250 Foundations Comprehensive Final

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply.

Encourage motion of the joint, Maintain joints in functional alignment when resting

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply

Clean the eyelid and eyelashes, Apply clean gloves before beginning the procedure, Press on the nasolacrimal duct after instilling the solution

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report?

Loss of central vision

A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals. Which food items will the nurse recommend?

Meatloaf and strawberries Rationale: Meat provides protein, and fruit provides vitamin C; both promote would healing wound healing.

A client with renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply

Ensure that the consent form is signed, Assess the client for iodine sensitivity, Administer an enema or cathartic to the client

Which diagnostic study is used to determine a client's bone density?

standard X-ray

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

Institute measures to prevent constipation

Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address?

Detached retina Rationale: The detached retina is caused by vitreous traction on the retina

which statement by an older adult most strongly supports the nurse's conclusion that the client is impacted with stool.

"I feel like i have to go,but I just seep"

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective?

"I should call the clinic if my eye begins to hurt." Rationale: Pain after a cataract extraction and intraocular lens implant may indicate infection, increases intraocular pressure, or hemorrhage and should be reported immediately.

A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect?

1Retinol (Vitamin A) Rationale: Joint pain, hair loss, jaundice, anemia, irritability, pruritus, and enlarged liver and spleen are signs of vitamin A toxicity.

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client?

An increase in the pressure within the eyeballRationale: An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow.

Which client is MOST at risk for osteoporosis?

A 66-year-old white women, 5 foot, 1 inch tall (155 cm) and 100 lb (45 kg), who is a paralegalRationale: A postmenopausal woman who is small-boned, thin, and relatively sedentary is at risk for osteoporosis; other risk factors are family history and white or Asian ethnicity. The post menopausal years are considered to be 65 years and older; however, each individual is unique.

The nurses is reviewing the plan of care for a client who is scheduled for a barium swallow. What will the plan include?

Administering a laxative after the procedure

A nurse is providing discharge instructions for a client with diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply.

Avoid heavy lifting, Avoid drinking alcohol, Eat small, frequent meals

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences

Chinese Americans

Which drug is derived from a natural source and may be prescribed for the treatment of osteoporosis

Calcitonin

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis?

Cannot see objects in the center of the visual field

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply.

Carrots, Green leafy greens, Yellow/Orange vegetables

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern?

Offer a cup of prune juice

Which term should the nurse use to describe bone loss greater that normal but less than that caused by osteoporosis?

Osteopenia

A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client?

Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3)

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter?

Tubing luer-lok port

A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client?

Vitamin B12 injections Rationale: A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200-835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B12 deficiency and should be given injections. Vitamin B12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb vitamin B12

A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance?

Vitamin C Rationale: Vitamin C aids the absorption of iron

A think 24-year-old women who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend?

Vitamin D and calcium citrate Rationale: All women except those who are pregnant or lactating, should ingest between 1000 to 1300 mg of calcium daily; if the client is unable to ingest enough calcium in food, supplements of calcium and vitamin D are recommended.

A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is MOST appropriate for the nurse to teach the client about meal management?

divide food into four to six meals a day

which medication used to treat urinary incontinence strengthens the urinary sphincters and has anticholinergic action

duloxetine

A nurse is obtaining a health history from a client with the diagnosis of peptic ulcer disease. Which client statement provides evidence to support the identification of a possible contributory factor.

"I smoke one pack of cigarettes a day"

The laboratory report of a client reveals that the platelet count is 60,000/microliter. Which integumentary changes can be anticipated in this client? Select all that apply.

Petechiae, Ecchymosis, Hematoma Rationale: Normal blood platelet counts range between 150,000 and 400,00/ uL (150-400 x 10^9/L). A count of less than 100,000/ uL (100 10^9/L) is referred to as thrombocytopenia, which results in prolonged bleeding time. Petechiae, ecchymosis, and the formation of hematoma are the results of bleeding disorders.

