480- Final Review

A nurse is teaching a client who has a new prescription for NPH insulin. Which of the following instructions should the nurse include? a. Discard the medication if it's cloudy b. Briskly shake the medication before filling the syringe c. Administer the medication into the muscle d. Abdomen allows for best absorption

Abdomen allows for best absorption

A nurse in the emergency department is preparing to care for a client who received multiple injuries during a fight. The nurse should plan to base his primary focus on which of the following? (SATA) a. Airway b. Bowel sounds c. Disability d. Exposure e. Urinary output

Airway Disability Exposure

A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside? a. Bag valve mask device b. Defibrillator machine c. Chest tube equipment d. Central venous catheter tray

Bag valve mask device

A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first? a. Dobutamine b. Methylprednisolone c. Furosemide d. Epinephrine

Epinephrine

A nurse is reviewing the laboratory data of a client who has cirrhosis. The nurse should expect to find which of the following values? a. . b. . c. . d. .

Expect increase ALT,ALP, AST (note)

A nurse is assessing a client who is in skeletal traction. Which of the following should the nurse identify as an indication of infection at the pin sites? a. Serosanguineous drainage b. Mild erythema c. Warmth d. Fever

Fever

The student nurse is reviewing the signs of kidney transplant rejection and realizes which of the following is not a sign of rejection? a. Tachycardia b. Pain at transplant site c. Fever d. hypotension

Hypotension

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? a. Increased respiratory rate from 18-28 b. Increased oral temp from 36.6C (97.8F) to 37C (98.6F) c. Increased blood pressure from 112/68 to 120/72 d. Increased heart rate from 68 to 72/min

Increased respiratory rate from 18-28

A nurse is caring for a client who is experiencing Cushing's Triad following a subdural hematoma. Which of the following medications should the nurse plan to administer? a. Albumin 25% b. Dextran 70 c. Hydroxyethyl glucose d. Mannitol 25%

Mannitol 25%

A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan? a. Apply pressure to needlestick site for 10 min b. Assess for signs of infection c. Monitor hemoglobin and hematocrit d. Monitor for the presence of WBC's in the urine

Monitor hemoglobin and hematocrit

A nurse on a medical-surgical unit is planning to delegate tasks to an adult volunteer. Which of the following tasks should the charge nurse avoid assigning to the volunteer? a. Delivering meal trays to clients in their rooms b. Assessing a client who has difficulty seeing the foods on the tray while eating c. Delivering a routine urine specimen to the laboratory d. Observing a postoperative client who is confused.

Observing a postoperative client who is confused.

A hospice nurse is reviewing the prescriptions for a client who is receiving hospice care. Which of the following prescriptions should the nurse reject? SATA a. Provide skin care with a moisture barrier cream b. Administer artificial tears PRN c. Obtain vitals every 2 hours d. Perform mouth care every hour e. Perform diagnostic testing

Obtain Vitals every 2 hours Perform diagnostic testing

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? a. HCO3 30 b. PaCO2 50 c. pH 7.45 d. Potassium 3.3

PaCO2 50

A nurse is caring for a client who has a new prescription for propranolol. The nurse should monitor the client for which of the following reactions to this medication? a. Ototoxicity b. Tachycardia c. Postural hypertension d. Hypokalemia

Postural hypertension

A nurse is teaching a client who has hepatitis A about preventing transmission of the virus. Which of the following strategies should the nurse include in the teaching? a. Avoid eating at fast food restaurants b. Avoid serving raw foods c. Practice effective hand hygiene d. Wear barrier protection during vaginal intercourse

Practice effective hand hygiene

A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? a. Provide a non-skid mat to alleviate plate movement b. Encourage the client to use his right hand when feeding himself c. Remind the client to look for food on the left side of the tray d. Encourage use of the wide grip utensils

Remind the client to look for food on the left side of the tray

A nurse is caring for a client who has a traumatic brain injury. Which of the following should the nurse identify as an indication of increased intracranial pressure (ICP)? a. Tachycardia b. Amnesia c. Hypotension d. Restlessness

Restlessness

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? a. The client states having a severe headache b. The client's bladder becomes distended c. The client's blood pressure becomes elevated d. The client states having nasal congestiona.

