327 final
A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is
"I should expect to have pain."
The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?
"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."
When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?
"You shouldn't experience a headache after this type of anesthesia."
Why would a client with COPD report feeling fatigued? Select all that apply. The client is using all expendable energy just to breathe. Muscle function gradually decreases over time in clients with COPD. The client is using all expendable energy for activities of daily living (ADLs). Lung function gradually decreases over time in clients with COPD.
-The client is using all expendable energy just to breathe. -Lung function gradually decreases over time in clients with COPD.
The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking?
1-2 months
The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.
5% DW
A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform? -A sleeve resection -A lung volume reduction -A wedge resection -Lobectomy
A lung volume reduction
A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated? -A chest tube -A tracheostomy -An endotracheal tube -A feeding tube
A tracheostomy
A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem? -Pneumoconiosis -Pleural effusion -Acute respiratory failure -Pneumonia
Acute respiratory failure
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? -Administer an over-the-counter decongestant. -Use an anti-allergy medication to decrease rhinitis. -Place a warm cloth over the sinus area of the forehead. -Gently blow the nose to eliminate nasal secretions.
Administer an over-the-counter decongestant.
The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?
An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.
The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.
An elevated hematocrit level Electrolyte imbalance
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? -Anemic hypoxia -Histotoxic hypoxia -Hypoxic hypoxia -Stagnant hypoxia
Anemic hypoxia
What is the most commonly prescribed treatment for the common cold? -Antihistamines -Decongestants -Antitussives -Expectorants
Antihistamines
A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.
Arteriography Cystoscopy Paracentesis Open reduction of a fracture
The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)
Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees
Which action by the nurse indicates understanding of one basic principle of providing effective pain management?
Awakening a new postoperative client to take pain medication
While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding? -Eupnea -Apnea -Biot's respiration -Cheyne-Stokes
Biot's respiration
A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose? • Bowel disease of unknown origin • Cancer • Inflammatory bowel disease • Occult bleeding
Cancer
A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? -Trauma -Infection -Cancer -Emphysema
Cancer
A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?
Chlorhexidine
The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply.
Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain
A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type? -Wheezes -Rhonchi -Crackles -Pleural rub
Crackles
A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment? -Daily oral doses of isoniazid (Nydrazid) and rifampin (Rifadin) for 6 months to 2 years -Isolation until 24 hours after antitubercular therapy begins -Nothing, until signs of active disease arise -Daily doses of isoniazid, 300 mg for 6 months to 1 year
Daily doses of isoniazid, 300 mg for 6 months to 1 year
When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.) -Decreased alveolar duct diameter -Increased presence of mucus -Decreased gag reflex -Increased presence of collagen in alveolar walls -Decreased presence of mucus
Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus
A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply. -Place the client in the prone position. -Educate the client about the need to cleanse the thoracic area. -Apply pressure to the puncture site after the procedure. -Prepare the client for magnetic resonance imaging after the procedure to verify tube placement. -Complete a respiratory assessment after the procedure.
Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion? -Fluoroscopy -Chest x-ray -Magnetic resonance imaging (MRI) -Computed tomography (CT) scan
Fluoroscopy
Which factor increases blood urea nitrogen (BUN)?
Gastrointestinal bleeding
The nurse should monitor a client receiving mechanical ventilation for which of the following complications? -Gastrointestinal hemorrhage -Immunosuppression -Increased cardiac output -Pulmonary emboli
Gastrointestinal hemorrhage
A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe?
IV penicillin G; single dose
Which measure may increase complications for a client with COPD? -Administration of antibiotics -Increased oxygen supply -Administration of antitussive agents -Decreased oxygen supply
Increased oxygen supply
During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?
Metabolic acidosis
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? -Absent cough and gag reflexes -Blood-tinged secretions -Oxygen saturation of 90% -Respiratory rate of 13 breaths/min
Oxygen saturation of 90%
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation? -PaO2 -PaCO2 -pH -SaO2
PaCO2
A nurse would implement droplet precautions for a client with which condition? Select all that apply
Parvovirus B 19 Pertussis Mumps
A nurse implements aseptic technique as a means to break the chain of infection at which element?
Portal of entry
The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?
Post-discharge diet
The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply. -White blood cell count -Protein level -Albumin level -Platelet count -Glucose
Protein level Albumin level Glucose level
An older adult has been medicated with an oral opioid for postoperative pain. To make the pain medication more effective, the nurse first
Provides the client with a fresh gown and changes the bed linens
When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?
Rapid, thready pulse
Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? -Apply a compression dressing to the area -Measure the patient's pulse oximetry -Report the finding to the physician immediately -Record the observation
Record the observation
The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.)
Regulated health practices Sanitation techniques Immunization programs
The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:
Remove the patch after 12 hours.
A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.
