WGU HESI OA 2
An adolescent with a history of asthma arrives in the emergency department experiencing respiratory distress. The primary health care provider admits the adolescent. Implementing which prescription is the nurse's priority? A. administer the nebulizer tx to facilitate breathing B. obtain a blood specimen to send to the lab for tests C. notify the respiratory therapist to perform chest physiotherapy D. send a requisition to central supply for an inceptive spirometer
administer the nebulizer treatment to facilitate breathing
which medication is prescribed to improve the physical manifestations of Parkinson disease? A. carbidopa - levodopa B. Isocarboxazid C. Dopamine D. pyridoxine (vitamine B6)
carbidopa - levodopa
which condition would the nurse suspect in a client reporting fever, redness, skin breakdown, and inflammation on the legs with an area that is tender and edematous with diffused borders? A. shingles B. cellulitis C. folliculitis D. onychommycosis
cellulitis
Which condition would the nurse suspect in a client who has a small pustule at a hair follicle opening with minimal erythema on the scalp? A. furuncle B. cellulitis C. folliculitis D. carbuncle
folliculitis
which type of shock would the nurse suspect when a client is admitted to the emergency department after a motor vehicle accident with abdominal pain, a blood pressure decrease from 120/76 to 60/40 hg and a heart rate increase from 82 bpm to 121 bpm A. septic shock B. cardiogenic shock C. hemorrhagic shock D. neurogenic shock
hemorrhagic shock
which factor in a pregnant client's history would the nurse recognize as a risk factor for abruptio placenta? A. hydramnios B. hypertension C. cardiac disease D. diabetes mellitus
hypertension
laboratory reports reveal that the clients thyroxine levels are low. Which medication might have led to this condition? A. lithium B. fluozetine C. risperidone D. carbamazepine
lithium
which response would the nurse give to a client with end-stage renal disease who states, "I heard that it is inevitable that I will need a kidney transplant. If so, which one of my kidneys will be removed?
neither of your kidneys will be removed unless they become infected?
which condition is characterized by infection of a client's bone or bone marrow? A. osteomalacia B. osteomyelitis C. herniated disc D. spinal stenosis
osteomyelitis
which nursing intervention would the nurse include in the plan of care for a client after a hip replacement? SATA A. place a pillow between the client's legs B. require the client to sit in an armless chair C. cross the client's legs at the ankles and knees D. require the client to use an elevated toilet seat E. keep the client's hip in a neutral, straight position
place a pillow between the client's legs, require the client to use an elevated toilet seat, and keep the client's hip in a neutral, straight position.
Which laboratory value would the nurse assess to evaluate response to the medication epotein? A. hemoglobin B. platelet count C. prothrombin time D. partial thromboplastin time
hemoglobin
a 28 year old women is diagnosed as having breast cancer a simple mastectomy is performed. Which action would be included in the plan of care immediately after surgery?
placing the client in semi-fowler position with the left arm elevated (this decreases edema).
When the nurse is auscultating a client's heart, where would S1 be the loudest? A. base of the heart B. apex of the heart C. left lateral border D. right lateral border
apex of the heart
which information would the nurse include when explaining the cause of TIAs to a client? A. genetic valvular heart disease B. atherosclerotic plaques within arteries C. developmental defect in arteries D. emboli ascending from the lower extremities
atherosclerotic plaques within arteries
Which action would the nurse take first for a client with blunt abdominal trauma? A. ensure a patent airway B. monitor the level of consciousness C. infuse warm normal saline solution D. maintain client warmth using blankets
ensure a patent airway
which information is important for the nurse to include in a teaching program for a client admitted to the hospital after having a tonic-clonic seizure and being diagnosed with a seizure disorder?
explain strategies a client may use to prevent physical trauma form occurring during a seizure
Which clinical finding would the nurse observe in a client diagnosed with bipolar disorder, manic episode? A. passivity B. fatigue C. anhedonia D. grandiosity E. talkativness F. distractibility
grandiosity, talkativeness, distractibility
which condition involves a cytotoxic hypersensitivity reaction? SATA Graves disease contact dermatitis myasthenia gravis rheumatoid arthritis immune thrombocytopenic purpura
graves disease, myasthenia gravis, immune thromovytopenic purpura. Contact dermatitis and RA are examples of delayed hypersensitivity and immune complex reactions.
The risk for which pregnancy complication is increased in the client with type 1 diabetes mellitus? A. hypertensive disorders of pregnancy B. placenta accreta C. increased appetite D. oligohydramnios in the third trimester
hypertensive disorders of pregnancy
When teaching a health awareness class, which situation would the nurse teach as being the highest risk factor for the development of a DVP? A. pregnancy B. inactivity C. aerobic exercise D. tight clothing
inactivity
which outcome is likely if the nurse paplates a clients joints during an acute episode of rheumatoid arthritis? A. pain B. swelling C. nodule formation D. tophaceous deposits
pain
which condition results in elevated serum adrenocorticotropic hormone (ACTH) and urine cortisol levels? A. Diabetes insipidus B. adrenal Cushing syndrome C. pituitary Cushing syndrome D. syndrome of inappropriate antidiuretic hormone
pituitary Cushing syndrome
a primary health care provider recommends that an adolescent with the diagnosis of osteogenic sarcoma have the affect leg amputated and then be treated with chemotherapy. The parents are concerned about what to tell their child and ask the nurse for advice. Which topic would the nurse suggest they discuss? A. causes of cancer and details about the treatment B. chemotherapy and the possibility of an amputation C. the amputation and information about chemotherapy D. treatment choices that it is too soon for a final decision
the amputation and information about chemotherapy
Which test is used to diagnose diseases of the vestibular system? A. Rinne test B. Caloric reflex test C. Pure-tone audiometry D. Auditory brainstem response
Caloric reflex test The caloric reflex test is a test of the vestibulo-ocular reflex that involves irrigating cold or warm water into the external auditory canal. it is used to check for nystagmus, nausea and vomiting, falling, or vertigo, conditions associated with diseases of the vestibular system. The rinne test is a turning fork test that aids in differentiating between conductive and sensorineural hearing loss. Pure-tone audiometry determines the client's hearing range in terms of decibels (dB) and Hertz (Hz). This test is used to diagnose conductive and sensorineural hearing loss. An auditory brainstem response test provides diagnostic information related to acoustic neuromas, brainstem problems, and strokes.
which client statement indicates to the nurse that further teaching about epotein for the treatment of anemia associated with chronic renal failure is necessary?
