Adult 2 Final Exam questions

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.) A. Antibody-antigen binding B. Invasion C. Opsonization D. Recognition E. Sensitization F. Production

ABDEF

The nurse caring for clients assesses their daily laboratory profiles. Which lab results are considered to be in the normal range? (Select all that apply.) a. Segmented neutrophils: 68% B. Bands: 19% C. Monocytes: 12% d. Lymphocytes: 38% E. Eosinophils: 2% F. Basophils: 1%

ADEF

client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) a. First-degree relative with prostate cancer B. Smoking C. Obesity d. Advanced age E. bating too much red meat F. Race

ADEF

After teaching a client who is recovering from a colon resection to treat early-stage colorectal cancer (CRC), the nurse assesses the client's understanding. Which statements by the client indicate understanding of the teaching? (Select all that apply.) A. I must change the ostomy appliance daily and as needed." B. I will use warm watcr and a soil washcloth to clean around the stoma." C. I might start bieyeling and swimming again once my incision has healed." d. "I will make sure that I make lifestyle changes to prevent constipation." E. I will be sure to have the recommended colonoscopies."

CDE

nurse has delegated feeding a client to assistive personnel (AP). What action(s) does the nurse include in the directions lo the AP? (Select all that apply) A. Allow 30 minutes for eating so food doesn't get spoiled. B. Assess the patient's mouth while providing premeal oral care. C. Ensure that warm and cold items stay at appropriate temperatures. D. Remove bedpans, soiled linens, and other unpleasant items. E. Sit with the client, making the atmosphere more relaxed.

CDE

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action would the nurse take? a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide intravenously. C. Encourage the client to take deep breaths. d. Teach the client fall prevention measures.

D

A client with multiple sexual partners has been assessed for symptoms of dvsuria and green. malodorous vaginal discharge. The nurse administers and injection of celtriaxone and gives the client a prescription for doxycycline. The client asks why two drugs are needed. What answer by the nurse is best? A. It is very common to be infected with both gonorrhea and chlamydia." B. Giving two medications increases the chance of curing the infection." C. Some people are not affected by the infection and need more medication." D. This will prevent vou from needing a 3-month follow-up test."

A

The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy with a vaginal repair. Which statements by the client indicate a need for further teaching'? (Select all that apply.) A. I should not have any problems driving to see my mother, who lives 3 hours away." B. Now that I have time off from work, I can return to my exercise routine next week." C. My granddaughter weighs 23 lb (10.5 kg) so I need to refrain from picking her d. "I will have to limit the number of times that I climb our stairs at home to fewer than five times a day." E. I need to refrain from sexual intercourse for 4 -6 wecks." F. When I do resume intercourse, I will use a water-based lubricant and go slowly."

AB

A nurse provides diabetic education at a public health fair. Which disorders would the nurse include as complications of diabeles mollitus? (Select all that apply.) A. Stroke B. Kidney failure C. Blindness d. Respiratory failure E. Cirrhosis

ABC

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other'? (Select all that apply.) a. Antibody-mediated immunity B. Cell-mediated immunity C. Inflammation d. Red blood cells e. White blood cells

ABC

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) A. Smoking B. Multiple births c. Poor diet d. Nulliparity E. Younger than 18 at first intercourse F. Infections with HPV

ABF

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) a. Pancreatitis B. Polyarthritis C. Heart disease d. Myalgia E. Peptic ulcer disease f. Ulcerative colitis

BCD

The nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.) A. colonization b. Host C. Mode of transmission d. Portal of entry E. Reservoir f. Poor hygiene

BCDE

A client is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? A. Administer a dose of allopurinol. B. Assess the client's serum potassium level. C. Gentlv inquire about advance directives d. Prepare the client for emergency surgery.

C

A client is having an esophagogastroduodenoscopy (EGD) and has been given midazolam hydrochloride. The client's respiratory rate is 8 breaths/min, What action by the nurse is appropriate? A. Administer naloxone. b. Call the Rapid Response Team. C. Provide physical stimulation. d. Ventilate with a bag-valve-mask.