A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce?

Antacids commonly interfere with the absorption of other drugsRationale: Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin

Which nursing interventions are beneficial in the event of fire in the hospital? Select all that apply.

Asking ambulatory clients to help push wheelchair clients out of danger, Maintaining injured clients' respiratory status manually until removed from the fire area

Which key feature does the nurse associate with a stage 2 pressure ulcer?

Presence of non-intact skin

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?

Unstageable

A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections?

"Wear cotton underpants."Rationale: Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the MOST appropriate nursing action?

Applying cold compress to the affected area Rationale: A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client.

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is MOST important for the nurse to do?

Assess the client's condition per hospital protocol.Rationale: A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints required to be deprescribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes is emptied, measured, and documented at the end of each shift.

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply.

Avoid intramuscular injections, Examine the skin for ecchymotic areas

Which beta-adrenergic blocker is prescribed to clients with glaucoma?

Betaxolol

Upon assessment the nurse finds to following (See Image). The nurse will prepare the client for which type of surgery?

Cataract removal Rationale: The given figure indicates a mature cataract due to increased lens density; surgery (Cataract removal) is the only treatment for this defect .

A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include?

Continuation of therapy for life Rationale: Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should they nurse instruct the client to do?

Empty the bladder before a urinary catheter is insertedRationale: Emptying the bladder before a urinary catheter is inserted measure how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating.

What should the nurse teach the client with gastroesophageal reflux disease to do after meals?

Rest in a sitting position for one hour

Which beta-adrenergic blocker is used to reduce a client's intraocular pressure?

Timolol Glaucoma is manifested by increased intraocular pressure. Timolol is a beta-adrenergic blocker used in the treatment of glaucoma. Carbachol is a cholinergic agonist used to treat glaucoma. Travopost is a prostaglandin agonist, and apraclonidine is an adrenergic agonist used in the treatment of glaucoma.

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct?

Urinary retention due to bladder atonyRationale: Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder.

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen?

Urinate small amount, stop flow, fill half a cup

The nurse is preparing to initiate intravenous antibiotic therapy for a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intravenous antibiotics, which task should the nurse insure has been completed?

Wound Culture Rationale:A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given.

While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis?

Dark red color

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply.

"I should drink at least six glasses of water every day.", "I can include bran muffins in my breakfast daily.", "I will walk every day as part of my exercise regimen."

Which client statement indicates to the nurse that a client who is receiving cyanocobalamin (Vitamin B12) therapy for an intrinsic factor deficiency understands the treatment?

"I should have a vitamin B12 injection every month"

A registered nurse is teaching a client regarding preventive measures for genital tract infections. Which statement made by the client indicates the need for further education? Select all that apply.

"I should take frequent bubble bathes." "I should choose hosiery with a nylon crotch." "I should use colored and scented toilet tissues

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning?

"I will avoid draining urine from the tubing before ambulation."

A registered nurse is teaching a student nurse about the role of nurses in case of a fire in the hospital. Which statement made by the student nurse indicates ineffective learning?

"I will continue oxygen for all clients, even those who can breathe without it."

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by nursing student indicate effective learning? Select all that apply

"I will elevate the head of the client's bed to no more than 30 degrees.", "I will ensure that the client is turned and repositioned at least every two hours.", "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. Which is the nurse's MOST appropriate response?

"It is the visualization of the inside of the bladder with an instrument connected to a source of light."

A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. What is the BEST reply by the nurse?

"They are done to identify other health risks.

Which nursing intervention is indicated for aging clients with decreased bone density?

Demonstrating weight-bearing exercises to the client

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider MOST desirable? Select all that apply

Boiled spinach, Dried apricots

The nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? Select all that apply.

Cigarette smoking, Familial predisposition, Inadequate intake of dietary calciumRationale: Cigarette smoking is a high-risk behavior associated with an increased incidence of osteoporosis in later life. Familial predisposition is considered a risk factor for the development of osteoporosis. Inadequate calcium intake during the premenopausal years is a risk factor for the development of osteoporosis after menopause.