I realize it is important to take this medication because it will cure my anemia.
which statement shows ineffective learning after the nurse teaches self-management tips on the safety and quality care for skin cleaning to a client with a pressure ulcer? A. i will use tepid rather than hot water B. i will clean my skin as soon as soiling occurs C. i will apply powders and talc on the perineum D. i will pat my skin gently rather than rubbing it dry
I will apply powders and talc on the perineum
After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? A. I will avoid crossing my legs B. Pillows placed under my knees with help avoid clots C. Staying on bed rest as long as possible is best for me D. Three times everyday I will massage my lower legs to get blood moving
I will avoid crossing my legs
Which education would the nurse provide the parent of an infant with pyloric stenosis? A. It is unlikely that sx will be necessary B. This is a condition with an excellent prognosis C. This condition results from an error of metabolism D. Special feedings will be needed for a few weeks after sx
This is a condition with an excellent prognosis
Which topic would the nurse plan to include in teaching a client with a new diagnosis of asthma? A. Home oxygen therapy B. Antibiotic treatment C. Incentive spirometer use D. Use of peak flow meter
Use of peak flow meter Daily peak flow monitoring is recommended for clients with asthma because changes in peak flow frequently occur before the client notices any respiratory distress. because asthma is an intermittent airway problem, home oxygen therapy in not needed. Asthma is not an infectious process and antibiotics are not prescribed. Incentive spirometers are prescribed to encourage clients to take deep breaths and prevent atelectasis, which is not a concern with asthma.
An adolescent child with sickle cell anemia is admitted to the pediatric unit during a vaso-occlusive crisis. Which pathophysiology is correct? A. severe depression of the circulating thrombocytes B. diminished RBC production by the bone marrow C. pooling of blood in the spleen with splenomegaly as a consequence D. blockage of small blood vessels as a result of clumping of RBCs
blockage of small blood vessels as a result of clumping RBCs
When a client is admitted to the ER with a possible spinal cord injury the nurse would monitor for which clinical manifestations of spinal shock? A. hypotension B. spastic paralysis C. urinary retention D. increased pulse pressure E. bradycardia
bradycardia hypotension urinary retention
Which charactersitcs of urine changes in the presence of a urinary tract infection (UTI) A. clarity B. viscosity C. glucose level D. specific gravity
clarity
Which statement is true regarding antipsychotic medications? A. All first and second generation antipsychotics are equally effective B. Second-generation antipsychotics pose a risk of extrapyramidal symptoms. C. First-generation antipsychotics pose a significant risk of metabolic side effects. D. clozapine is more effective than other second-generation antipsychotics
clozapine is more effective than other second-generation antipsychotics
which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome (FES)? A. nausea B. dyspnea C. orthopnea D. paresthesia
dyspnea
the nurse is providing care in the postanethesia care unit to a client who underwent a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness? A. assessing for pain B. assessing for gag reflex C. encouraging deep breathing D. encouraging ankle pump exercises
encouraging deep breathing
a client is admitted with a head injury and has large amounts of clear, colorless urine draining from the urinary catheter. Which physiological response is possibly causing the increased urine output? A. increased serum glucose B. deficient renal perfusion C. inadequate antidiuretic hormone (ADH) secreation D. excess amounts of IV fluid
inadequate antidiuretic hormone (ADH) secreation
Which signs and symptoms would the nurse observe in a client diagnosed with schizophrenia? A. traumatic flashbacks and hypervigilance B. depression and psychomotor retardation C. loosened associations and hallucinations D. ritualistic behavior and obsessive thinking
loosened associations and hallucinations
A 26-year-old G1 P0 client at 29 weeks gestation has gained 8 lbs in 2 weeks. Her blood pressure has increased from 128/74 hg to 150/90 mm hg, and she has developed 1+ proteinuria on a urine dipstick. Which condition do these signs suggest? A. mild preeclampsia B. severe preeclampsia C. chronic hypertension D. gestational hypertension
mild preeclampsia mild preeclampsia: is systolic bp below 160 mm and diastolic bp is below 110 mm, proteinuria is present but no indication of organ dysfunction. severe preeclampsia: bp greater then 160/110 and proteinuria of 5 g or more per 24 - hour specimen
Which medications may be prescribed to induce abortion in a pregnant adolescent client? A. zidovudine B. misoprostol C. mifepristone D. methotrexate E. leuprolide
misoprostol, mifepristone, methotrexate
Which action would be the highest priority for the nurse to implement for a client experiencing an eclampic seizure? A. prevent injury B. assess fetal heart tones C. place an oral airway D. increase the magnesium sulfate infusion rate
prevent injury
which factor is a likely cause of hyponatremia? SATA A. DI B. profuse diaphoresis C. excessive sodium intake D. Rapid IV infusion of 5% dextrose in water E. Removal of the parathyroid glands
profuse diaphoresis Rapid IV infusion of 5% dextrose in water
A client is being treated for pituitary Cushing syndrome. The nurse anticipates that which medication will be prescribed? A. mitotane B. cabergoline C. cyproheptadine D. bromocriptine mesylate
cyproheptadine
which abnormal finding would the nurse monitor for during the oliguric phase of acute kidney injury? A. hypothermia B. hyperkalemia C. hypocalcemia D. hypernatremia
hyperkalemia
Where on the maternal abdomen would the nurse place the fetal heart transducer when the fetus is in the left sacrum anterior position? A. left lower quadrant B. left upper quadrant C. right upper quadrant D. middle lower quadrant
left upper quadrant The left sacrum anterior position indicates that the fetus is in a breech presentation and the head is in the fundus; fetal heart sounds are best heard in the left upper quadrant. Fetal heart sounds will be in the left lower quadrant if the fetus is in the left occiput anterior position. fetal heart sounds will be in the right upper quadrant if the fetus is in the right sacrum anterior position. The fetal heart sounds will not be heard in the midline part of a lower quadrant in a single fetus pregnancy.
which principle underlying the function of a portable drainage system will the nurse consider when caring for a client returning from sx with a drain attached to a portable would drainage system exiting form the surgical site? A. gravity B. osmosis C. active transport D. negative pressure
negative pressure
Which client statement indicates that the instructions to a client with a seizure disorder receiving phenytoin and phenobarbital are understood? A. I will not have any seizures with these medications B. these medicines must be continued to prevent falls and injury C. stopping the medications can cause continuous seizures and I may die D. by staying on the medications I will prevent post seizure confusion
stopping these medications can cause continuous seizures and I may die
which significant clinical finding would the nurse expect when reviewing the history of a client with preeclampsia? A. proteinuria B. tachycardia C. increased serum glucose D. tonic-clonic movement
proteinuria
Which characteristic will the client diagnosed with chronic schizophrenia likely exhibit? SATA A. Apathy B. Hostility C. Flatness D. Elation E. Sadness F. Depression
Apathy, Flatness
Which diagnosis increases the risk for the development of a pulmonary embolism? A. Atrial fibrillation B. Forearm laceration C. Migraine headache D. Respiratory infection
Atrial Fibrillation Inadequate atrial contraction that occurs during fibrillation leads to the pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headaches. Respiratory infection do not increase pulmonary embolism risk.