Reorient the client. Assess for hypoxia. Assess urine output
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to -Report decreased congestion. -Assume an upright position to facilitate drainage. -Increase fluid intake. -Use a room vaporizer to loosen secretions.
Report decreased congestion.
The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is: -Diminished alveolar surface area. -Hypercapnia resulting from decreased carbon dioxide elimination. -Hypoxemia secondary to impaired oxygen diffusion. -Respiratory acidosis.
Respiratory acidosis
The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction? • Avoid driving for 24 hours. • Continue a clear liquid diet. • Resume regular diet. • Increase fluid intake.
Resume regular diet.
A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.
Scrub clothes Caps
An adult client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse's response? -The cells in small cell cancer of the lung are not large enough to visualize in surgery. -Small cell lung cancer is self-limiting in many clients and surgery should be delayed. -Clients with small cell lung cancer are not normally stable enough to survive surgery. -Small cell cancer of the lung grows rapidly and metastasizes early and extensively.
Small cell cancer of the lung grows rapidly and metastasizes early and extensively
An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care? -Suction the client's airway secretions. -Immobilize the ribs with an abdominal binder. -Prepare the client for surgery. -Immediately sedate and intubate the client.
Suction the client's airway secretions.
A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.
The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the
Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH? -The lungs eliminate carbonic acid by blowing off more CO2. -The lungs increase respiratory volume. -The lungs retain more CO2 to lower the pH. -The kidneys retain more HCO3 to raise the pH.
The lungs eliminate carbonic acid by blowing off more CO2.
How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)
The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly
An client is described as having pectus carinatum. What would be the physical manifestation of this condition? -The sternum protrudes and the ribs are sloped backward. -The sternum is depressed from the second intercostal space. -The thoracic and lumbar spine have a lateral S-shaped curvature. -The chest is rounded, ribs are horizontal, and sternum is pulled forward.
The sternum protrudes and the ribs are sloped backward.
The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management? -The dose range is higher with cancer clients, and the medical team will be very careful to prevent addiction. -Frequently, female clients and younger clients need higher doses of opioids to be comfortable. -The increased risk of overdose is an inevitable risk of maintaining adequate pain control during cancer treatment. -There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.
A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position? -Inform that physician that the client is in a recumbent position and anticipate an order for a portable chest x-ray. -Turn the client to enable assessment of all the patient's lung fields. -Avoid turning the client, and assess the accessible breath sounds from the anterior chest wall. -Obtain a pulse oximetry reading, and, if the reading is low, reposition the client and auscultate breath sounds.
Turn the client to enable assessment of all the patient's lung fields.
The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?
Up to 2 hours before surgery
The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain?
Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.
A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube? • Auscultate the client's abdomen after injecting air through the tube. • Assess the color and pH of aspirate. • Locate the marking made after the initial x-ray confirming placement. • Use a combination of at least two accepted methods for confirming placement.
Use a combination of at least two accepted methods for confirming placement.
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? -Encouraging the client to drink three glasses of fluid daily -Keeping the client in semi-Fowler's position -Using a Venturi mask to deliver oxygen as ordered -Administering a sedative as ordered
Using a Venturi mask to deliver oxygen as ordered
A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication? -Venous thromboemboli -Pneumothorax -Pulmonary hypertension -Cor pulmonale
Venous thromboemboli
Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.
Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.
The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated? -Crackles -Rhonchi -Rubs -Wheezes
Wheezes
The circulating nurse is preparing a patient for a surgical procedure. What primary responsibility does the circulating nurse have in the perioperative experience?
discussing the complications of the surgical procedure with the patient
It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to -ensure adequate rest periods. -manage respiratory distress. -aid the client's caregivers. -manage decreased energy levels.
manage decreased energy levels.
The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse -stays with and closely monitors the client. -obtains a light, mirror, gauze, and curved hemostats. -prepares for a needle aspiration. -orally suctions the client, as needed.
obtains a light, mirror, gauze, and curved hemostats.
Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order?
rectal
The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer? • V formation on dorsum of tongue • thin white coating on dorsum of tongue • red plaque on undersurface of tongue • large vallate papillae on dorsum of tongue
red plaque on undersurface of tongue
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?
shock
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of • tonus. • flaccidity. • atony. • Spasticity
spasticity.
After teaching a client who has had a Roux-en-Y gastric bypass which client statement indicates the need for additional teaching? • "I need to chew my food slowly and thoroughly." • "I need to drink 8 oz of water before eating." • "A total serving should amount to be less than 1 cup." • "I should pick cereals with less than 2 g of fiber per serving."
• "I need to drink 8 oz of water before eating."
