Top secret

A nurse is caring for a client admitted with meningitis. The student nurse asks, "I know that the client has a lot of ederas in the brain, but what causes it?" Which of the following responses from the nurse best answers the student's question?

"Cerebral edema is caused by the by-products of the pathogen that causes the meningitis."

A nurse is caring for a client who has a new diagnosis of hepatitis C. Which of the following responses from the nurse best explains how a person can become infected with the virus?

"Coming into contact with infected blood, such as from that of a dirty needle, can cause you to become infected with hepatitis C."

A nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

"I'll call my doctor if I notice any unusual menstrual bleeding."

A nurse is caring for a client who has sickle cell anemia. The client asks, "Why do I feel so tired and fatigued all of the time?" Which of the following information should the nurse provide?

"You have fewer red blood cells."

A client who has Type 2 diabetes mellitus asks the nurse. "Why did I develop diabetes?" Which of the following responses should the nurse make?

"Your body has insulin resistance and decreased insulin secretion."

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)

-Buffalo hump -Purple striations -Moon face

A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.)

-Causes joint stiffness -Causes joint pain -Affects weight-bearing joints -Crepitus can occur in affected joints

A nurse is caring for a client who is 1 day postoperative following a mastectomy. Which of the following exercises should the nurse assist the client to perform on the affected side? (Select all that apply.)

-Flexing and extending her elbow -Squeezing a rolled washcloth -Flexing and extending her hand

The nurse has admitted to the intermediate care Unita client who sustained a spinal cord injury at T1 in a motor vehicle accident. Which of the following nursing care activities can the nurse delegate to the unlicensed assistive person (UAP) when working with this client? Select. all that apply.

-Provide mouth care. -Measure oxygen saturation level every hour.

A nurse is planning a menu for a client who has folic acid deficiency anemia. Which of the following foods should the nurse include as high in folate?

1/2 cup of asparagus

The nurse is caring for a client who has a prescription for a continuous infusion of regular insulin at 0.2 units/kg/hr IV. The client weighs 51. lb (23.2 kg). How many units/hr should the nurse administer to the client? Record your answer using 1 decimal place.

4.6

A nurse has just received intershift report on a medical nursing unit. Which client should the nurse assess first?

90 year old client with muscle weakness and pneumonia

Which client's laboratory value requires immediate intervention by a nurse?

A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday.

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone odor to breath

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing manifestation of which of the following complications?

Acute compartment syndrome

A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

Amylase

For each of the following findings in the client's medical record, click to specify if they are consistent with angina or a myocardial infarction (MI). Each finding may support more than one disease process.

Angina Treadmill stress test Result of nitroglycerin therapy Client's initial report of manifestations Myocardial Infarction Client's initial report of manifestations 12 Lead EKG report Provider consult

A nurse is teaching a client who has a new diagnosis of aplastic anemia. Which of the following information should the nurse include in the teaching?

Aplastic anemia results from decreasted bone marrow production of RBCs

A nurse in an emergency department is caring for a client who has a deep laceration on her left lower forearm and is bleeding heavily from the wound. Which of the following interventions should the nurse perform first?

Apply pressure directly to the wound.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; Pa02, 96 mm Hg. What is the best nursing action based on these results?

Assess the client for pain and administer pain medication as prescribed.

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV Ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mr over the past 2 hours. The postoperative hematocrit is 3696 (0.36), and the hemoglobin is 12 g/dL (120 g/L). Which action should the nurse carry out first?

Assess vital signs

Which advice would be appropriate for the nurse to give to a client with dumping syndrome?

Avoid foods that are concentrated on carbohydrates.

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Basal cell carcinoma

A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should the nurse take?

Call emergency services

Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome?

Central-type obesity, with thin extremities.

A nurse is preparing to initiate a transfusion of packed RBC for a client who has anemia. Which of the following actions should the plan to nurse take?

Check the client's vital signs every hour during the transfusion.

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition (TPN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion?

Check the reports of a portable chest Xray

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Clean the perineal area with an antiseptic solution daily.

A nurse is teaching a client who has a prescription of a nasogastric tube (NG) to treat a pyloric obstruction. Which of the following rationales for the use of the nasogastric tube should the nurse include in the teaching?

Decompress the stomach.