Which client activity warrants the highest priority for education about health promotion to prevent head and neck cancer? SATA A. Chews tobacco B. Multiple sex partners C. Uses condoms when having sex D. History of alcohol abuse for 5 years E. Brushes with a soft-bristle toothbrush
Chews, tobacco, multiple sex partners, history of alcohol abuse for 5 years
Which manifestation would the nurse expect a client with DI to exhibit? A. Increased blood glucose B. Decreased serum sodium C. Increased specific gravity D. Decreased urine osmolarity
Decreased urine osmolarity
which complication would the nurse assess in both clients who have Parkinson's disease and clients who have Myasthenia Gravis A. cogwheel gait B. impaired cognition C. difficulty swallowing D. non-intention tremors
Difficult swallowing
Which response to amlodipine prescribed for hypertension will the nurse instruct the client to report to the health care provider? A. Blurred vision B. Dizziness on rising C. Difficulty breathing D. excessive urination
Difficulty breathing
A client is taught how to recognize signs of a hypoglycemic reaction. Which symptoms identified by the client indicate to the nurse that the teaching was effective? SATA A. Fatigue B. Nausea C. Weakness D. Nervousness E. Increased thirst F. Increased perspiration
Fatigue, weakness, nervousness, increased perspiration
Which intervention would the nurse implement for a client in alcohol detoxification who reports numbness and tingling in the feet and legs? A. Massaging the clients legs with lotion B. Emphasizing the need to rest and keep the legs elevated C. Keeping the bed linens off the client's legs with a mechanical aid D. Monitoring the progression of symptoms for compartment syndrome
Keeping the bed linens off the client's legs with a mechanical aid
a health care team is caring for a client with DI. Which task is most suitable to be delegated to a LPN to provide effective client care? SATA A. emptying the urinary drainage bag B. monitoring urine output C. assisting the client with eating D. administration of IV fluids E. Adminsitering oral rehydration medication
Monitoring urine output, administering oral rehydration medication
Which condition would the nurse suspect in the male client whose laboratory report shows creatine kinase levels higher than the normal range? A. Osteomalacia B. Osteoporosis C. Muscle Trauma D. Skeletal Muscle Necrosis E. Progressive Muscular Dystrophy
Muscle trauma, Progressive muscular dystrophy
Which interventions would the nurse implement in caring for a client with DI after a head injury? SATA A. Provide adequate fluids within easy reach B. Report an increasing urine specific gravity C. Administer prescribed erythromycin D. Assess for and report changes in neurological status E. Monitor for constipation, weight loss, hypotension, and tachycardia
Provide adequate fluids within easy reach, assess for and report changes in neurological status, monitor for constipation, weight loss, hypotension, and tachycardia.
Which dermatological problem is treated by using intralesional corticosteroids? A. psoriasis B. cellulitis C. erysipelas D. carbuncles
psoriasis
how will the nurse document the abnormal heart sounds heard in early diastole during the cardiac assessment of an older adult? A. systolic murmur B. third hear sound C. fourth heart sound D. pericardial friction rub
third heart sound
which health problem history would increase an older adult's risk for experiencing a CVA? A. glaucoma B. hypothyroidism C. continuous nervousness, stress D. transient ischemic attacks
transient ischemic attacks TIAs are temporary neuro deficits related to cerebral hypoxia. About 1/3 of the people who have TIAs will have a cerebrovascular accident within 2-5 years.
The nurse is assessing a pregnant client at the end of their second trimester. Which finding would cause the nurse to suspect that the client has preeclampsia? A. progressive weight gain B. two urine samples showing proteinuria C. dependent ankle edema during the late afternoon D. blood pressure fluctuations on three successive measurements
two urine samples showing proteinuria
Which stage of pressure ulcer would the nurse document for a client who has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia? A. stage 1 B. stage 2 C. stage 3 D. unstageable
unstageable
which assessment finding differentiates central and nephrogenic diabetes insipidus? A. urine output B. specific gravity C. urine osmolarity D. serum osmolarity
urine osmolarity
Which action would the nurse take first when caring for a client who is admitted to the emergency department after experiencing a seizure? A. asking the emergency provider for a prophylactic anticonvulsant B. obtain a history of seizure type and incidence C. ask the client to remove any dentures and eyeglasses D. observe the client for increased restlessness and agitiation
obtain a history of seizure type and incidence.
while auscultating the heart, a health care provider notices S3 heart sounds in four clients. Which client has the highest risk for heart failure? A. child client B. pregnant client C. older adult client D. young adult client
older adult client s3 is indicative of congestive heart failure in adults over 30 years old. in young, pregnant, and under 30 year old clients, the third heart sound is often considered to be a normal parameter.
Which clinical manifestation would the nurse expect to find upon assessment of a client with Cushing syndrome? SATA A. Polyuria B. Truncal obesity C. Hypotension D. Sleep disturbance E. Thin arms and legs
Truncal obesity, sleep disturbance, thin arms and legs
which nursing intervention would be contraindicated for a client who has a fracture and has compartment syndrome? A. applying cold compress B. reducing traction weight C. loosening the clients bandage D. elevating the extremity above the heart level E. Splitting the cast in half
applying cold compress, elevating the extremity above the heart level.
which finding in a client with asthma exacerbation requires the most rapid action by the nurse? A. report of chest tightness B. heart rate of 112 beats per minute C. expiratory wheezes in both lungs D. markedly decreased breath sounds
markedly decreased breath sounds
which is a clinical manifestation of worsening preeclampsia? A. polyuria B. vaginal spotting C. protein creatinine ration of 0.5 D. blood pressure of 130/80 mm
protein creatinine ratio of 0.5
For which client condition would the triage nurse assign a red tag based on priority? A. Arrhythmia B. Pressure injuries C. Abdominal Trauma D. Second- degree burns
Abdominal Trauma A client with abdominal trauma should be treated immediately because it is a life-threatening complication. The client with arrhythmia may be given next priority of care. The client with second- degree burns should be given third priority of care because the clients condition may worsen if treatment is not provided as early as possible.