The nurse is educating a client on home care following removal of a ganglion cyst from the right wrist. Which statement by the client demonstrates that the nurse's teaching has been effective? • "I will leave the dressing on until I follow up with my doctor as scheduled." • "If my hand becomes numb and cool I will elevate it above my heart." • "I will notify my doctor if I develop redness and purulent drainage for 2 days." • "If my pain is not relieved I will use a heat pack and take some more medication."
• "I will leave the dressing on until I follow up with my doctor as scheduled."
After undergoing a total cystectomy and urinary diversion a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? • "I'll have to wear an external collection pouch for the rest of my life." • "I should eat foods from all the food groups." • "I'll need to drink at least eight glasses of water a day." • "I'll have to catheterize my pouch every 2 hours."
• "I'll have to wear an external collection pouch for the rest of my life."
When discussing physical activities with the client who has just undergone a right total hip replacement which instruction should the nurse provide? • "Limit hip flexion to 90 degrees." • "Perform rotation exercises each day." • "Intermittently cross and uncross your legs several times each day." • "Avoid weight bearing until the hip is completely healed."
• "Limit hip flexion to 90 degrees."
A nursing student asks the nurse why older adults are at risk for falls. The best response by the nurse is: • "Muscles atrophy with aging." • "Bones become more fragile." • "Cartilage deteriorates with age." • "Ligaments become lax with age."
• "Muscles atrophy with aging."
What instructions should the nurse include in the discharge teaching for the client following an arthroscopy? • "The pain should be well-controlled with Tylenol." • "Numbness and tingling in the foot are expected the first 24 hours." • "It is normal to feel hot spots over the puncture site." • "Keep the leg in the dependent position as much as possible."
• "The pain should be well-controlled with Tylenol."
The nurse is providing instructions to the client following application of a fiberglass cast. Which statement by the client indicates further education is needed? • "Under no circumstances should I get my cast wet." • "The cast should not come in contact with other plastics." • "I should avoid touching the cast while it is wet." • "The cast will be hot while it is drying."
• "Under no circumstances should I get my cast wet."
The older client asks the nurse how best to maintain strong muscles. What is the nurse's best response? • "Weight-resistance exercises can strengthen muscles." • "Cardio-training is the best way to build muscle." • "Weight-bearing exercises can strengthen muscles." • "Range of motion exercises build muscle mass."
• "Weight-resistance exercises can strengthen muscles."
A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond? • "Your appendix doesn't play a major role so you won't notice any difference after your recovery from surgery." • "The surgeon will encourage you to limit your fat intake for a few weeks after the surgery but your body will then begin to compensate." • "Your body will absorb slightly fewer nutrients from the food you eat but you won't be aware of this." • "Your small intestine will adapt over time to the absence of your appendix."
• "Your appendix doesn't play a major role so you won't notice any difference after your recovery from surgery."
A client comes back to the clinic with a continued complaint of back pain. What time frame does the nurse understand constitutes "chronic pain"? • 4 weeks • 3 months • 6 months • 1 year
• 3 months
The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time? • 15 minutes • 30 minutes • 60 minutes • 80 minutes
• 30 minutes
A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use? • 5-mL • 10-mL • 20-mL • 30-mL
• 30-mL
A patient is being seen in the ophthalmology clinic for a suspected detached retina. What clinical manifestations does the nurse recognize as significant for a retinal detachment? Select all that apply. • A visual field of floating particles • A definite area of blank vision • Momentary flashes of light • Pain • Halos around the eyes
• A visual field of floating particles • A definite area of blank vision • Momentary flashes of light
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer? • Herpes simplex 1 • Actinic cheilitis • Chancre • Krythoplakia
• Actinic cheilitis
A client is hospitalized for open reduction of a fractured femur. During the postoperative assessment the nurse notes that the client is restless and observes petechiae on the client's chest. Which nursing action is indicated first? • Elevate the affected extremity. • Contact the nursing supervisor. • Administer oxygen. • Contact the health care provider.
• Administer oxygen
A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease rather than ulcerative colitis as the cause of the client's signs and symptoms? • A pattern of distinct exacerbations and remissions • Severe diarrhea • An absence of blood in stool • Involvement of the rectal mucosa
• An absence of blood in stool
A patient has a cast removed after bone healing takes place. What should the nurse instruct the patient to do after removal? (Select all that apply.) • Apply an emollient lotion to soften the skin. • Control swelling with elastic bandages as directed. • Gradually resume activities and exercise. • Use friction to remove dead surface skin by rubbing the area with a towel. • Use a razor to shave the dead skin off.
• Apply an emollient lotion to soften the skin. • Control swelling with elastic bandages, as directed. • Gradually resume activities and exercise.
High doses of which medication can produce bilateral tinnitus? • Meclizine • Aspirin • Promethazine • Dimenhydrinate
• Aspirin
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min frequent swallowing and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse? • Assess lung sounds bilaterally. • Administer prescribed morphine intravenously. • Obtain consent for the esophagogastroscopy. • Suction the oral cavity of the client.