The client states having a severe headache

A nurse in the emergency department is caring for a client who reports chest pressure and shortness of breath. Which of the following laboratory tests should the nurse anticipate the provider to prescribe? a. Troponin I b. Lipase c. BNP d. AST

Troponin I

While caring for a client, the nurse experiences a needle stick injury. Which of the following actions should the nurse take first? a. Complete an incident report b. Request the risk manager obtain consent for HIV testing from the client c. Wash the site of injury with soap and water d. Consent to post exposure treatment with antiviral medications

Wash the site of injury with soap and water

A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output total's most likely indicates oliguria? a. 720 b. 550 c. 300 d. 500

300

An IV with nitroglycerin is infusing at 8 mL/hr. The concentration of the IV is 50 mg in 250 mL of D5W. How many mg/hr is the patient receiving?

1.6 mL/hr

The doctor orders Zosyn 2.25 mg IVPB q8h. The pharmacy sends up Zosyn 2.25 mg premixed in 50 mL of D5W to infuse over 30 minutes. Which of the following should the nurse set the pump at mL/hr?

100 mL/hr

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations. a. Kussmaul respirations b. Apneustic Respirations c. Cheyne-Stokes respiration d. Orthopnea

Cheyne-Stokes respiration

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? a. Dehydration b. Polyphagia c. Hyperglycemia d. Oliguria

Dehydration

A nurse is caring for a client who has thrombophlebitis and is receiving a continuous heparin infusion. Which of the following medications should the nurse have available to reverse heparins effects? a. Vitamin k b. Protamine sulfate c. Acetylcysteine d. Deferasirox

Protamine sulfate

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone(SIADH) and a sodium level of 123. Which of the following precautions should the nurse anticipate? a. Maintain an IV of 0.45% sodium chloride b. Restrict fluid intake to 1000 mL per day c. Provide a diet containing 2 g of sodium per day d. Administer desmopressin acetate 0.? Mg daily

Restrict fluid intake to 1000 mL per day

A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? a. Sodium 126 b. Potassium 3.5 c. Magnesium 1.9 d. Chloride 99

Sodium 126

A nurse is caring for a client who has hypernatremia and required IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client? a. Lactated Ringers b. 3% sodium chloride c. 0.45% sodium chloride d. Dextrose 10% in water

0.45% NaCl

A provider prescribes esmolol 45 mcg/kg/min by continuous IV infusion for a patient who weighs 39 kg. Available is esmolol 2500 mg in 250 mL dextrose 5% of water (D5W). The nurse should set the IV pump to deliver how many mL/hr?

105? or 10.5

The physician reduces an IV to 30 mL/hr. The total volume to be infused indicates 270 mL are remaining in the present IV bag. THe nurse notices that it is exactly 1030. At what time will the infusion be complete?

1930

The nurse is caring for a patient admitted yesterday for an ischemic stroke. The nurse is to begin a Heparin infusion at 1,000 units per hour and titrate per hospital protocol. Available is Heparin 25,000 units in 500 mL D5W. At what rate (mL/hr) will the nurse begin this infusion to run the ordered dose?

20 mL/hr

A client who has type 1 diabetes mellitus is to have IV fluid that contains 51 units of Regular insulin (Humulin ..) in 1,000 mL to infuse at 2 units/hr. The nurse should set the IV pump to deliver how many mL/hr? (round to the nearest whole number)

39 mL/hr

An adult client weighing 205 lb (round wt to whole number) arrives to the hospital after sustaining burns to the entire right arm, anterior face, and anterior upper trunk (Round TBSA to tenth). How many mL/hr of IV fluid should the nurse administer during the first 8 hr? (Round the answer to the nearest whole number)

4185 or 523 mL/hr

A nurse is assessing a client in a health clinic for risk factors for contracting hepatitis. Which of the following clients is at risk for developing hepatitis C? a. A client who eats raw shellfish b. A client with a history of illicit drug use c. A client who consumed non purified water d. A client who recently traveled to an undeveloped country

A client with a history of illicit drug use

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? a. Alkalosis b. Acetone breath odor c. Cheyne-Stokes breathing d. Myoclonic jerking

Acetone breath odor

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy . The client's spouse asks the nurse what happens during the procedure. Which of the following nursing statements is appropriate? a. . b. . c. . d. .