The nurse is caring for four clients: Client: A, who has emphysema and whose oxygen saturation is 95%. Client B, with a postoperative hemoglobin of 8.7 mg/dI Client C. newy admitted with a potassium level of 3.8 mEq/L Client D, scheduled for an appendectomy who has a white blood cell count of 15,000 mm3. What intervention should the nurse implement?

Determine if Client B has two units of packed cells available in the blood bank.

A nurse is providing care for a client who is postoperative for removal of a pituitary tumor. Which of the following priority developments should the nurse anticipate?

Diabetes insipidus (DI)

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings?

Difficulty starting the flow of urine

10. The nurse formulates a nursing diagnosis of, "High risk for ineffective airway clearance" for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?

Diminished cough effort.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?

Document that the client responds to painful stimulus.

A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?

Drinks more soft drinks than previously.

A nurse is caring for a client in the primary care office who states, "I think I have been experiencing symptoms of reflux." Which of the following manifestations should the nurse anticipate for a client who has GERD?

Dyspepsia

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Excessive thrombosis and bleeding

The nurse should call the HCP suspecting which of the following diagnosis.

Fat embolism

A nurse is assessing a client who has an obstruction of the common bile duct resulting from chronic cholecystitis. Which of the following findings should the nurse expect?

Fatty stools

A client is admitted to the hospital for chemotherapy complications. Laboratory results show an absolute neutrophil count of 450 cells/mm3 (0.45 ×109/L.). What information contained in the admission history of this client will need to be addressed during discharge education?

Garden as a hobby

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?

History of NSAID use

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was

Hoarseness

A nurse is caring for a client who has a positive Trousseau's sign and bone pain. Which of the following electrolyte imbalances should the nurse suspect to find with this client?

Hypocalcemia

The nurse is assessing a client newly admitted to the emergency with a blood glucose level of 750 mg/di; during the examination, the nurse notes a fruity odor on the client's breath. The client is placed in continued cardiac monitoring, and the ABGs received from the laboratory showed a Metabolic acidosis. Which of the following respiratory patterns will the nurse should identify as expected in this patient?

Kussmaul

A nurse is planning care for a newly admitted client who has skeletal traction for a fractured femur. Which of the following interventions should the nurse include in the plan?

Monitor the client's pedal pulses every hour.

The nurse observes the chest tube drainage has exceeded 300 mL of bright red bloody fluid for the past 30 minutes in the client after a coronary artery bypass graft. What is the nurse's next action?

Notify the healthcare provider.

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?

Observe for indications of hypokalemia

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

Oliguria

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 clients intake of protein

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

Restlessness

A nurse is providing care to a client who has peritonitis. Which of the following conditions is the highest priority for the nurse to monitor?

Sepsis

Which statement is true regarding the use of skin traction?

Skin traction is a short-term intervention used before other definitive treatments for fractures.

A client has a spinal cord injury at the level of C6, and is in the day room experiencing flushing of the skin, diaphoresis, and a throbbing headache. What is the nurse's priority action at this time?

Stabilized cervical spine

A nurse is caring for a client following a CVA and observes the client experiencing severe dysphagia. The nurse notifies the provider. Which of the following nutritional therapies will likely be prescribed?

Supplements via nasogastric tube

A nurse is caring for an older adult client who has just returned from PACU after receiving a spinal anesthetic during knee surgery. For which of the following findings should the nurse notify the provider?

Systolic blood pressure changed from 140 mm Hg to 120 mm Hg

A nurse is caring for a client who reports to the clinic for laboratory tests. The client has an acute kidney injury caused by acute tubular necrosis and asks why their glomerular filtration rate keeps decreasing. Which of the following pathophysiological changes occurring in the kidney should the nurse explain as the cause of decrease?

The glomerular filtration rate decreases because there is injury to the renal tubular cells.

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Turn the client's head to the side.

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

Urine specific gravity 1.002

The healthcare provider performs a paracentesis on a client with ascites and 3 liters of fluid are removed. Which assessment parameter is most critical for the nurse to monitor following the procedure?

Vital signs.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

Vitamin B12 injections

A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

Walking briskly

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Yellow-green drainage on the surgical incision

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect?

confusion

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

hyperkalemia

to determines the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about..

occurrence of a weak urinary stream.

A nurse is caring for a client who reports low back pain and asks the nurse for specific exercise recommendations. Which of the following activities should the nurse suggest?

swimming