• Assess lung sounds bilaterally.
The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to • Reinforce the neck dressing when blood is present on the dressing. • Assess the graft for color and temperature. • Administer prescribed intravenous vancomycin at the correct time. • Cleanse around the drain using aseptic technique.
• Assess the graft for color and temperature.
The client has just had a central line inserted for parenteral nutrition. The client is awaiting transport to the Radiology Department for catheter placement verification. The client reports feeling anxious. Respirations are 28 breaths/minute. The first action of the nurse is • Auscultate lung sounds. • Position client flat in bed. • Elevate the head of the bed. • Consult with the healthcare provider.
• Auscultate lung sounds.
The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease? • Minimize intake of caffeine beer milk and foods containing peppermint or spearmint. • Avoid eating or drinking 2 hours before bedtime. • Elevate the foot of the bed on 6- to 8-inch blocks. • Eat a low-carbohydrate diet.
• Avoid eating or drinking 2 hours before bedtime.
The nurse recognizes that the client with osteomyelitis is at risk for: • Impingement syndrome • Metastatic bone disease • Bone abscess formation • Pathological fractures
• Bone abscess formation
The client is admitted to the hospital with a diagnosis of left femoral neck fracture. Which treatment modality would the nurse expect the health care provider to order? • Buck's traction • Casting • External fixator • Skeletal traction
• Buck's traction
A nurse is providing an educational class to a group of older adults at a community senior center. In an effort to prevent osteoporosis the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. • Vitamin B12 • Potassium • Calcitonin • Calcium • Vitamin D
• Calcium • Vitamin D
The orthopedic nurse is caring for a client diagnosed with a fracture of the radius. When the nurse is considering all of the various types of bone fractures which bone type is most anticipated? • Collagen • Cortical • Cancellous • Cartilage
• Cancellous
The nurse is caring for a patient with a pelvic fracture. What nursing assessment for a pelvic fracture should be included? (Select all that apply.) • Checking the urine for hematuria • Palpating peripheral pulses in both lower extremities • Testing the stool for occult blood • Assessing level of consciousness • Assessing pupillary response
• Checking the urine for hematuria • Palpating peripheral pulses in both lower extremities • Testing the stool for occult blood
A client was playing softball and dislocated four of his fingers when diving for a ball. The physician manipulated the fingers into alignment and applied a splint to maintain alignment. What type of procedure does the nurse document this as? • Open reduction • Closed reduction • Open reduction with internal fixation • External fixation
• Closed reduction
A client reports to the emergency department after experiencing pain in the left arm. The client reports having extended both arms in an attempt to prevent a fall. Which fracture type does the nurse anticipate? • Colles' fracture • Spiral fracture • Greenstick fracture • Compound fracture
• Colles' fracture
A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action? • Recognize this as an expected finding. • Place the bag in a warm environment for 30 minutes. • Shake the bag vigorously for 10 to 20 seconds. • Contact the pharmacy to obtain a new bag of PN.
• Contact the pharmacy to obtain a new bag of PN
The nurse is assessing the feet of a patient and observes an overgrowth of the horny layer of the epidermis. What does the nurse recognize this condition as? • Bunion • Clawfoot • Corn • Hammer Toe
• Corn
A client with a fractured distal left radius reports discomfort at the cast site with pain specifically in the upper forearm. What would the nurse expect the physician to do? • Cut a cast window. • Remove the cast. • Apply a fiberglass cast. • Initiate physical therapy.
• Cut a cast window.
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) • Decreased sensory function • Excruciating pain • Loss of motion • Capillary refill less than 3 seconds • 2+ peripheral pulses in the affected distal pulse
• Decreased sensory function • Excruciating pain • Loss of motion
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. For what early complications should the nurse monitor this client? Select all that apply. • Systemic infection • Complex regional pain syndrome • Deep vein thrombosis • Compartment syndrome • Fat embolism
• Deep vein thrombosis • Compartment syndrome • Fat embolism
A group of students are reviewing the structure and function of bones. The students demonstrate understanding of the information when they state that cortical bone is found primarily in which of the following? • Rounded irregular ends • Epiphyses • Diaphyses • Osteoblasts
• Diaphyses
A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply. • Hypertension • Diarrhea • Decreased bowel sounds • Tachycardia • Diaphoresis
• Diarrhea • Tachycardia • Diaphoresis
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication? • Steroids • Antibiotics • Antiemetics • Diuretics
• Diuretics
A client with a tibia fracture was placed in an external fixator 24 hours ago. The nurse is completing pin care and notices redness at the pin site and a small amount of serous drainage. What action by the nurse is appropriate? • Notify the physician. • Document the findings. • Prepare for surgical removal of the fixator. • Assess the client's hemoglobin and hematocrit.