Which type of brain tumor can originate from cells that form the myelin sheath around the nerves? A. Meningioma B. Astrocytoma C. Ependymoma D. Acoustic Neuroma
Acoustic neuroma Acoustic neuromas can originate from cells that form the myelin sheath around the nerves. Meningiomas originate from the meninges; they can be benign or malignant. Astrocytomas can originate from supportive tissues, glial cells, and astrocytes. Ependymomas can originate from the ependymal epithelium and can range from being to highly malignant.
For which complications would the nurse monitor a client hospitalized with end-stage kidney disease? SATA A. Anemia B. Dyspnea C. Jaundice D. Hyperexcitablitiy E. Hypophosphatemia
Anemia, Dyspnea Anemia results from decreased production of erythropoietin by the kidneys, which causes decreased erythropoiesis by bone marrow. Dyspnea is a result of fluid overload, which is associated with chronic kidney failure. Jaundice occurs with biliary obstruction or liver disorders, not with kidney failure. Hyerphosphatemia occurs with kidney failure, not hypophosphatemia. hyperexcitabliltiy is not a feature of end-stage kidney disease.
Which classification medication is used to manage rapid-cycling bipolar disorder? A. Anti-anxiety medication B. Anti-parkinson medication C. Antidepressant medication D. Anticonvulsant medication
Anticonvulsant Medication Anticonvulsant medications are therapeutic for clients with rapid-cycling bipolar disorder. Anti-anxiety medications are not primarily used for rapid-cycling bipolar disorder. Anti-anxiety medications may be helpful for clients with treatment-resistant mania. Antiparkinson medications are not used for rapid-cycling bipolar disorder. An antidepressant medication is not used unless the client also is taking an antipsychotic medication.
Which factor places an infant at risk for sudden infant death syndrome (SIDS)? SATA A. Breast feeding B. Cigarette smoking C. Prone sleep position D. Advanced maternal age E. Lower socioeconomic status
Cigarette smoking, prone sleep position, lower socioeconomic status
Based on the age and findings, which client would the nurse consider at the highest risk for developing pneumonia?
Client C 67 years old, blood urea nitrogen of 25mg/ dL, respiratory rate of 38 breaths/ min, blood pressure 80/ 60 mm Hg
Which finding in the older adult client is associated with a urinary tract infection (UTI)? SATA A. Dysuria B. Urgency C. Confusion D. Incontinence E. Slight rise in temperature
Confusion, Incontinence, Slight rise in temperature
Which nursing intervention is the most effective in preventing a seizure in a client with severe preeclampsia? A. providing a plastic airway B. controlling external stimuli C. having an emergency equipment available D. keep calcium gluconate at the bedside.
controlling external stimuli
Which statement would the nurse include when educating parents on the prevention of sudden infant death syndrome (SIDS)? A. do not prop your infants bottle B. place an infant monitor where your baby sleeps C. place your infant in an appropriately sized, rear facing car seat D. encourage your infant to use a pacifier for the first 6 months of life
Encourage your infant to use a pacifier for the first 6 months of life.
Which action will the nurse take to support cognitive ability in clients who have Alzheimer disease? A. Encouraging caregivers to support safe independence B. Using calendars, clocks and pictures to support memory C. Providing a limited number of choices to support decision-making D. Quizzing the client regularly to assess orientation to person, place, and time E. Administering prescribed rivastigmine to clients with severe dementia
Encouraging caregivers to support safe independence, Using calendars, clocks, and pictures to support memory, Providing a limited number of choices to support decision-making
A client in active labor is 100% effaced, dilated 3 cm, and at 1+ station. Which stage of labor has this client reached? A. First B. Latent C. Second D. Transitional
First Stage The first stage of labor lasts from the onset of contractions until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. There is no latent stage of labor. The second stage of labor lasts from complete dilation to birth. There is not transition stage of labor. Transition is the last phase of the first stage of labor.
The nurse is caring for a client who had surgery for a biliary complication and now has a T-tube. The nurse explains that the T-Tube was place for which reason? A. Divert the bile flow to the cystic duct B. Drain serosanguineous fluid from the operative site C. Help bile drain while the common bile duct is edematous D. Prevent postoperative infection at the site of the incision
Help bile drain while the common bile duct is edematous
A client is being considered for bariatric surgery. Which client health problem does the nurse identify as consistent with morbid obesity? A. Dumping syndrome B. Compartment syndrome C. Hypoventilation syndrome D. Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Hypoventilation syndrome
The nurse suspects that a client has Diabetes Mellitus. Which statements made by the client helped the nurse reach this conclusion. SATA A. I am 65 years old B. I quite often feel thirsty C. I eat food every 2 hours D. I have excessive sweating E. I sometimes experience shortness of breath
I am 65 years old I quite often feel thirsty I eat food every 2 hours
Which condition is commonly seen in preschoolers? A. Impetigo B. Bronchiolitis C. Mononucleosis D. Pyloric stenosis
Impetigo
when palpating the chest during a respiratory assessment, which finding would the nurse expect in a client with pneumonia? A. bilateral decreased chest expansion B. increased fremitus over the affected area C. tracheal deviation away from the affected area D. decreased chest expansion on the affected side
Increased fremitus over the affected area
Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? A. The client will take anticonvulsant medications for life B. Individuals taking phenytoin must floss teeth regularly C. a diagnosis of epilepsy prevents individuals from ever obtaining a driver's license. D. Loss of consciousness during a seizure requires emergency evaluation
Individuals taking phenytoin must floss their teeth regularly
Which factor explains why a client who experiences an acute episode of rheumatoid arthritis has swollen finger joints? A. urate crystals in the synovial tissue B. inflammation in the joints synovial lining C. formation of bony spurs on the joint surfaces D. deterioration and loss of articular cartilage joints
Inflammation in the joint's synovial lining
A client presenting with an acute asthma attack is being assessed in the emergency department. The client's spouse reports that the client is currently is undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has which type of asthma? A. Allergic B. Emotional C. Extrinsic D. Intrinsic
Intrinsic Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered to be extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold dust, and others.
