational: The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate.

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. Rational: After three negative sputum cultures, the client is no longer considered infectious.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation?

Stress ulcers Rational: Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the client's bedside?

Suction machine Rational: The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?

Tachycardia Rational: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIS). Which of the following information should the nurse include in the teaching?

Take daily cranberry supplements.. Rational: The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.

A nurse is caring for a client who was just admitted from the emergency department (ED).Drag words from the choices below to fill in each blank in the following sentence.

The client is most likely experiencing acute chest syndrome and pneumonia. Rational: Fluid volume overload is incorrect. While the client is experiencing an increased respiratory rate and shortness of breath, fluid volume overload typically includes moist crackles on auscultation, pitting edema in dependent areas, neck vein distension, and hypertension. Right-sided heart failure is incorrect. While clients who have sickle-cell disease are at risk for developing heart failure, the client does not have manifestations of right-sided heart failure. Right-sided heart failure typically presents with signs of fluid volume overload, which includes jugular vein distention, dependent edema, and blood pressure alterations. Acute chest syndrome is correct. The client is most likely experiencing acute chest syndrome, which can be caused by respiratory infections and debris from sickled cells. The client is displaying manifestations of acute chest syndrome, which include cough, shortness of breath, wheezing, tachypnea, fever, and chest pain. Pneumonia is correct. The client is most likely experiencing pneumonia as evidenced by the manifestations of cough, shortness of breath, fever, tachypnea, blood-tinged sputum, and chest pain. Pneumothorax is incorrect. While the client is experiencing increased respiratory distress, a pneumothorax typically presents with reduced or absent breath sounds and unequal chest expansion.

A nurse is caring for a client. A nurse is prioritizing client care.Complete the following sentence by using the lists of options.

The nurse should first address the client's oxygen saturation followed by the client's temperature. Rational: Dropdown 1 Oxygen saturation is correct. The first action the nurse should take when using the airway, breathing, and circulation approach to client care is to address the client's oxygen saturation. The client's oxygen saturation is 88%, which indicates hypoxemia and requires supplemental oxygen. Loss of appetite is incorrect. The nurse should address the client's loss of appetite, which is a manifestation of an infection. However, there is another finding the nurse should address first. BUN level is incorrect. The nurse should address the client's BUN level because it is elevated. However, there is another finding the nurse should address first. Dropdown 2 Heart rate is incorrect. The nurse should address the client's elevated heart rate, which can result in decreased cardiac output. However, there is another finding the nurse should address first. Temperature is correct. The nurse should next address the client's elevated temperature, which is a manifestation of an infection. The client's elevated temperature can cause an increase in other vital signs, such as heart rate. Headache is incorrect. The nurse should address the client's headache, which is a manifestation of an infection. However, there is another finding the nurse should address first.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)?

Troponin 18 ng/mL Rational: Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred.

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?

Try to walk at least three times per week for exercise. Rational: The development of a regular exercise routine can improve outcomes in clients who have heart failure.

A nurse is caring for a client who has a stage 3 pressure injury. Which of the following findings contributes to delayed wound healing?

Urine output 25 mL/hr Rational: Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity 1.045 Rational: A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips. Rational: Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which ofthe following neurologic deficits should the nurse expect to find when assessing the client? (Select all that apply.)

Visual spatial deficits Left hemianopsia One-sided neglect Rational: Expressive aphasia is incorrect. Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke. Visual spatial deficits is correct. Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia is correct. Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. Right hemiplegia is incorrect. Right hemiplegia occurs secondary to a left-hemispheric stroke. One-sided neglect is correct. One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Warfarin Rational: Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

A nurse and an assistive personnel (AP) are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?

Wear a Mask Rational: Bacterial meningitis requires droplet precautions. Therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings. Rational: The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.