• Document the findings.
A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction? • Diffuse pain • Dyspepsia • Constipation • Abdominal bleeding
• Dyspepsia
The health care provider is preparing to bivalve the client's cast. Which supplies should the nurse assemble? • Elastic compression bandages • Gauze bandages and tape • Sterile saline and basin • Stockinette and cotton padding
• Elastic compression bandages
A client has delayed bone healing in a fractured right humerus. What should the nurse prepare the client for that promotes bone growth? • Electrical stimulation • Administration of low-dose heparin • Joint fusion • Administration of antibiotics
• Electrical stimulation
An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom? • Hiatal hernia • Gastroesophageal reflux disease • Gastritis • Esophageal tumor
• Esophageal tumor
Which portion of the middle ear equalizes pressure? • Eustachian tube • Ossicles • Auricle • Cochlea
• Eustachian tube
The nurse is caring for a patient postoperatively following orthopedic surgery. The nurse assesses an oxygen saturation of 89% confusion and a rash on the upper torso. What does the nurse suspect is occurring with this patient? • Polyethylene-induced infection • Pneumonia • Fat emboli syndrome • Disseminated intravascular coagulation
• Fat emboli syndrome
A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia? • Fear of eating • Taste of food • Size of the stomach • Absorption of food
• Fear of eating
The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be • Diarrhea • Hemorrhoids • Fecal incontinence • Dark tarry stools
• Fecal incontinence
The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take? • Remove the tape from the nose of the client. • Withdraw the tube gently for 6 to 8 inches. • Provide oral hygiene. • Flush with 10 mL of water.
• Flush with 10 mL of water.
The nurse is very concerned about the potential debilitating complication of peroneal nerve injury. What symptom does the nurse recognize as a result of that complication? • Permanent paresthesias • Footdrop • Deep vein thrombosis (DVT) • Infection
• Footdrop
A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding? • Abdominal lesions are usually due to age-related skin changes. • Integumentary diseases often cause GI disorders. • GI diseases often produce skin changes. • The client needs to be assessed for self-harm.
• GI diseases often produce skin changes.
A patient is receiving parenteral nutrition. The current solution is nearing completion and a new solution is to be hung but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate? • Slow the current infusion rate so that it will last until the new solution arrives. • Hang a solution of dextrose 10% and water until the new solution is available. • Have someone go to the pharmacy to obtain the new solution. • Begin an infusion of normal saline in another site to maintain hydration.
• Hang a solution of dextrose 10% and water until the new solution is available.
A client has just undergone a leg amputation. What will the nurse closely monitor the client for during the immediate postoperative period? • Neuroma • Hematoma • Chronic osteomyelitis • Unexplainable burning pain (causalgia)
• Hematoma
While riding a bicycle on a narrow road the patient was hit from behind and thrown into a ditch sustaining a pelvic fracture. What complications does the nurse know to monitor for that are common to pelvic fractures? • Paresthesia and ischemia • Hemorrhage and shock • Paralytic ileus and a lacerated urethra • Thrombophlebitis and infection
• Hemorrhage and shock
The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit what does the nurse identify as the client goal? • Recover from the general anesthesia • Decrease nausea and vomiting • Increase the amount of fluids • Ambulate independently
• Increase the amount of fluids
The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly? • Maintain intermittent or continuous suction at a rate greater than 120 mm Hg. • Keep the vent lumen above the patient's waist to prevent gastric content reflux. • Irrigate only through the vent lumen. • Tape the tube to the head of the bed to avoid dislodgement.
• Keep the vent lumen above the patient's waist to prevent gastric content reflux.
An emergency department nurse is assessing a 17-year-old soccer player who presented with a knee injury. The client's description of the injury indicates that his knee was struck medially while his foot was on the ground. The nurse knows that the client likely has experienced what injury? • Lateral collateral ligament injury • Medial collateral ligament injury • Anterior cruciate ligament injury • Posterior cruciate ligament injury
• Lateral collateral ligament injury
A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the: • Right lower quadrant. • Left lower quadrant. • Right upper quadrant. • Left upper quadrant.
• Left lower quadrant.
The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion what will the nurse select? • Salem sump tube • Miller-Abbott tube • Sengsten-Blakemore tube • Levin tube
• Levin tube
The client with a newly applied cast reports severe unrelenting pain. What is the nurse's best response? • Make the client NPO and notify the health care provider. • Loosen the edges of the cast and elevate the leg. • Reposition the extremity for comfort and apply ice. • Administer a dose of morphine sulfate.
• Make the client NPO and notify the health care provider.