Blank

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make? a. DIC is controllable with lifelong heparin usage b. DIC is characterized by an elevated platelet count c. DIC is caused by abnormal coagulation involving fibrinogen d. DIC is a genetic disorder involving a vitamin k deficiency

DIC is caused by abnormal coagulation involving fibrinogen

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Decamethasone c. Heparin d. Atropine

Heparin

A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingual for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make? a. A headache is an indication of an allergy to the medication b. A headache is an expected adverse effect to the medication c. A headache indicates tolerance to the medication d. A headache is likely due to the anxiety about the chest pain

A headache is an expected adverse effect to the medication

A nurse is teaching about self monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. I will check my urine once a day for ketones b. I will notify my provider if pre-meal glucose is 120 c. I will check my blood sugar every 4 hours when I am sick d. I will check blood glucose every 5 minutes when I am lightheaded

I will check my blood sugar every 4 hours when I am sick

A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member request that the nurse apply restraints. Which of the following responses should the nurse make? a. I will provide more stimulation in his environment b. I will call the doctor to get the prescription c. I will cover the catheter so he cannot see it d. Let's wait until tonight to see if he continues the behavior

I will cover the catheter so he cannot see it

A nurse is providing a discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching? a. Its okay to have a couple glasses of wine with dinner each evening b. I'll be sure to eat more foods with vitamin k c. I'll take aspirin for my headaches d. I'll use my electric razor for shaving

I'll use my electric razor for shaving

A nurse is assessing a client who is postoperative following a craniotomy. Which of the following findings requires intervention by the nurse? a. PaCO2 35 b. ICP 18 c. Pulse ox 94% d. Blood pressure 140/82

ICP 18

A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider inspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see? a. Decreased aspartate transaminase b. Increased serum amylase c. Decreased serum lipase d. Increased serum calcium

Increased serum amylase

A nurse is planning care for a client who has deep vein thrombosis of the lower leg. Which of the following interventions should the nurse include in the plan of care? a. Keep the clients affected leg elevated.... b. Have..... c. Apply... d. Massage...

Keep the clients affected leg elevated

A nurse is teaching a client about causes of biliary cirrhosis. Which of the following information should the nurse include in the teaching? a. Excessive alcohol consumption b. Hepatitis C d. Obstruction of the biliary duct.

Obstruction of the biliary duct.

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? a. Hypertension b. Flushing of the skin c. Oliguria d. bradypnea

Oliguria

A nurse is admitting a client who has acute pancreatitis and is NPO. Which of the following provider prescriptions should the nurse anticipate? a. . b. . c. . d. .

PPI "ole"

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? a. Repeat auscultation after asking the client to breathe deeply and cough b. Instruct the client to limit fluid intake to less than 2000 mL/day c. Prepare to administer antibiotics d. Place the client on bedrest in semi-fowler's position

Repeat auscultation after asking the client to breathe deeply and cough

A nurse is admitting a client who has hepatitis C. Which of the following precautions should the nurse implement? a. Droplet b. Contact c. Airborn d. Standard

Standard

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? a. Stridor b. Copious oral secretions c. Hoarseness d. Sore throat

Stridor

A nurse is assessing a client who has a wrist restraint applied. For which of the following should the nurse loosen the restraints? a. The client has a capillary refill of less than 2 seconds b. The client has full range of motion in her wrist c. The client is attempting to remove the restraints d. The clients radial pulse is weak

The clients radial pulse is weak

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client total body surface area (TBSA)? a. 9% b. 18% c. 36% d. 54%

54%

A nurse is preparing to administer moxifloxacin 400 mg by intermittent IV bolus over 60 min. Available is moxifloxacin 400mg in 250 ml dextrose 5% (D5W). The drip factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

63

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? a. Measure blood glucose levels every 4 hours b. Administer a diuretic c. Initiate fluid restrictions d. Check urine specific gravity

Check urine specific gravity

A nurse is assessing a client in shock. Which of the following findings support this conclusion? a. Confusion b. Polyuria c. Hypertension d. Increased CVP

Confusion

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? a. Check the tubing connections for leaks b. Check the suction control outlet on the wall c. Clamp the chest tube d. Continue to monitor the client's respiratory status

Continue to monitor the client's respiratory status

A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (SATA) a. Contractures of the extremities b. Polyuria c. Diarrhea d. Crackles in the lungs e. Pressure Ulcers

Contractures of Extremities Crackles in the lungs Pressure Ulcers

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history? a. Gallstones b. Hypolipidemia c. COPD d. Diabetes mellitus