C

nurse is observing as an assistive personnel pertorms hygiene and provides comfort measures to a client with an infection. What action by the AP requires intervention by the nurse? A. Not using gloves while combing the client's hair B. Rinsing the client's commode pan after use C. Ordering an oscillating fan for the client d. Wearing gloves when providing perianal care

C

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? A. Administer sleeping medication B. Perform most activities for the client. C. Increase the client's oxygen during activity. d. Pace activities, allowing for adequate rest

D

A client with HIV-III is admitted to the hospital with Toxoplasma Gondii infection. Which action by the nurse is most appropriate? A. Initiate Contact Precautions B. Conduct frequent neurologic assessments. C. Conduct frequent respiratory assessments. d. Initiate Protective Precautions

D

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 19-year-old Caucasian B. A 22-year-old African American C. 44-Year-old Asian American d. A 58-year-old American Indian

D

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? A. Administration of oxygen via facemask B. Intravenous administration of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin

D

A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take? A. Obtain a urine culture and sensitivity. B. Place the client on restricted fluids. C. Assess the client's creatinine level. D. Increase the client's fluid intake.

D

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client's arterial blood gas valucs are pH 6.88, PaO. 50 mm Hg. PaCO: 60 mm Hg, and HCOs 22 mEq/L (22 mmol/L). What action would the nurse take first? A. Apply oxygen by mask or nasal cannula. B. Apply a paper bag over the client's nose and mouth. C. Administer 30 ml. ot sodium bicarbonate intravenously. D. Administer 50 mL of 20% glucose and 20 units ol' regular insulin.

A

client has pelvic inflammatory disease (PID. What complications does the nurse monitor the client for? (Select all that apply.) A. Chronic pelvic pain b. Infertility C. Ectopic pregnancy d. Tubo-ovarian abscess E. Peri-hepatitis F. Pancreatitis

ABCDE

The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.) a. Alcohol B. Caffeine C. Corticosteroids D. Fruit juice e. Nonsteroidal anti-inflammatory drugs (NSAIDs)

ABCE

A chent is being admitted with suspected tuberculosis ( B). What actions by the nurse are best? (Select all that apply.) A. Admit the client to a negative-airflow room. B. Maintain a distance of 3 feet (1 m) from the client at all times. C. Obtain specialized respirators for caregiving D. Other than wearing gloves, no special actions are needed. E. Wash hands with chlorhexidine after providing care. f. Assure client has a respirator for moving between departments.

AC

woman is interested in alternative and complementary treatments for the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which therapies wound the nurse suggest? (Select all that apply.) a. Acupuncture B. Chiropractic C. Journaling d. Aromatherapy E. Shiatsu f. Black cohosh

ANS: A, D, E Alternative and complementary measures are chosen by many women. For nausea and vomiting, the best choices would be acupuncture, aromatherapy, and shiatsu. Chiropractic treatments would help pain. Journaling would be beneficial for fear and anxiety. Black cohosh is frequently used for hot flashes.

A client has a positive HSV-2 test but is asymptomatic. What action by the nurse is best? A. Encourage the client to have frequent SIl screening B. Teach the client ways to prevent getting STIs. C. Provide the same education as it the client were symptomatic. d. Intonn the client that partner notification is wecessary.

B

A client has a recurrence of gastric cancer and is crying. What response by the nurse is most appropriate? A. Do you have family or friends for support?" B. Would you tell me what vou are feeling now. C. Well, we knew this would probably happen." D. Would vou like me to refer vou to hospice?"

B

client has a leg wound that is in Stage II of the inflammatory response. For what sign or symptom does the nurse assess? a. Noticeable rubor B. Purulent drainage C. Swelling and pain d. Warmth at the site

B

A client has urinary incontinence. Which assessment finding indicates the outcomes for a priority nursing diagnosis have been met? A. client reports satisfaction with undergarments for incontinence B. client reports drinking 8-9 glasses of water each day C. skin in perineal area is intact without redness on inspection D. family states that client is more active and socializes more

C

A client is admitted with a diagnosis of possible strangulated inguinal hernia. For which complication would the nurse monitor? a. Paralytic ileus B. Bowel volvulus C. Sepsis d. COlitis

C

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action would the nurse take? A. Ask if the client is experiencing pain in the right shoulder. B. Perform a rectal examination and assess for polyps. C. Recommend that the client have computed tomography. d. Administer a laxative to increase bowel movement activity.