A nurse is assessing a client who reports a throbbing burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. The nurse should recognize the signs and symptoms of what health problem? • Morton neuroma • Pes cavus • Hallux valgus • Onychocryptosis
• Morton neuroma
A client is having traction applied to a fractured left lower extremity prior to surgery. What outcomes does the nurse expect from the application of the traction for the client? Select all that apply. • Surgery will not be required. • Muscle spasms will be relieved. • The bones of the left leg will be aligned. • Immobilization of the left leg will be maintained. • Less pain medication will be required.
• Muscle spasms will be relieved. • Immobilization of the left leg will be maintained. • The bones of the left leg will be aligned.
A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer? • "My pain resolves when I have something to eat." • "The pain really interferes with my quality of life." • "I know that my father and my grandfather both had ulcers." • "I seem to have bowel movements more often than I usually do."
• My pain resolves when I have something to eat."
A patient has serous otitis media with significant hearing loss in the right ear. The patient states "I have not been able to hear for 2 months." What procedure does the nurse anticipate preparing the patient for? • Irrigation of the ear • Myringotomy • Removal of cerumen with a cerumen curette • Instillation of otic solution
• Myringotomy
The nurse is assessing a client with multiple sclerosis who is demonstrating involuntary rhythmic eye movements. What term will the nurse use when documenting these eye movements? • Vertigo • Tinnitus • Nystagmus • Astigmatism
• Nystagmus
A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about? • Nystatin • Cephalexin • Fluocinolone acetonide oral base gel • Acyclovir
• Nystatin
A group of students are reviewing information about bones in preparation for a quiz. Which of the following indicates that the students have understood the material? • The yellow marrow is responsible for manufacturing red blood cells. • Long bones typically contain more red bone marrow than yellow. • Osteoclasts are involved in the destruction and remodeling of bone. • Osteocytes are transformed into osteoblasts or mature bone cells
• Osteoclasts are involved in the destruction and remodeling of bone.
An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? • Palpate the client's parotid glands to detect swelling and tenderness. • Assess the temporomandibular joint for evidence of a malocclusion. • Test the integrity of cranial nerve XII by asking the client to protrude the tongue. • Inspect the client's gums for bleeding and hyperpigmentation.
• Palpate the client's parotid glands to detect swelling and tenderness.
A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland? • Buccal • Parotid • Sublingual • Submandibular
• Parotid
A patient has a long leg cast applied. Where does the nurse understand a common pressure problem may occur? • Dorsalis pedis • Peroneal nerve • Popliteal artery • Posterior tibialis
• Peroneal nerve
Which actions by the nurse demonstrate an understanding of caring for a client in traction? Select all that apply. • Placing a trapeze on the bed • Ensuring that the weights are hanging freely • Assessing the client's alignment in the bed • Removing skeletal traction to turn and reposition the client • Frequently assessing pain level
• Placing a trapeze on the bed • Ensuring that the weights are hanging freely • Assessing the client's alignment in the bed • Frequently assessing pain level
A 75-year-old client had surgery for a left hip fracture yesterday. When completing the plan of care the nurse should include assessment for which complications? Select all that apply. • Pneumonia • Necrosis of the humerus • Skin breakdown • Sepsis • Delirium
• Pneumonia • Skin breakdown • Sepsis • Delirium
Which intervention would the nurse implement with the client in skeletal traction? Select all that apply. • Apply 8-pound weight to the rope. • Ensure the pins or wires are covered with caps. • Remove foam boot and inspect skin daily. • Position trapeze within the client's reach. • Instruct the client on isometric exercises for immobilized extremity.
• Position trapeze within the client's reach. • Instruct the client on isometric exercises for immobilized extremity. • Ensure the pins or wires are covered with caps.
A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume? • Protein-rich foods • Potassium-rich foods • High-fiber foods • High-fat foods
• Potassium-rich foods
A client with a short arm cast is suspected to have compartment syndrome. What actions should the nurse include in the plan of care? Select all that apply. • Elevate the arm above the heart. • Prepare to remove the cast. • Provide support to the injured extremity. • Assess neurovascular status every 8 hours. • Apply ice to extremity.
• Prepare to remove the cast. • Provide support to the injured extremity
The nurse screens a middle-aged client's vision and notes that the client has difficulty reading print when it is placed at arm's length. The client tells the nurse that the same problem happened to his father. The nurse is aware that the health care practitioner will refer this client to an ophthalmologist for correction of what vision problem? • Myopia • Astigmatism • Presbyopia • Hyperopia
• Presbyopia
The nurse is assessing a client's ulnar nerve. What technique will the nurse use? • Prick the distal fat pad of the small finger. • Ask the client to touch the thumb to the small finger. • Prick the skin mid-way between the thumb and second finger. • Ask the client to flex the wrist.
• Prick the distal fat pad of the small finger.
