The End II

The nurse providing care for a patient who has an adrenocortical adenoma causing hyperaldosteronism should

monitor the blood pressure every 4 hours.

Manifestations, hypercortisolism

moon face

MI, what do you admin for pain and anxiety

morphine

Parkinson's disease, taking carbidopa/levodopa, what do you report that's considered significant

muscle twitching

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next?

Assess the client's bowel sounds.

The nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. Which of the following medications taken by the client interacts with contrast material and places the client at risk for acute kidney injury?

-Metformin

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

-Observe for signs of infection.

A nurse on a medical-surgical unit is caring for a client who reports pain in the jaw, back, and shoulder, and shortness of breath and nausea. Which of the following actions should the nurse take?

-Obtain an EKG.

A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. which of the following instructions should the nurse include

-Reduce intake of foods high in potassium

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

-Reduce the client's intake of protein.

A nurse is caring for a client who has cancer & is 20 wks pregnant. The client's provider recommends chemotherapy for the client, but the client is uncertain about the recommend treatment. Which of the following statements by the nurse is appropriate?

-This must be a difficult decision for you

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following findings should the nurse expect?

-Tingling of the extremities.

The patient admitted to the intensive care unit after a motor vehicle accident has been diagnosed with AKI. Which finding indicates the onset of oliguria resulting from AKI?

-Urine output less than 400 mL for the past 24 hours

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?

-WBC 2300

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematous (SLE). Which of the following findings should the nurse expect?

-a dry, red rash across the bridge of the nose and one the cheeks

A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease's progression. In addition to skin changes, which of the following findings should the nurse expect?

-finger contractures

Select all that apply, what can cause intrarenal or intrinsic acute kidney injury

-glomerulonephritis, -heavy metals

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which go the following findings is the highest priority for the nurse to report to the provider?

-presence of peripheral edema

A nurse is performing discharge teaching with a client about the care of a newly created ileal conduit. The nurse should instruct the client to empty the appliance.

-when the bag is 2/3 full

A client has a tentative diagnosis of primary Sjögren's syndrome. Which finding would be common?

Dry eyes and mouth (disease causes not enough tears and saliva)

A nurse is assessing a client who has infective endocarditis. Which of the following should be the priority for the nurse to report to the provider?

Dyspnea

During the advanced stages of amyotrophic lateral sclerosis (ALS), which service would be most beneficial to the family and patient?

Hospice services

A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?

How to draw up and administer injections of the medication

Exacerbation of psoriasis, pt gets betamethasone, what indicates need for further teaching

I will apply plastic wrap over my topical medication and change it every 12 hrs.

. A patient who has non-Hodgkins lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse?

Lip swelling (angioedema)

A nurse is reviewing the laboratory results of a client who has acute leukemia and received an aggressive chemotherapy treatment 10 days ago. Which of the following Hematologic laboratory values should the nurse expect? Select all that apply.

-Decreased platelet count - Decreased leukocyte count -Decreased erythrocyte count

.A nurse is reviewing the laboratory results of a client who has liver failure with ascites and is receiving spironolactone. Which of the following findings should the nurse expect?

-Decreased sodium level

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required?

Magnesium hydroxide

Which nursing action will the nurse include in the plan of care for a 35-yr-old male patient admitted with an exacerbation of inflammatory bowel disease (IBD)?

Monitor stools for blood.

What position should the post-op thyroidectomy be in?

Semi fowlers

A nurse is reinforcing teaching with a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client requires further teaching when she identifies which of the following as a factor that can exacerbate SLE?

-Exercise

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for:

-Headache, deteriorating level of consciousness, and twitching

Which of the following assessment findings is a consequence of the oliguric phase of acute kidney injury (AKI)?

-Hyperkalemia

Addison disease with temp of 102F, BP 78/35, reports weakness and abdominal pain, what is most likely related to current manifestations. Select all that apply

-I injured my leg last week when I fell off the ladder -I think I have had the flu for the last week.

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

-Keep blood pressure equipment in the client's room

A nurse is planning care for a client who has leukemia and a platelet count of 130,000/mm³. Which of the following interventions should the nurse include in the plan of care?

-Limit IM injections

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this clients education? (Select all that apply.)

- Do not share utensils, plates, and cups with anyone else. -Wash your clothing separate from others in the household. -Take a laxative 2 days after therapy to excrete the radiation.

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

- Loss of color discrimination. - Coarse facial features - Enlarged distal extremities - Hepatomegaly

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the cli- ent's nostril. The nurse should take which initial action?

- Test the drainage for glucose.

A client who is 1 day postop following a thyroidectomy reports severe muscle spasms of the lower extremities. Which action should the nurse implement?