C

nurse assesses clients on a medical surgical unit. Which client is at greatest risk for pressure injury development? a. A 44 year old prescribed IV antibiotics for pneumonia B. A 26 year old who is bedridden with a fractured leg C. A 65 year old with hemiparesis and incontinence d. A 78 year old requiring assistance to ambulate with a walker

C

30-year-old male client is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate? A. Gardasil protects against all HPV strains. B. You are too old to receive the vaccine. C. Only lemales can receive the waecing " d. "You will only need I dose ol'the vaccine "

D

A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? A. Amt pressure in fluid container B. Date of catheter tubing change C. Type of dressing over the site D. Skin color and capillary refill

D

The nurse assesses a client with gastroenteritis. What risk factor would the nurse consider as the most likely cause of this disorder? A. Consuming too much fruit B. Consuming fried or pickled foods C. Consuming dairy products d. Consuming raw seatood

D

While evaluating a client for treatment of gonorrhea, which question is the most important for the nurse to ask A. Do you have a history of sexually transmitted infection?* B. "When was your last sexual encounter?" C. When did vour symptoms begin?" d. "Can you remember your partners and contact them to get treated?"

D

Which statements are true regarding Standard Precautions'? (Select all that apply.) A. Always wear a gown when performing hygiene on clients. b. Sneeze into your sleeve or into a tissue that you throw away. C. Remain 3 feet (1 m) away from any client who has an infection. D. Use personal protective equipment as needed for client care. E. Wear gloves when touching clients' excretions or secretions F. Cohorting clients who have infections caused by the same organism.

DE

nurse assesses an older adult's skin. Which findings require immediate referral? (Select all A. Excessive moisture under axilla b. Increased hair thinning C. Presence of toenail fungus d. Lesion with various colors E. Spider veins on legs F. Asymmetric 6-mm dark lesion on forehead

DF

A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? A. Do any of your family members have this problem?" B. Do vou drink any cranberry juce?" C. Do you urinate after sexual intercourse?" D. Do vou experience burning with urination!"

A

A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is best? a. Encourage the client to complete S TI screening. B. Recommend at over-the-counter wart treatment for genital warts C. Report the case to the centers for Infection Control and Prevention (CDC). d. Discuss popular options for contraception.

A

A client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered? A. Alpha-fetoprotein (AFP) B. Prostate-specific antigen (PSA) C. Serum acid phosphatase (PAP) D. C-reactive protein (CRP)

A

A client in the emergency department reports difficulty breathing. The nurse assesses the client's appearance as depicted below: (dark blue visible veins on chest) What action by the nurse is most important? A. Assess blood pressure and pulse. B. Attach the client to a pulse oximeter. C. Have the client rate his or her pain. D. Facilitate urgent radiation therapy.

A

A client is to receive a fecal microbiota transplantation tomorrow (FMT. What action by the nurse is best? A. Administer bowel cleansing as prescribed. B. Educate the client on immunosuppressive drugs. c. Inform the client he/she will drink a thick liquid. d. Place a nasogastric tube to intermittent suction.

A

nurse prepares a client for a percutaneous kidney biopsy. What actions should the nurse take prior to this procedure? (Select all that apply.) A. Keep the client NPO for 4 to 6 hours. B. Review coagulation study results. C. Maintain strict bedrest in a supine position. D. Assess for blood in the cent's unne. E. Administer client's antihypertensive medications.

ABE

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? SATA A. increased pulse rate B. distended neck veins C. decreased BP D. warmth and pink skin E. skeletal muscle weakness F. visual disturbances

ABEF

nurse is preparing a client for a percutaneous kidney biopsy. Which laboratory tests results would the nurse review prior to the procedure? (Select all that apply.) A. Hemoglobin B. Hematocrit C. Sodium D. Potassium E. Platelet count F. Prothrombin time

ABEF

A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? a. Initiate a dedicated team to insert access devices. B. Require additional education for all nurses. C. Limit the use of peripheral venous access devices. D. Perform quality control testing on skin preparation products.