Which clinical finding would the nurse expect during the physical assessment of an infant with developmental dysplasia of the hip (DDH)? A. Limited abduction of the affected hip B. Downward and inward rotation of the affected hip C. Inability to flex and extend the hip on the affected side D. Free abduction of the affected hip when placed in the frog position
Limited abduction of the affected hip
Which clinical manifestation is associated with cellulitis? A. Lymphadenopathy B. Occasional Papules C. Vesicles that evolve into pustules D. Isolated erythematous pustules
Lymphadenopathy
A vaginal examination reveals that a client's cervix is 90% effaced and dilated to 6 cm. The fetus's head is at station 0, and the fetus is in a right occiput anterior position. The contractions are occurring every 3-4 minutes, are lasting 60 seconds, and are of moderate intensity. Which description is appropriate to use when reporting on the client's condition? A. Early first stage of labor B. Transition stage of labor C. Beginning second stage of labor D. Midway through the first stage of labor
Midway through the first stage of labor The cervix is 90% effaced and dilated 6 cm during the active phase of (or midway through) the first stage of labor. When the cervix is dilated 6 cm. the individual is beyond the early stage of labor. Transition is the last phase of the first stage of labor, which begins when the cervix is dilated 8 cm. The second stage of labor beings when the cervix is fully dilated and 100% effaced.
Which finding would the nurse expect when assessing a client who is in an early stage of MS? A. headache B. nystagmus C. skin infection D. scanning speech E. Intention tremors
Nystagmus, scanning speech, intention tremors
Which explanation would the nurse provide to a client about TIAs? A. temporary episodes of neurological dysfunction B. Intermittent attacks caused by multiple small clots C. Ischemic attacks that result in progressive neurological deterioration D. Exacerbations of neurological dysfunction alternating with remissions
Temporary episodes of neurological dysfunction
a pregnant client experiences increased adrenocorticotropic hormone, salivary cortisol, and blood glucose levels. Which would be included in the client's plan of care? A. daily weights B. single dose of 200 mg of mifepristone C. obtaining intake and output information every 6 hours D. daily dietary intake of 5 g sodium
daily weights
Why is the vomitus of an infant with pyloric stenosis white rather than bile-stained? A. The pyloric sphincter obstructs the bile duct. B. There is an obstruction above the opening of the common bile duct C. The bile duct sphincter is connected to the hypertrophied pyloric muscle. D. There is a constriction of the cardiac sphincter that obstructs the flow of bile.
There is an obstruction above the opening of the common bile duct.
Which medication is considered a typical antipsychotic? SATA A. Asenapine B. Lurasidone C. Aripiprazole D. Thioridazine F. Chlorpromazine
Thioridazine, Chlorpromazine First-generation antipsychotic medications are also know as typical/ conventional antipsychotics. Thioridazine and chlorpromazine are typical antipsychotics. Asenapine, Lurasidone, and Aripiprazole are atypical antipsychotics, aslo know as second-generation antipsychotics.
which clinical finding in a client receiving morphine warrants immediate follow up by the nurse? SATA A. polyuria B. unconsciousness C. bradycardia D. dilated pupils F. Bradypnea
Unconsciousness, bradycardia, bradypnea Morphine is a CNS depressant if severe it can cause unconsciousness. Morphine causes constriction of pupils.
Which step would the nurse include during the administration of epoetin prescribed to a client with acquired immunodeficiency syndrome (AIDS)? A. administer the medication via the z track method B. shake the vial before withdrawing the solution C. obtain the clients pulse rate before administration D. use a syringe that has a 1-inch (2.5 cm), 25-gauge needle.
Use a syringe that has a 1 inch (2.5 cm). 25 gauge needle
Which laboratory result in a client who has just been admitted with anemia of unknown etiology requires the most rapid action by the nurse? A. Hematocrit 30% B. Hemoglobin 10 g/dL C. Platelet count 120,000 mm D. WBC 950 mm
WBC count 950 mm The laboratory results indicate pancytopenia (consistent with aplastic anemia) with an extremely low white blood cell count that will increase client risk for infection. The nurse will take actions to prevent exposure of this client to other clients with infectious diagnoses as well as notify the health care provider of the laboratory results. The client's hematocrit is low, but does not require immediate action to correct. The hemoglobin level is low, as would be expected in a client with anemia. but is not critically low. The platelet count is slightly below the normal level but would not increase the risk for spontaneous or prolonged bleeding.
a client who sustained serious burns now has a stress ulcer. if complications occur, which clinical indicators of shock would the nurse immediately report to the primary health care provider? SATA A. Weakness B. Diaphoresis C. Tachycardia D. cold extremities E. flushed skin tone
Weakness, diaphoresis, tachycardia, cold extremities
Which assessment findings would indicate a possible asthma exacerbation? SATA A. Fever B. Stridor C. Wheezing D. Tachycardia E. Hypotension
Wheezing, Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase (tachycardia). An increased temperature is characteristic of infection, not asthma. Stridor is usually caused by foreign body obstruction and/ or upper airway obstruction (such as croup), not asthma. Hypertension, not hypotension, may occur with asthma.
how will the nurse describe cardiogenic shock when a family member of a client asks for more information about the condition? A. an irreversible phenomenon B. a failure of the circulatory pump C. usually a fleeting reaction to tissue injury D. generally caused by decreased blood volume
a failure of the circulatory pump
which intervention would the nurse perform when caring for a client in the emergency department reporting chest pain? SATA A. providing oxygen B. assessing vital signs C. obtaining a 12 - lead EKG D. drawing blood for cardiac enzymes E. Auscultating heart sounds F. Adminsitering nitroglycerin
all of them
Which approach would the nurse use for an older adult client with Alzheimer disease who frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause? A. pointing out reality to the client B. providing nursing care when the client is receptive C. encouraging the client to talk about personal feelings D. retraining the client when hostility is being exhibited
providing nursing care when the client is receptive.