The nursing is caring for four different clients with eye disorders.Which client should be assessed for asthma before prescribing beta-adrenergic blockers?

Client D Reduced outflow of acqueous humor and increased intraocular pressure causes glaucoma, which can be treated with different types of drugs. Before prescribing beta-adrenergic blockers, the client should be assessed for moderate to severe asthma because if these drugs are absorbed systematically, they constrict pulmonary smooth muscle and narrow airways. Increased lens density and reduced visual sensory perception indicates cataracts that can be treated only with cataract surgery. Increased tear secretion and blood shot eye appearance is observed in a client with conjuctivitis; this can be treated with ophthalmic antibiotics. Degeneration of corneal tissue indicates keratoconus, which can be cured by performing a surgery called keratoplasty (corneal transplant).

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal?

Control the intraocular pressure Rationale: Individuals with glaucoma have increased intraocular pressure that must be returned to the expected range, or blindness will result.

A nurse is assessing a client's eye and finds the following (see image). Which condition can be identified from the given figure?

Corneal ulcer Rationale: The condition depicted in the figure is a corneal ulcer. Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi.

A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report?

Decreased peripheral visionRationale: With glaucoma, loss of peripheral vision occurs long before central vision is affected. The client also ma complain of seeing halos around lights.

A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. What signs and symptoms should be included in the teaching? Select all the apply.

Fatigue,Dry Skin, Progressive weight gain

After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthetic care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information?

Has sharp pain in the affected eyeRationale: Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye. Four hours is too soon to be concerned that the client has not voided.

The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis?

Heberden Nodes

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe the BEST meet this client's immediate nutritional needs?

High in protein and vitamin C

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply.

Hips and Knees

Which clinical indicator is the nurse MOST likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

Which client responses does the nurse determine represent the HIGHEST risk for the development of pressure ulcers?

Incontinence and inability to move independently

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment?

Monthly injections of cyanocobalamin Rationale: Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life.

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients. staff, and family members? Select all that apply.

Move bedridden clients via stretcher, Turn off all sources of supplemental oxygen, Provide manual respiratory support to critically ill clients Close all windows and doors and use an ABC fire extinguisher

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should be the nurse assess? Select all that apply.

Nail beds, Conjunctivae, Palms of hands

A dehydrated older adult is admitted to the hospital from a nursing home. The transfer form documents a history of liquid fecal incontinence. Which intervention by the nurse will facilitate identification of the cause of this incontinence.

Perform a digital rectal examination

A client has sensorineural hearing loss. Which finding in the client's history will alert the nurse to the most likely cause of the sensorineural hearing loss?

Prolonged exposure to noise Sensorineural hearing loss occurs due to damage to the auditory nerve in the inner ear. Prolonged exposure to noise can cause damage to the cochlea. Cerumen in the ear can cause obstruction in the ear and lead to a conductive hearing loss. Foreign bodies can cause infection and inflammation in the ear, thereby leading to a conductive hearing loss. Perforation of the tympanic membrane leads to an increased risk of ear infections, which can cause conductive hearing loss.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis?

Receives long-term steroid therapy Rationale: Increased levels of steroids will accelerate bone demineralization.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take?

Remove anyone who is in immediate danger.Rationale: The nurse is following the standard fore safety procedure RACE: R: removing any clients from immediate danger A: alarming or activating the fire alarm C: containing the fire source by closing all windows and fire doors E: extinguishing the fire and/or evacuating

A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching?

Replace the drainage bag with a new bag once a week.Rationale: It is recommended to changed the bag at least once a week.

A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which medications are within the classification of an H2 receptor antagonist? Select all that apply.

Nizatidine, Ranitidine, FamotidineRationale: Nizatidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD.

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified?

NosocomialRationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients.

The nurse understands that the BEST way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what?

Perform catheter care twice a day