A

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.) A. Peau d'orange B. Dense breast fissue C. Nipple retraction d. Mobile mass at 2 o'clock E. Nontender axillary nodes f. Skin ulceration

ACDF

The nurse plans care for a patient who has hepatopulmonary syndrome. Which interventions would the nurse include in this client's plan of care? (Select all that appl.) A. Oxygen therapy B. Prone position C. Feet elevated on pillows D. Daily weights E. Physical therapy F. Respiratory therapy

ACDF

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values were pH 7.32, Pa02 85 mm lg, PaCO2 34, and HCO3 16 mtg/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next? A. Assess client's rate, rhythm, and depth of respiration. B. Measure the client's pulse and blood pressure. C. Document the findings and continue to monitor. D. Notify the primary health care provider.

A

A nurse assesses a client who is experiencing an acid base imbalance. The client's arterial blood gas values are pH 7.2, Pa02 88, PaCO2: 38, and HCO3: 19 (19 mol/L). Which assessment would the nurse perform first? a. Cardiac rate and rhythm B. Skin and mucous membranes C. Musculoskeletal strength D. Level of orientation

A

A nurse assesses a client who is prescribed alosetron. Which assessment question would the nurse ask this client before starting the drug? A. Have you been experiencing any constipation?" B. Are you eating a diet high in fiber and fluids?" C. Do you have a history of high blood pressure?" D. What vitamins and supplements are you taking'"

A

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? a. Drainage from a fistula B. Diminished bowel sounds C. Pain at the incision site d. Nasogastric (NG) tube drainage

A

A nurse assesses a client with diabetes mellitus who is admitted with an acid- base imbalance. The client's arterial blood gas values are pH 7.36, Pa02 98 mm Hg, PaCO2 33 mm Hg, and lICO; 18 mlq/L. (18 mmol/L.). Which sign or symptom does the nurse identify as an example of the client's compensatory mechanisms? A. Increased rate and depth of respirations B. Increased urinary outnut C. Increased thirst and hunger D. Increased release of acids from the kidneys

A

A nurse assesses an older adult client with the skin disorder shown below: (small pinpoint red dots) How will the nurse document this finding? A. Petechiae B. Ecchymoses c. Actinic lentigo d. Senile angiomas

A

A nurse assesses an older client who is scratching and rubbing white ridges on the skin between the tingers and on the wrists. Which action would the nurse take? A. Request a prescription for permethrin B. Administer an antihistamine. C. Assess the client's airway. D. Apply gloves to minimize friction.

A

A nurse cares for a client with end-stage pancreatic cancer. The client asks. "Why is this happening to me?" How would the nurse respond? A. I don't know. I wish I had an answer for you, but I don't." B. It's important to keep a positive attitude for your family right now." C. Scientists have not determined why cancer develops in certain people." D. I think that this is a trial so you can become a better person because of it.

A

A nurse cares for a patient who is prescribed pioglitazone. Atter o months ot therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take? A. Have you gained unexpected weight this week?" "B. Has your urinary output declined recently?" C. Have you had fever and achiness this week?" D. Have you had abdominal pain recently?"

A

A nurse contacts the primary health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL. (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? A. Intravenous fluids B. Hemodialysis C. Fluid restriction d. Urine culture and sensitivity

A

A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, Pa02 86 mm Hg, PaCO: 55 mm Hg, and HCO: 22 mBq/L (22 mmol/I). Which intervention does the nurse implement first? A. Assess the airway. B. Administer prescribed bronchodilators. c. Provide oxygen d. Administer prescribed mucolvtics

A

A nurse has taken an informed consent to a woman who is having a transvaginal repair of a prolapsed uterus. What client statement indicates a need for more information? A. The mesh they use may become infected." B. I may still need to do my kegul exercises.* C. I will watch for any sions of infection." D. I know how to use the incentive spirometer."

A

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? A. 34 y/o NPO and receiving rapid IV D5W infusions B. 50 y/o with infection prescribed sulfonamide antibiotic C. 67y/o who is experiencing pain and is prescribed ibuprofen D. 73y/o with tachycardia who is receiving digoxin

A

A nurse is assessing clients with pressure injuries. Which wound description is correctly matched to its description? a. Suspected deep tissue injury: nonblanchable deep purple or maroon. B. Stage 2: may have visible adipose tissue and slough C. Stage 3: may have a pink or red wound bed. D. Stage 4: wound bed is obscured with eschar or slough

A

A nurse is caring for a client admitted for Non-Hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nurse is most important? A. Request an order for serum electrolytes and uric acid. B. Increase the client's IV infusion rate. C. instruct assistive personnel to strain all urine D. Administer an IV antiemetic.