Gallstones

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (SATA) a. Headache b. Neck pain and stiffness c. Slurred speech d. Pupillary changes e. Disorientation

Headache Slurred Speech Pupillary Changes Disorientation

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? a. Increased heart rate b. Widening pulse pulse pressure c. Increased deep tendon reflexes d. Pulse oximetry 96%

Increased Heart Rate

A nurse in an emergency room is caring for a client who sustained partial-thickness to both lower legs, chest, face, and both forearms. Which of the following is the priority actions the nurse should take? a. Insert an indwelling urinary catheter b. Inspect the mouth for signs of inhalation injury c. Administer IV pain meds d. Draw blood for CBC

Inspect the mouth for signs of inhalation injury

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? a. Administer diuretics b. Restrict the clients intake of fluids c. Reduce the clients intake of protein d. Administer vitamin k

Reduce the clients intake of protein

A nurse is the triage office in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? a. A conscious client adult who reports SOB, has a respiratory rate of 24, a capillary refill of <2 seconds b. An unconscious adult who has a sucking chest wound, respirations of 38, and a capillary refill of < 2 seconds c. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18, and a capillary refill of <2 seconds d. An unconscious adult client who has no respirations, capillary refill > 2 seconds, and paramedics have already tried to reposition airway without results

An unconscious adult who has a sucking chest wound, respirations of 38, and a capillary refill of < 2 seconds

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? a. Change GCS score from 13 to 11 b. Diplopia c. A drop in heart rate from 76 to 70 d. A drop in respiratory rate from 20 to 15

Change GCS score from 13 to 11

A nurse is caring for a client who is 12 hours postoperative and has a chest tube to a disposable water seal drainage system with suction. The nurse should intervene for which of the following observations? a. Constant bubbling in the suction control chamber b. Continuous bubbling in the water seal chamber c. Bloody drainage in the collection chamber d. Fluid level fluctuations in the water seal chamber

Continuous bubbling in the water seal chamber

A nurse in a dialysis center is caring for a client who has a new-diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse "I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again." The nurse should identify that this client is demonstrating which of the following Kubler Ross stages of grieving? a. Bargaining b. Denial c. Depression d. Anger

Denial

A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the station? (The answers where not shown for this one)

Disoriented Patient?

A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following? a. Dilated pupils b. Dysrthythmias c. Diarrhea d. Gastric ulcer

Dysrthythmias

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia. The nurse should indicate the need for taking which of the following actions? a. Defibrillate b. Electrocardioversion c. CPR d. Radiofrequency ... ablation

Electrocardioversion

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include? a. Encourage brief exercise before meals to promote appetite b. Place food on the affected side of the mouth c. Encourage the client to flex down when swallowing d. Place the client with the head reclined back to facilitate swallowing

Encourage the client to flex down when swallowing

A nurse is teaching an older adult client who has diabetes mellitus about preventing long term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? a. Have an eye examination once per year b. Examine your feet carefully every day c. Wear compression stockings daily d. Maintain stable blood glucose levels

Maintain stable blood glucose levels

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? a. Elevating her feet b. Massaging her legs c. Flexing her ankles d. Ambulating soon after surgery

Massaging her legs

A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? a. The nurse separates the clients labia with her dominant hand b. The nurse coats the indwelling catheter with lubricant c. The nurse provides perineal care prior to inserting the urinary catheter d. The nurse applies the sterile drape prior to inserting the urinary catheter

The nurse separates the clients labia with her dominant hand

A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the clients right nostril. Which of the following actions should the nurse take first? a. Visual assessment for the halo sign b. Suction the nostril c. Notify the physician d. Ask the client to blow his nose

Visual assessment for the halo sign

A nurse is caring for a client who has severe head injuries and is declared brain dead. The transplant coordinator has spoken with the client's family about organ donation. The client's spouse states she is confused and does not know what she should do. Which of the following responses by the nurse is appropriate? a. There is such a shortage of organs in this country, so i think you should go ahead and consent to donate your spouse's organs b. What do you think your spouse would have wanted? c. Most religions support organ donations, so don't let that stand in the way d. Don't you think you would feel a little better about the situation if you donate your spouse's organs?

What do you think your spouse would have wanted?