An older adult client with a diagnosis of left-sided stroke is admitted to the facility. To prevent the development of disuse osteoporosis which objective is most appropriate? • Maintaining protein levels • Maintaining vitamin levels • Promoting weight-bearing exercises • Promoting range-of-motion (ROM) exercises
• Promoting weight-bearing exercises
A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on? • H2-receptor antagonist and two antibiotics • H2-receptor antagonist proton-pump inhibitor and an antibiotic • Proton-pump inhibitor an antibiotic and bismuth salts • Proton-pump inhibitor and two antibiotics
• Proton-pump inhibitor and two antibiotics
A client who is postoperative from bariatric surgery reports foul-smelling fatty stools. What is the nurse's understanding of the primary reason for this finding? • Rapid gastric dumping • Excessive fat intake • Decreased motility • Decreased gastric size
• Rapid gastric dumping
The nurse advises the patient who has just been diagnosed with acute gastritis to: • Take an emetic to rid the stomach of the irritating products. • Refrain from food until the GI symptoms subside. • Restrict food and fluids for 12 hours. • Restrict all food for 72 hours to rest the stomach.
• Refrain from food until the GI symptoms subside.
A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply. • Remove gas and fluids from the stomach • Diagnose gastrointestinal motility disorders • Flush ingested toxins from the stomach • Evaluate for masses in the large colon • Administer nutritional substances
• Remove gas and fluids from the stomach • Diagnose gastrointestinal motility disorders • Flush ingested toxins from the stomach • Administer nutritional substances
A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works? • Restricts the client's ability to eat. • Impairs caloric absorption. • Restricts the client's ability to digest fat. • Impairs gastric motility.
• Restricts the client's ability to eat.
A client is admitted to the hospital for a fracture of the right femur. Which clinical manifestation supports the diagnosis? • Swelling of the right leg • Pain in the right thigh • Hematoma over the right trochanter • Right leg shorter than left
• Right leg shorter than left
The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to? • Referred pain • Rebound pain • Rovsing sign • Cremasteric reflex
• Rovsing sign
The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator? • Serum calcium • Serum lipase • Serum bilirubin • Serum amylase
• Serum lipase
A client is having a cast applied for a fractured leg that extends from below the knee to the base of the toes. The foot is flexed at a right angle in a neutral position. What type of cast is the client having applied? • Short leg cast • Long leg cast • Walking cast • Hip spica cast
• Short leg cast
The nurse is conducting a musculoskeletal assessment on a client documented to have rheumatoid arthritis. Which would the nurse anticipate finding when inspecting the client's fingers? • Soft subcutaneous nodules along the tendons • Hard nodules adjacent to the joints • Hard nodules of bony overgrowth • Soft nodules along the palmar surface
• Soft subcutaneous nodules along the tendons
A nurse cares for a client who is post op from bariatric surgery. Once able the nurse encourages oral intake for what primary purpose? • Stimulate GI peristalsis • Assess for intact swallowing • Assess for gastric perforation • Stimulate digestive hormones
• Stimulate GI peristalsis
Which are accurate clinical manifestations of a retinal detachment? • Sudden onset of a greater number of floaters • Cobwebs • Bright flashing lights • Pain
• Sudden onset of a greater number of floaters
A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client? • Take the medication 2 hours before or after other medications • Blood levels will be evaluated after 1 week • Take the medication at bedtime to accommodate sedative effects • Ensure adequate potassium intake during therapy
• Take the medication 2 hours before or after other medications
The nurse is working in a long-term care facility. Which clues that the nurse notes suggest that the client is not hearing what the nurse said? Select all that apply. • The client does not want to be social. • The client responds inappropriately. • The client asks for surrounding sounds be increased. • The client nods the head and smiles. • The client withdraws from activity.
• The client does not want to be social. • The client responds inappropriately. • The client nods the head and smiles. • The client withdraws from activity.
A nurse is assessing a client who is receiving traction. The nurse's assessment confirms that the client is able to perform plantar flexion. What conclusion can the nurse draw from this finding? • The leg that was assessed is free from DVT. • The client's tibial nerve is functional. • Circulation to the distal extremity is adequate. • The client does not have peripheral neurovascular dysfunction.
• The client's tibial nerve is functional.
The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length? • A length of 50 cm (20 in) • A point that equals the distance from the nose to the xiphoid process • The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process • The distance determined by measuring from the tragus of the ear to the xiphoid process
• The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process
A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis? • Gastric cancer does not cause signs or symptoms until metastasis has occurred. • Adherence to screening recommendations for gastric cancer is exceptionally low. • Early symptoms of gastric cancer are usually attributed to constipation. • The early symptoms of gastric cancer are usually not alarming or highly unusual.
• The early symptoms of gastric cancer are usually not alarming or highly unusual
A client arrives in the emergency room complaining of severe pain in her left hip after falling out of the bed. What indication upon assessment does the nurse recognize as a dislocated left hip? Select all that apply. • The left leg is shorter than the right. • Limited range of motion of the left hip. • The skin over the left hip is warm. • The skin of the lower left leg is pale. • The client is able to bend the knee but not move toes.