A

A nurse is caring for a client who has methicillin-resistant staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate? A. Prepare to administer vancomycin B. Strictly limit visitors to immediate family only. C. Wash hands only after taking off gloves after care d. Wear a respirator when handling urine output.

A

A nurse is caring for a client who has the following labs: potassium 2.4, magnesium 1.8, calcium 8.5, and sodium 144. Which assessment does the nurse complete first? A. depth of resp B. bowel sounds C. grip strength D. electrocardiography

A

A nurse learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ? a. Bone marrow b. Spleen C. Thymus d. Tonsils

A

A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement will the nurse include in this client's teaching? A. "Avoid carrying your grandchild with the arm that has the central catheter." B. "Be sure to place the arm with the central catheler in a sling during the day." c. "flush the peripherally inserted central catheter line with normal saline daily." d. "You can use the arm with the central catheter for most activities of daily living."

A

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of carc to delay the onset of microvascular and a. Maintain tight glycemic control and prevent hyperglycemia." B. Restrict your fluid intake to no more than 2 L a day." C. "Prevent hypoglycemia by cating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis "

A

A nurse teaches a young female client who is prescribed cephalexin for a urinary tract infection. Which statement would the nurse include in this client's teaching? A. Use a second form of birth control while on this medication." B. You will experience increased menstrual bleeding while on this drug." C. You may experience an irregular heartbeat while on this drug." D. Watch for blood in your urine while taking this medication."

A

A primary health care provider notifies the nurse that a client has a "bandemia." What action does the nurse anticipate? A. Administer antibiotics B. Place the client in isolation. C. Administer IV leukocytes. d. Obtain an immunization historv.

A

ANer leaching a client with diabeles mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for turther teaching' A. The lower abdomen is the best location because it is closest to the pancrcas. B. I can reach my thigh the best, so I will use the different arcas of my thighs." C. By rotating the sites in one area, my chance of having a reaction is decreased." D. Changing injoction sites from the thigh to the arm will change absorption rates."

A

Afer leaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the A. I should drink at least 3 1. of tlaid every day." B. I will eliminate all dairy or sources of calcium from my diet." C. Aspirin and aspirin-containing products can lead to stones." D. The doctor can give me antibiotes at the first sign of a stone.*

A

An older adult has had an instance of drug toxicity and asks why this happens, since the client has been on this medication for years at the same dose. What response by the nurse is best? a. "Changes in your liver cause drugs to be metabolized differently." B. Perhaps you don't need as high a dose of the drug as before." C. Stomach muscles atrophy with age and you digest more slowly." D. Your body probably can't tolerate as much medication anymore."

A

The nurse assesses a client who is recovering from a paracentesis I hour ago. Which assessment finding would require immediate action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg C. Respiratory rate decreases from 22 to 16 breaths/min D. A decrease in the client's weight by 3 lb (1.4 kg)

A

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? A. Increased rate and depth of respiration B. Extremity tremors followed by seizure activity C. Oral temperature of 102° F (38.9° C) Stestbanks.com d. Severe orthostatic hypotension

A

The nurse caring for oncology clients knows that which form of metastasis is the most common? A. Bloodborne b. Direct invasion C. Lymphatic spread d. Via bone marrow

A

The nurse delegates completing a bladder scan to assistive personnel (AP). Which action by the AP indicates that the nurse must provide additional instructions when delegating this task? A. Selecting the female icon for all female patients and male icon for all male patients B. Telling the client, "This test measures the amount of urine in your bladder." C. Applying ultrasound gel to the scanning head and removing it when finished D. Taking at least two readings using the aiming icon to place the scanning head

A

The nurse has educaled a client on precautions lo lake with thrombocytopenia. Wha statement by the client indicates a need to review the information? A. "I will be careful if I need enemas for constipation." B. "I will use an electric shaver instead of a razor." C. "I should only eat soft food that is either cool or warm." D. "I won't be able to play sports with my grandkids.*

A

The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399 mm' (0.399 × 10'/IL). What action by the nurse is best? A. Counsel the client on safer sex practices/abstinence. B. Encourage the client to abstain from alcohol. C. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. d. Help the client plan high-protein/iron meals.