before beginning administration of morphine via patient - controlled analgesia (PCA), which assessment would the nurse perform first? A. temperature B. blood pressure C. respirations D. urinary output
respirations
Which mechanism of action would the nurse identify for levodopa therapy prescribed to a client diagnosed with Parkinson disease? A. blocks the effects of acetylcholine B. increases the production of dopamine C. restores the dopamine levels in the brain D. promotes the production of acetylcholine
restores the dopamine levels in the brain
which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry red skin with blisters? A. first degree burns B. second degree burns C. third degree burns D. fourth degree burns
second degree burns
which activities would the nurse include when reaching adults about activities that increase the risk of developing bladder cancer? SATA A. jogging 3 miles a day B. drinking 3 cans of cola a day C. smoking 2 packs of cigarettes a day D. working with dyes used in rubber everyday E. using a jackhamer and chainsaw everyday
smoking two packs of cigarettes a day, working with dyes used in rubber everyday
which stage of the HIV disease is present in the client with a laboratory report revealing a CD4 + t-cell count of 520 cells/mm according to the centers for disease control and prevention? A. stage 1 B. stage 2 C. stage 3 D. stage 4
stage 1 greater than 500 - stage 1 499-200 - stage 2 less than 200 - stage 3 confirmed HIV infection - stage 4
which disorder would the nurse suspect in a client who reports hair loss, joint pain, and a facial rash and has a medical record showing the presence of a butterfly rash? A. scleroderma B. angioedema C. rheumatoid arthritis D. systemic lupus erythematosus
systemic lupus erythematosus
a hostile client with the diagnosis of schizophrenia says, the voices are saying that they are going to poison me because I'm bad. Which type of schizophrenic behavior is the client displaying? A. residual B. paranoid C. catatonic D. disorganized
paranoid
which intervention would result in further tissue necrosis when the registered nurse delegates the tasks of caring for a client with pressure ulcers?
performing irrigation of the wound by the patient care associate (PCA)
The registered nurse (RN) delegates the care of a client in the immediate postoperative period to the UAP. Which tasks are in the scope of practice of the UAP? SATA A. feeding the client B. ambulating the client for the first time C. monitoring the vital signs D. assisting the client with bathing E. teaching leg exercises to the client
feeding the client, assisting the client with bathing
Which bacterial skin infection is caused by group A B-hemolytic streptococci? SATA A. Furuncle B. Cellulitis C. Impetigo D. Folliculitis E. Erysipelas
Impetigo, Erysipelas Impetigo is caused by group A B-hemolytic streptococci, staphylococci, or a combination of both. Erysipelas is caused by group A B-hemolytic streptococci. Furuncle is a deep infection with staphylococci. Staphylococcus aureus and streptococci are the usual causative agents of cellulitis. Usually staphylococci are responsible for folliculitis.
While caring for a client during labor, what would the nurse remember about the second stage of labor? A. It ends at the time of birth B. it ends as the placenta is expelled C. it begins with the transition phase of labor D. it begins with the onset of strong contractions
It ends at the time of birth. The second stage of labor begins with full cervical dilation and ends with the birth of the infant. The third stage of labor begins after birth, continues until the separation of the placenta from the uterine wall, and ends with the expulsion of the placenta. The transition phase of labor is the last phase of the first stage of labor. The onset of strong contractions occurs during the active phase of the first stage of labor.
at which location can the fetal heart be heard when the fetus is in the Left occiput posterior position?
LLQ left lower quadrant RUQ - right sacrum anterior RLQ - right occiput posterior LUQ - left sacrum anterior LLQ - left occiput posterior
which information will the nurse share with a client who sustained a burn and asks, what is the difference between my full thickness and deep partial thickness burns
full thickness burns extend into the subcutaneous tissue; deep partial-thinkess burns extend through the epidermis and involve only part of the dermis.
The nurse is completing an assessment on an older adult who fell and fractured the left hip. Which clinical indicator would the nurse identify as typical with a fractured left hip? A. left hip is ecchymotic B. left leg is noticeably shorter than the right C. left leg is internally rotated D. left hip is tender when touched
left leg is noticeably shorter than the right
Which assessment would the nurse choose for a 4 week old boy whose mother reports, "he cries all the time and always acts hungry, but he throws up everything? A. inspecting the anus for rectal prolapse B. obtaining the elimination history for celiac disease C. noting the color of vomitus for a bile duct obstruction D. palpating the abdomen for hypertrophic pyloric stenosis
palpating the abdomen for hypertrophic pyloric stenosis
which action will the nurse take when caring for a terminally ill client receiving a morphine drip that exceeds the typical recommended dosage whose spouse tells the nurse that the client is again uncomfortable and needs the morphine increased ( the prescription states to titrate the morphine to comfort level)? A. add a placebo to the morphine to appease the spouse B. discuss with the spouse the risk for morphine addiction C. assess the clients pain before administering the dose of morphine D. check the clients HR before increasing the morphine to the next level
assess the clients pain before increasing the dose of morphine
Which comment made by health-department staff during the evaluation of health-department training for human immunodeficiency virus (HIV) surveillance requires clarification by the nurse? A. if the HIV antibody test is positive, it will be followed with a western blot test to check for false positives, correct? B. The HIV antibody test helps us identify people with symptomatic acquired immunodeficiency syndrome (AIDS) so that we can get them early treatment. C. It seems odd that voluntary screening for HIV can either be anonymous or confidential, but I guess maybe more people will come for screening if its anonymous D. We need to encourage voluntary HIV screening for all individuals between the ages of 13 and 64 to the CDC.
The HIV antibody test helps us identify people with symptomatic acquired immunodeficiency syndrome (AIDS) so that we can get them early treatment.
Which statement made by the student nurse regarding the gross anatomy of the physiology of the kidneys indicates the need for additional teaching? A. The right kidney is a little longer and narrower than the left kidney B. The existence of three kidneys with normal kidney function is normal C. The presence of a single kidney with normal kidney function is normal D. The urinary bladder lies directly behind the pubic bone
The right kidney is a little longer and narrower then the left kidney.
which type of shock is associated with a ruptured abdominal aneurysm? A. vasogenic shock B. neurogenic shock C. cardiogenic shock D. hypovolemic shock
hypovolemic shock
which information would the nurse use to explain a positive diagnosis for HIV infection?
positive enzyme - linked immunosorbent assay (ELISA) and western blot tests.
Which factor is the most likely cause of anemia in a client with celiac disease? SATA A. Lack of gluten in diet B. Inadequate caloric intake C. Absence of intrinsic factor D. Incomplete absorption of iron E. Incomplete absorption of folic acid
Incomplete absorption of iron, Incomplete absorption of folic acid Because mucosal lesions limit nutrient absorption there is inadequate iron and folic acid for hemoglobin synthesis, resulting in anemia. Lack of gluten in the diet is not the cause of anemia. The anemia is caused by inadequate absorption rather than the quantity consumed. Lack of the intrinsic factor causes pernicious anemia, not the anemia associated with celiac disease.