A nurse is teaching an older adult client who is postoperative following insertion of a permanent pacemaker. The nurse should instruct the client to notify the provider about which of the following manifestations? a. Increased ... b. Increased heart rate c. Fatigue d. Sneezing

Fatigue

A nurse is an emergency department is reviewing the medical record of a client who has extensive burn injury. The nurse should expect which of the following laboratory findings in this client? a. . b. . c. . d. .

Blank

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? a. . b. . c. . d. .

Blank

Before administering a medication to a client, the nurse must identify the client. Which of the following methods of identification should the nurse use? a. Ask the client's full name and DOB b. Verify the client's room number c. Check the client's name on the MAR d. Ask a family member to verify the client's identity

Ask the client's full name and DOB

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching? a. Keep the open vial of insulin at room temperature b. Inject the insulin into a large muscle c. Aspirate the medication prior to administration d. Administer the insulin in two separate injections

Aspirate the medication prior to administration or Keep at room temperature

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? a. Turn the screws on the device once a day b. Assess for signs of infection c. Apply talcum powder under the vest to limit friction d. The purpose of the device is to allow for neck movement during the healing process

Assess for signs of infection

A nurse is the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate a. Complete muscular assessment b. Administer an an c. Decrease environmental stimuli d. Assess the cranial nerves

Assess the cranial nerves

A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the clients restored rhythm is symptomatic bradycardia? a. Epinephrine b. Magnesium c. Atropine d. Sodium bicarbonate

Atropine

A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection? a. Temp of 98.9 b. Hypotension c. Azotemia d. weight loss

Azotemia

A nurse in an emergency department is caring for a client who has deep partial and full thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation phase of injury? a. . b. . c. . d. .

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A nurse is planning care for a client who has cirrhosis and ascites. Which of the following interventions should the nurse include in the plan of care? a. Decrease the client's fluid intake b. Increase the clients saturated fat intake c. Increase the clients sodium intake d. Decrease the clients carbohydrate intake

Decrease the client's fluid intake

A nurse is at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client rehabilitation program? a. Establish the ability to communicate effectively b. Compensate for loss of depth perception c. Learn to control impulsive behavior d. Improve left side motor function

Establish the ability to communicate effectively

Which statement by a patient who had a cystoscopy the previous day should be reported immediately to the health care provider? a. "My urine looks pink" b. "My IV site is bruised" c. My sleep is restless" d. My temperature is 101"

My temperature is 101

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip? a. Pacemaker spikes after QRS complex b. Pacemaker spikes before each P... c. Pacemaker spikes before each QRS complex d. Pacemaker spikes .... Each T wave.

Pacemaker spikes before each QRS complex

A client who is having burn debridement states "You are the worst nurse I have ever seen. All you do is hurt me." which of the following responses should the nurse make?

Pick the most therapeutic response

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment? a. Body mass index of 30 b. Pacemaker c. ... d. ....

Maybe infection?

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus? a. HbA1c 5.5% b. 2 hour blood glucose 170 c. Fasting blood glucose 155 d. Casual blood glucose 180

Fasting blood glucose 155

A nurse is teaching self management to a client who has hepatitis B. Which of the following instructions should the nurse include in the teaching? a. You may donate blood 6 months after completing the medication regimen b. Consume a high protein diet c. Rest frequently throughout the day d. Take acetaminophen every 4 hours as needed for pain

Rest frequently throughout the day

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8. Which of the following medications should the nurse plan to administer? a. Lactulose b. Magnesium c. Sodium polystyrene d. Chloride

Sodium Polystyrene

A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the nurse ask the AP to perform first? a. Take an ABG specimen to the lab b. Transport a client to the radiology department for an x-ray c. Pass fresh water to clients on the unit d. Obtain a routine urine sample from a newly admitted client

Take an ABG specimen to the lab

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? a. Assign assistive personnel to keep his room neat and clean b. Rotate nursing staff so he can have varied interactions c. Talk with the client during wound care d. Keep family members aware of his condition

Talk with the client during wound care

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (move the stages of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.) Inject air into NPH solution vial Withdraw short-acting insulin into syringe Roll NPH vial between palms of hands Inspect vials for contaminants Inject air into regular insulin vial Add intermediate insulin to syringe

Inspect Roll Inject NPH Inject Regular Withdraw Add

A nurse is providing discharge teaching for a client who has chronic pancreatitis. Which of the following statements should the nurse make? a. . b. . c. . d. .

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