A

The nurse is caring for a client who has frequent gastric pain and dyspepsia. Which procedure would the nurse expect for the client to make an accurate diagnosis? A. Esophagogastroduodenoscopy (EGD) B. Abdominal arteriogram C. Nuclear medicine scan D. Magnetic resonance imaging (MRI)

A

The nurse is caring for a client who is prescribed lactulose. The client states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond? A. Diarrhea is expected; that's how your body gets rid of ammonia. B. You may take antidiarrheal medication to prevent loose stools "* C. Do nol take any more of the medication until your stools fin up." D. We will need to send a stool specimey to the laboratory as soon as possible"

A

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse? A. Hematiria b. Urinary hesitancy c. Postvoid dribbling d. Weak urinary stream

A

The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement ow the client indicates a lack of understanding a. "I need to change my tampon every 8 hours during the day." B. At night, I should use a feminine pad rather than a tampon." C. If I don't use tampons, I should not get TSS." D. It is best it I wash my hands before inserting the tampon."

A

The nurse is managing care for a client receiving feeding through a gastrostomy tube (G-tube). What assessment would the nurse perform? A. Check the skin around the tube insertion site. B. Weigh the client every shift with the same scale. C. Draw blood to assess albumin every shift D. Irrigate the tube at least once a day.

A

The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching? a. "Be sure to take the drug with cach meal." B. Take the drug every evening before bedtime." C. Take the drug on an empty stomach in the moming." D. Decide on the best day of the week to take the drug."

A

The nurse is teaching a 45-year-old woman about her fibrocystic breast changes. Which statement by the chent indicates a lack of understanding. A. This condition will become malignant over time." B. I understand that hormone-based drugs have serious adverse effects." C. One cup of collec in the morning should be enough for me." D. This condition makes it more difficult to examine my breasts."

A

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? a. History ot hepatitis B B. History of kidney disease C. History of cardiac disease d. History of rectal bleeding

A

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates the client needs further information? A. There should be no problem with drinking wine with dinner each night." B. Tam so glad that I weaned myself oft of coffee about a year ago." C. I need to inform my allergist that I cannot take my normal antihistamine." d. "My routine of drinking a quart (liter) of water first thing in the morning needs to change."

A

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates the client needs more information? A. I have lo wash the outside of the catheler once a day with soap and water. B. I should take extra time to clean the catheter site by pushing the foreskin back." C. The drainage bag needs to be changed at least once a weck and as needed." D. I should pour a solution of vinegar and water through the tubing and bag.

A

The nurse notes that the primary health care provider documented the presence of mucosal erythroplasia in a client. What does the nurse understand that this most likely means for this client? A. Early sign of oral cancer b. Fungal mouth infection C. Inflammation of the gums d. Obvious oral tumor

A

To promote comfort and the passage of flatus after a colonoscopy, in what position does the nurse place the client? A. Left lateral b. Prone C.Right lateral a. Supine

A

What does the nurse learn about the function of colony-stimulating factor? a. Triggers the bone marrow to shorten the time needed to produce mature WBCs B. Causes capillary leak in acute inflammation. C. Responsible for creating exudate (pus) at infectious sites. d. Dilates blood vessels at the site of inflammation leading to hypereremia.

A

a nurse is assessing a client with hyperkalemia and notes handgrip strength has diminished since previous assessment 1 hr ago. What action does the nurse take first? A. assess resp rate, rhythm, and depth B. measure pulse and BP C. document findings and monitor client D. call HCP

A

client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide, and fluorouracil for breast cancer. Which side effect seen in the client would the nurse report to the primary health care provider immediately? A. Shortness of breath B. Nausea and vomiting c. Hair loss d. Mucositis

A

client is receiving rituximab. What assessment by the nurse takes priority? a. Blood pressure B. Temperature C. Oral mucous membranes D. Pain

A

client is receiving total parenteral nutrition (IFN). On assessment, the nurse notes that the client's pulse is 128 beats/min, blood pressure is 98/56 mm Hg, skin is dry, and skin turgor is poor. What action should the nurse perform next? a. Assess the 24-hour intake and output. B. Assess the client's oral cavity. C. Prepare to hang a normal saline bolus. d. Increase the infusion rate of the TPN.