Which client most likely suffered a skin injury from sunburn?
client 1, pink to red color, mild edema, painful, no blisters, no eschar, 3-6 days healing time.
the nurse performed physical assessments for four female clients during their general checkup. Which client is most at risk for developing breast cancer?
client B, age 60. family history of breast cancer, no children, age of onset of menopause 50
which client with complications of fracture would the nurse expect may be treated with a fasciotomy?
client b compartment syndrome
which property would the nurse understands that the medication is being used primarily for when aspirin is prescribed on a regular schedule for a client with rheumatoid arthritis? A. analgesic B. antipyretic C. anti-inflammatory D. antiplatelet
anti-inflammatory
which intervention would the nurse implement for a client with Parkinsonism who takes an anticholinergic medication for morning stiffness and tremors in the right arm who reports some numbness in the left hand during a visit to the clinic?
make immediate arrangements for further medical evaluation by the client's primary health care provider. (may be indicative of an impending CVA).
Which situation belongs to the first level of needs according to Maslow's Hierarchy? SATA A. A client who is homeless B. A client reports feeling dizzy for 2 days C. A client reports a neighbor repeatedly beats them up D. A client reports an inability to consume food because of throat pain E. A client with a leg amputation reports they will walk one day
A client who is homeless, A client reports feeling dizzy for 2 days, A client reports an inability to consume food because of throat pain. According to Maslow's hierarchy of human needs, the first level constitutes physiological needs such as air, water, food and body temperature. A homeless client who lacks shelter probably does not receive enough food to eat. This indicates a physiological need. A client who has been feeling dizzy for 2 days may have some serious underlying health issue. This is an example of a first-level need. A client who is unable to eat food because his or her throat hurts may need pain medication, which is a first-level need. A client who may be harmed physically by a neighbor may need security. This is an example of a second need. Fifth level needs are self-actualization needs. a client who has undergone leg amputation and wishes to walk again is an example of a client with a fifth-level need.
The registered nurse teaches the nursing student about antipsychotic medications. Which statements made by the nursing student needs correction? SATA A. Antipsychotic medications only benefit clients with psychotic symptoms. B. Atypical antipsychotics carry a lower risk of extrapyramidal side effects C. Only second-generation antipsychotics are used in combination with lithium and valproate. D. Antipsychotic medications are always used in combination with lithium and valproate. E. Antipsychotic medications are used acutely to control symptoms during manic episodes.
Antipsychotic medications only benefit clients with psychotic symptoms, antipsychotic medications are always used in combination with lithium and valproate. Antipsychotic medications can be used to treat clients either with or without psychotic symptoms. Antipsychotic medications do not always need to be used in combination with lithium and valproate. Atypical antipsychotics are second-generation medications that carry a lower risk of extrapyramidal side effects in comparison with conventional medications. Second-generation antipsychotics are primarily used to treat BPD because they have a low risk of producing symptoms such as tardive dyskinesia. In clients diagnosed with BPD, antipsychotic medications are used acutely to control symptoms during manic episodes.
Which clinical manifestations would the nurse expect to identify in a client experiencing spinal shock immediately after sustaining a functional transection of the spinal cord at C7-C8? SATA A. Spasticity B. Incontinence C. Flaccid paralysis D. Respiratory Failure E. Lack of reflexes below the injury
Flaccid paralysis, Lack of reflexes below the injury
The nurse provides education for an active adolescent with a new ileostomy. The nurse would instruct the client to avoid participating in which sports activities? A. Football B. Swimming C. Ice hockey D. Track Events E. Cross - Country Skiing
Football and Ice hockey Trauma to the abdominal wall and to the stoma should be avoided. Contact sports such as football and ice hockey are contraindicated. Trauma to the abdominal wall is a minimal risk when swimming. Track events are not associated with trauma to the abdominal wall. Cross-country skiing is not associated with trauma to the abdominal wall.
Which is the reason the nurse would monitor for a client with a diagnosis of Cushing syndrome for symptoms of diabetes mellitus? A. Cortical hormones stimulate rapid weight loss B. Tissue catabolism results in a negative nitrogen balance C. Glucocorticoids accelerate the process of gluconeogenesis D. Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.
Glucocorticoids accelerate the process of gluconeogenesis.
Which characteristic of confusion would the nurse keep in mind when an older client with Alzheimer's disease is admitted to a long-term care facility? A. occurs with a transfer to new surroundings B. will be unchanged despite reality orientation C. is a common finding and expected with normal aging D. results from brain changes that make interventions futile
Occurs with a transfer to new surroundings A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with Alzheimer disease; with appropriate intervention, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. Although confusion may be a common finding in Alzheimer disease, it is not expected with normal aging. Although brain changes do occur with Alzheimer disease, interventions can be instituted to decrease confusion.
A newly hired nurse is delegated the task of developing a care plan for a diabetic client who just returned from surgery after undergoing amputation of the leg. Which task in the care plan is inappropriate according to guidelines? A. The registered nurse administering antidiabetic medications B. Instructing the licensed practical nurse to monitor vitals signs C. The RN assessing the client's blood glucose levels at regular intervals D. Instructing the licensed practical nurse (LPN) to change the dressing at the amputation site
Instructing the licensed practical nurse (LPN) to monitor vital signs The LPN's scope of practice includes monitoring vital signs in clients with a stable condition. Instructing the LPN to monitor the vital signs of a client in an acute condition is inappropriate. according to the guidelines. administering antidiabetic medications to a diabetic client who underwent amputation would be done by the RN because the condition of the client is acute. The RN is responsible for assessing the blood glucose levels of the client who underwent amputation. The LPN is instructed to change the dressing at the amputation site.
A 55 year old client has been diagnosed with endometrial cancer. Which findings in the client's history are risk factors associated with endometrial cancer? SATA A. Obesity B. Multiparity C. Cigarette smoking D. Early onset of menopause E. Family history of endometrial cancer F. Previous hormone replacement therapy
Obesity, cigarette smoking, family history of endometrial cancer, previous hormone replacement therapy.