• The left leg is shorter than the right. • Limited range of motion of the left hip. • The skin of the lower left leg is pale.
A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate? • The nerve fibers of the intestinal lining are experiencing neuropathy. • The pancreas secretes digestive enzymes. • Elevated glucose levels cause bacteria overgrowth in the large intestine. • Insulin has an adverse effect of constipation.
• The pancreas secretes digestive enzymes.
When conducting an eye exam the nurse practitioner is aware that a diagnostic clinical manifestation of glaucoma is: • A significant loss of central vision. • Diminished acuity. • Pain associated with a purulent discharge. • The presence of halos around lights.
• The presence of halos around lights.
Which nursing instruction is correct to provide the client following a barium enema? • The client will maintain a low residue diet. • The stools may be a white or clay colored. • Sips of fluid may be increased if tolerated. • An enema will be used to clear the bowel.
• The stools may be a white or clay colored.
Which statement describes benign paroxysmal positional vertigo (BPPV)? • The vertigo is usually accompanied by nausea and vomiting. • The onset of BPPV is gradual. • BPPV is caused by tympanic membrane rupture. • BPPV is stimulated by the use of certain medications such as acetaminophen.
• The vertigo is usually accompanied by nausea and vomiting.
For which of the following immobility-related complications is the client in traction at risk? Select all that apply. • Cachexia • Thromboemboli • Urinary stasis • Diarrhea • Lactose intolerance
• Thromboemboli • Urinary stasis
When preparing to insert a nasogastric tube the nurse determines the length of the tube to be inserted. The nurse nurse places the distal tip of the tube at which location? • Tip of patient's nose • Tragus of the ear • Base of the neck • Tip of the xiphoid process
• Tip of patient's nose
Which clinical manifestation would the nurse recognize as an indicator of peripheral neurovascular dysfunction? Select all that apply. • Toes mottled and cool • Capillary refill less than 3 seconds • Complaints of pins and needles in feet • Absence of pain • Dorsiplantar flexion strong
• Toes mottled and cool • Complaints of pins and needles in feet
The nurse is assessing a client for dietary factors that may influence her risk for osteoporosis. The nurse should question the client about her intake of what nutrients? Select all that apply. • Calcium • Simple carbohydrates • Vitamin D • Protein • Soluble fiber
• Vitamin D • Calcium
A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate? • Administer antibiotics via the tube as prescribed. • Wash the area around the tube with soap and water daily. • Cleanse the skin within 2 cm of the insertion site with hydrogen peroxide once per shift. • Irrigate the skin surrounding the insertion site with normal saline before each use.
• Wash the area around the tube with soap and water daily.
The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention • Change the transparent dressing every 3 days. • Wear a face mask during dressing changes. • Assess the PICC insertion site daily. • Use clean gloves when providing site care.
• Wear a face mask during dressing changes.
A middle-aged obese female presents to the ED with severe radiating right-sided flank pain nausea vomiting and fever. A likely cause of these symptoms is: • acute cholecystitis • hepatitis A • hepatitis B • pancreatitis
• acute cholecystitis
A client reports a sudden onset of tinnitus hearing loss and vertigo. The nurse carefully reviews the client's medication list to determine whether the client is taking a medication that might cause ototoxicity. Which medications would the nurse be most concerned with? Select all that apply. • aspirin • lasix • cisplatin • cephalexin
• aspirin • lasix • cisplatin
A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems? • Contractile spasms of the gallbladder decreases appetite and leads to malnutrition. • Inflammation of the gallbladder causes pain and impacts gastric motility. • Reduced or absent bile as a result of obstruction impacts digestion. • Increased bile as a result of inflammation leads to indigestion.
• educed or absent bile as a result of obstruction impacts digestion.
The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is: • stress and anxiety. • gram-negative bacteria. • alcohol and tobacco. • ibuprofen and aspirin.
• gram-negative bacteria.
A client has symptoms suggestive of peritonitis. Nursing management would not include: • limiting analgesics to avoid the formation of paralytic ileus. • accurate recording of input and output. • inserting a nasogastric tube. • inserting a urinary retention catheter.
• limiting analgesics to avoid the formation of paralytic ileus.
A client with a right leg fracture is returning to the orthopedist to have the cast removed. During cast removal it is important for the nurse to assure: • the client that he or she won't be cut. • that the cast cutter blade is sharp. • that pedal pulses are present. • All options are correct.
• the client that he or she won't be cut.
The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of: • total gastrectomy. • bariatric surgery. • diverticulitis. • gastroesophageal reflux disease (GERD).
• total gastrectomy.