A

nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states. "The stool in my pouch is still liguid." How would the nurse respond? A. The stool will always be liquid with this type of colostomy." B. Eating additional liber will bulk up your stool and decrease diarrhea." C. Your stool will become firmer over the neyt counle of weeks " D. This is abnormal. I will contact your primary health carc provider."

A

nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question would the nurse ask when determining this client's risk factors? A. Do you smoke cigarettes?" B. Do you use any alcohol?" C. Do you use recreational drugs?" D. Do you take any prescription drugs?"

A

nurse receives hand-oft report on tour postoperative clients who each had total hysterectomies. Which client would the nurse assess first upon initial rounding? A. Vaginal hysterectomy: two saturated perineal pads in 2 hours. B. Abdominal: temperature ol 99° F (37.2° C). blood pressure of 116/74 min Hg. C. Vaginal: opened incisional edges and moderate bleeding d. Abdominal: urinary catheter output of 150 mL in the last 3 hours

A

nurse reviews the electronic health record of a client who has Crohn disease and a draining fistula. Which documentation would alert the nurse to urgently contact the primary health care provider for additional prescriptions? a. Serum potassium of 2.6 m Eq/L (2.6 mmol/L) b. Client ate 20% of breakfast meal C. White blood cell count of 8200/mm° (8.2 × 10'/L) d. Client's weight decreased by 3 lb (1.4 kg)

A

woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L (2.2 mckat/L) Total calcium 12 mg/dL (3 mmol/L) 39% (0.39) Hemoglobin 14 g/dL. (140 mmol/L) Which test results indicate to the nurse that some further diagnostics are needed? A. Elevated alkaline phosphatase and calcium suggests bone involvement. B. Only alkaline phosphatase is decreased, suggesting liver metastasis. C. Hematocrit and hemoglobin are decreased, indicating anemia. D. The elevated hematocrit and hemoglobin indicate dehydration.

A

A nurse teaches a client about self-management after experiencing a urinarv calculus treated by lithotripsy. Which statements would the nurse include in this client's discharge (aching? (Select all that apply.) A. Finish the prescribed antibiotic even il you are feeling better." B. Drink at least 3 L of fluid each day." C. The bruising on your back may like several weeks to resolve." D. Report anv blood present in vour urine." E. It is normal to experience pain and difficully urinating."

ABC

A client has impaired tissue integrity and a nonhealing wound. The nurse has taught the client about diet changes to improve wound healing. What diet selections does the nurse evaluate as good understanding by the client? SATA A. chicken breast B. orange juice C. boost supplement D. spinach salad E. cantaloupe F. whole wheat bread

ABCD

When working with older adults to promote good nutrition, what action(s) by the nurse is(are) most appropriate? (Select all that apply.) A. Allow uninterrupted time for eating. B. Assess dentures (if worn) for appropriate fit. C. Ensure that the client has glasses on or contacts in when eating. D. Provide salty or highly spicy foods that the client can taste. E. serve high-calore, high-protein snacks one to two times a day.

ABCE

Which of the following is (are) (a) risk factors) for gastric cancer? (Select all that apply.) A. Achlorhydria B. Chronic atrophic gastritis C. H. pylori infection D. Iron deficiency anemia E. anemia

ABCE

The nurse learning about cancer development remembers characteristics of normal cells. Which characteristics does this include? (Select all that apply.) A. Differentiated function B. Large nucleus-to-cytoplasm ratio C. Loose adherence D. Nonmigratory E. Specific morphology f. Orderly and specific growth

A, D, E, F

A nurse assesses a client who is experiencing an acid-base imbalance. The client's arterial blood gas values are pH 7.32, Pa0): 94 mm lig, PaC'02 34 mm Ilg, and HCO: 18 mlo/I. (18 mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that apply.) A. Reduced deep tendon reflexes B. Drowsiness C. Increased respiratory rate D. Decreased urinary output E. Positive Trousseau sign f. Flaccid paralysis

ABC

client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history laking! (select all that apply.) A. Recent prostatectomy B. Long-term hypertension C. Diabetes mellitus D. Hour-long exercise sessions E. Consumption o beer each night f. Taking long hot baths

ABCE

A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) a. CD4+ cells begin to create new HIV virus particles. b. Antibodies produced are incomplete and do not function well. C. Macrophages stop functioning properly. D. Opportunistic infections and cancer are leading causes of death. E. People with HIV-I disease are not infectious to others. f. The CD4- I-cell is only allected when the discase has progressed to HIV-III

ABCD

A primary care clinic sees some clients with sexually transmitted infections. Which diseases would the nurse be required to report to the local authority? (Select all that apply.) A. Chlamydia B. Gonorrhea C. Syphilis D. Human immune deficiency virus E. Pelvic inflammatory disease f. Human papilloma virus

ABCD

The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.) a. Administer glucagon I mg subcutancously. B. Be sure the bed side rails are in the up position. C. Notify the primary health care provider immediately. D. Monitor the client's blood glucose level. E. increase the intravenous innision rale immedialeiv.