- verify most recent calcium level

A client who has had a significant myocardial infarction receives a referral to the cardiac rehabilitation unit. During his first visit to the unit, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do as the damage is done. Which of the following is an appropriate nursing response?

-"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely."

A nurse is caring for a client who is experiencing severe nausea and vomiting after a course of chemotherapy. The nurse should monitor the client for which of the following clinical manifestations?

-Metabolic Alkalosis.

A nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.)

-"Have you been under a lot of stress lately?" -Have you recently had any other health problems? - Have you changed any medications recently?

A nurse is reviewing discharge instructions with a client who has Raynaud's disease. Which of the following client statements indicates an understanding of the teaching?

-"I am going to take a stress management class."

In managing dermatitis, the nurse should provide which instruction(s)? (Select all that apply.). Avoid the irritant or allergen."

-"Provide adequate skin lubrication. -"Maintain skin moisture." - "Apply steroid-based preparations."

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

-"Wash your hair with a mild protein shampoo."

A nurse is caring for a client who is to start chemotherapy for advanced breast cancer. She tells the nurse she is worried about the adverse effects of the treatment. Which of the following responses should the nurse make?

-"What is it about the adverse effects that concern you?"

A nurse on an oncology unit is preparing to administer doxorubicin to a client who has breast cancer. Prior to beginning the infusion, the nurse verifies the client's current cumulative lifetime dose of the medication. For which of the following reasons is this verification necessary?

-An excess amount of doxorubicin can lead to cardiomyopathy

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? select all that apply

-Assess blood glucose level -neck vein distention -weigh daily

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

-BUN 45 mg/dL and creatinine 8 mg/dL

A nurse is assessing a client who has systemic lupus erythematosus and is taking hydroxychloroquine. The nurse should report which of the following adverse effects to the provider immediately?

-Blurred vision

Treatment for a patient diagnosed with rapidly progressive glomerulonephritis is directed towards which outcome?

-Correction of fluid overload

A nurse is admitting a client who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

- Bleeding

A nurse is preparing to care for a female client with esophageal varices who just had a Sengstaken-Blakemore tube inserted. The nurse gathers supplies, knowing that which of the following items must be kept at the bedside at all times?

A pair of scissors

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take?

Ask the client to empty his bladder before the procedure

After a total proctocolectomy and permanent ileostomy, the patient tells the nurse, "I cannot manage all these changes. I don't want to look at the stoma." What is the best action by the nurse?

Ask the patient about the concerns with stoma management.

. Which action for a patient with neutropenia is appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)?

Administering subcutaneous filgrastim (Neupogen) injection

The nurse is caring for a patient following an adrenalectomy. What is the highest priority in the immediate postoperative period?

Balancing fluids and electrolytes

After change-of-shift report, which patient should the nurse assess first?

Patient with myasthenia gravis who is reporting increased muscle weakness

A client diagnosed with exacerbation of systemic sclerosis (SSc) asks the nurse why a foot board and a bed cradle have been placed on the bed. The nurse explains that they are used for what purpose?

Promote comfort from Raynaud's phenomenon

Myocardial infarction, what lab do you expect ordered

Troponin

Which assessment finding(s) indicate to the nurse that a patient with infective endocarditis has decreased cardiac output?

Urine production of 25 mL/hr

What should you do 30-60 min before chest tube removal

administer an analgesic

Possible complications of cirrhosis and bleeding esophageal varices, what do you monitor

ammonia level

Guillain-Barr syndrome, what are symptoms

paresthesia and weakness of lower extremities

Common link between Crohn's disease and ulcerative colitis

both are inflammatory

Parkinson's disease, manifestations

bradykinesia

A 51-year-old male patient has a new diagnosis of Crohns disease after having frequent diarrhea and a weight loss of 10 pounds (4.5 kg) over 2 months. The nurse will plan to teach about

medication use.

Pt tested positive for HER2 gene; this is an increased risk for =

developing breast cancer

Manifestations common with psoriasis rather than atopic dermatitis

erythematous and scaly plaques

Crohns disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?

fistulas can form between the bowel and bladder.

Pheochromocytoma, what finding do you assess

headache

Paracentesis, what position do you place the pt

high fowlers

. Which finding indicates to the nurse that the current therapies are effective for a patient with acute adrenal insufficiency?

increased serum sodium levels.

Hypertrophic cardiomyopathy, priority goal

preventing sudden cardiac death

Hypertrophic cardiomyopathy, what is priority

preventing sudden cardiac death, preventing heart failure

Addison's disease

teach the client about cortisol replacement therapy

Pt prescribed isotretinoin, what do you ask before administering

which method of contraception are you using