A clients laboratory findings revealed increased levels of serum alkaline phosphatase and urinary hydroxyproline. Which condition will the nurse observe in the client's electronic medical chart? A. Osteomalacia B. Osteoporosis C. Osteomyelitis D. Osteitis deformans
Osteitis deformans In osteitis deformas or paget disease, there will be an increase in serum alkaline phosphatase and urinary hydroxyproline levels. In osteomalacia, there is a decrease in vitamin D, calcium, and phosphorous levels. In osteoporosis, there will be a decrease in calcium level and vitamin D. The alkaline phosphatase level is usually normal. Osteomyelitis is a bone infection in which there is an increase in white blood cell count and a blood culture test to identify the infectious organism.
which medication turns urine reddish-orange in color A. Amoxicillin B. Ciprofloxacin C. Nitrofurantoin D. Phenazopyridine
Phenazopyridine used to treat pain or burning sensation associated with urination
Which nursing intervention would be included in the treatment of an adolescent who is diagnosed with type 2 diabetes mellitus, has a body mass index (BMI) of 30, and reports fatigue, frequent urination, and tingling sensation in the feet? SATA A. Bariatric Sx B. Physical activities C. Dietary restrictions D. Dietary counseling E. Behavior modification
Physical activities, Dietary counseling, Behavior modification
which defense mechanism is most commonly used by clients who are diagnosed with schizophrenia, undifferentiated type? A. Projection B. Repression C. Regression D. Conversion
Regression
Which information will the employee health nurse include when teaching about ways to prevent transmission of influenza in the workplace? SATA A. sneeze or cough into the upper sleeve B. avoid use of over the counter antihistamines C. use alcohol-based hand sanitizers after blowing the nose D. turn the head away from others when coughing or sneezing E. Antiviral medications are the most effective means of transmission prevention
Sneeze or cough into the upper sleeve, use alcohol-based hand sanitizers after blowing the nose, turn the head away from others when coughing or sneezing.
How will the nurse respond to a client who expresses concern about air in the piggyback tubing after the nurse piggybacks an intravenous (IV) antibiotic solution into a primary IV line using gravity flow tubing? A. Air in the tubing, even if it got into the vein will not be fatal unless it is a large amount. B. The antibiotic and now the air are flowing into the primary IV bag, not into the venous system directly. C. The solution from the large IV bad begins to flow when the solution from the smaller bag ceases to flow. D. The clamp on the tubing leading from both bags will be closed for a few minutes to prevent air from entering the vein
The solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow. The secondary bag, containing the medication, is hung higher than the level of fluid in the primary IV so that gravity forces it to empty first. The primary IV will begin to flow as soon as the secondary bag is finished. Air in the secondary line will not enter the vein. Although it is true that it takes a very large amount of IV air to kill a person (200-300 ml estimation), smaller air emboli can cause problems without causing death. Air doesn't flow from the secondary to the primary bag. Closing the clamps on the tubing leading from both bags for a few minutes is contraindicated because it stops the infusion, which can clog the lumen of the catheter that is inserted into the vein.
Which adverse effect will the nurse instruct the client to anticipate when prescribed albuterol to relieve severe asthma? A. Tremors B. Lethargy C. Palpitations D. Bronchonsconstriction E. Decreased pulse rate
Tremors and palpitations Albuterol's sympathomimetic effect causes central nervous (CNS) stimulation, precipitating tremors, tachycardia, and palpitations. Lethargy is an adverse effect of medications that cause CNS depression, not CNS stimulation. Albuterol causes bronchodilation, not bronchoconstriction. Albuterol will cause tachycardia not bradycardia.
which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? A. atrophy of the sweat glands B. decreased subcutaneous fat C. stiffening of the collagen fibers D. degeneration of the elastic fibers
decreased subcutaneous fat
Which activities would the nurse initiate for a client with Alzheimer's disease who is admitted to a long-term care facility? SATA A. Weighing the client once a week B. Having specialized rehabilitation equipment available C. Keeping the client in pajamas and robe most of the day D. Establishing a schedule with periods of rest after activities E. Reviewing the clients weekly budget and use of community resources F. Setting up a plan for weekly entertainment through senior citizens' travel goup
Weighing the client once a week, having specialized rehabilitation equipment available, and establishing a schedule with periods of rest after activities. The nurse would weigh the client once a week, have specialized rehabilitation equipment available, and establish a schedule with periods of rest after activities. Monitoring weight is an objective way to assess nutritional status. Specialized rehabilitation equipment can facilitate the client's participation in self-care. Incorporating rest periods into the client's day prevents fatigue and energizes the client for the next period of activity. The client needs to wear clothes to help maintain a positive view of self. It is not appropriate to review budgeting and use of community resources with a client with Alzheimer's disease; these activities may produce frustration or withdrawal. A client with Alzheimer's disease is usually unable to participate in, or travel with, a senior citizen group.
Which potential complication would the nurse monitor for in a pregnant client with severe hypermesis gravidarum who is receiving total parenteral nutrition (TPN)? A. dehydration B. hypoglycemia C. allergic reaction D. diabetes insipidus
dehydration
Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? A. is able to obtain pulse oximeter readings B. demonstrates use of a metered-dose inhaler C. knows the health care provider's office hours D. can identify triggers that may cause wheezing
demonstrates us of a metered-dose inhaler
Which sign of compartment syndrome would the nurse assess for in the client who has sustained blunt trauma to the forearm? A. Warm skin at the site of injury B. Escalating pain in the fingers C. Rapid capillary refill in the affected hand D. Bounding radial pulse in the injured arm
escalating pain in the fingers
in which way does a sequestration crisis differ from a painful episode (vasoocclusive crisis) in a child with sickle cell disease? A. Peripheral ischemia occurs along with the pain. B. blood volume decreases and signs of shock appear C. red blood cell (RBC) production diminishes with severe anemia D. destruction of RBCs is accelerated and jaundice become evident
blood volume decreases and signs of shock appear
which primary short-term outcome established by the nurse and client will be added to the care plan when caring for a client who sustained a partial-thickness burn to the lower leg accounting for 5% of the total body surface area 1 day ago? A. the clients airway will remain patent B. the clients burns will heal free of infection C. the clients urine output will exceed 30 ml every hour D. the clients pain with remain at 2 or less on a scale of 0-10
the clients pain with remain at 2 or less on a scale of 0-10
a women who is 34 weeks pregnant is hospitalized for pyelonephritis. which assessments would the nurse include in the plan of care? SATA A. temperature B. dietary sodium C. uterine contractions D. blood pressure E. urine output F. homan sign
urine output temperature blood pressure uterine contractions
The nurse is caring for a client who is prescribed desmopressin acetate. Which is the expected outcome in the client? A. sodium: 136 mEq/ L B. specific gravity 1.005 C. urine output 3 L/day D. osmolarity: 100 mosm/kg
urine output: 3L/day
Which action by a client with asthma indicated that the client teaching about use of a peak flow meter has been effective? A. calls the health care provider when peak flows are in the green zone B. does deep breathing and relaxation exercises when peak flow is in the red zone. C. Uses a quick relief inhaled medication when peak flow is in the yellow zone D. Stops taking the daily inhaled corticosteroid when peak flow is in the yellow zone.
uses a quick relief inhaled medication when peak flow is in the yellow zone