ABCD

The nurse is teaching a client about the risk of uncontrolled or untreated the client's gastrocsophageal reflux disease (GERD). What complication(s) may occur if the GERD is not successfully managed? (Select all that apply:) A. Asthma b. Laryngitis c.Dental caries d. Cardiac disease E. Cancer

ABCDE

nurse begins a job at a Veterans Administration Hospital and asks why so much emphasis is on HIV testing for the veterans. What reasons is this nurse given? (Select all that apply.) A. Veterans have a high prevalence of substance abuse. B. Many veterans may engage in high risk behaviors C. Many older veterans may not know their risks. d. Evervone should know their HIV status E. Belief that the VA has tested them and would notify them if positive.

ABCDE

The nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.) A. Clotting abnormalities from thrombocythemia B. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia D. Potential for reduced gas exchange E. Various motor and sensory deticits increased risk of hone tractres

ABCDEF

The nurse is assessing a client who has undernutrition. What signs and symptoms) would the nurse expect? (Select all that apply.) a. Alopecia B. Stomatitis c. Muscle wasting d. Peripheral edema E. Anemia f. Dry, scaly skin

ABCDEF

The nurse is assessing a client with hepatitis C. The client asks the nurse how it was possible to have this disease. What questions might the nurse ask to help the client determine how the disease was contracted? (Select all that apply) A. How old are you?" B. Do you work in health care? C. Are you receiving hemodialysis?" D. Do you use IV drugs?" E. Did you receive blood before 1992? F. Have you even been in prison or jail?

ABCDEF

The nurse is caring for a client diagnosed with probable gastrosophageal reflux disease (GeRD). What assessment finding(s) would the nurse expect? (Select all that appl.) a. Dyspepsia B. Regurgitation c. Belching d. Coughing E. Chest discomfort f. Dysphagia

ABCDEF

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) a. Jaundice b. Clay-colored stools c. Icterus d. Ascites e. Petechiae f. Dark urine

ABCDEF

The nurse is caring for a client who just had a minimally invasive inguinal hernia repair. Which nursing actions would the nurse implement? (Select all that apply.) A. Apply ice to the surgical area for the first 24 hours after surgery. B. Encourage ambulation with assistance within the first few hours after surgery. C. Encourage deep breathing after surgery but teach the client to avoid coughing. D. Assess vital signs frequently for the first few hours after surgery. E. Teach the client to rest for several days after surgery when at home. f. Teach the client not to lift more than 10 1b (4.5 kg) until allowed by the surgcon.

ABCDEF

nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase C. Elevated glucose d. Decreased calcium E. Elevated bilirubin f. Elevated leukocyte count

ABCDEF

A nurse cares for an older adult who is admitted to the hospital with complications of diverticulitis. Which actions would the nurse include in the client's plan of care? (Select all that apply.) a. Administer pain medications as prescribed. B. Palpate the abdomen for distention. C. Assess for sudden changes in mental status. d. Provide the client with a high-fiber diet. e. Evaluate stools for occult blood.

ABCE

A nurse prepares to discharge a client who is newly diagnosed with a chronie inflammatory bowel disease. Which questions would the nurse ask in preparation for discharge? (Select all that apply.) Does your gym provide yoga classes? When should you contact your provider? What do you plan to eat for dinner? Do you have a scalc for daily weights? e. How many bathrooms are in your home?

ABCE

The nurse assists the wound care/ostomy nurse assess a client prior to ostomy surgery. Which assessments would the nurse complete before marking the placement for the ostomy? (Select all that apply.) A. Contour of the abdomen when standing B. Location of the client's belt line C. contour of the abdomen when ving D. Location of abdominal muscles E. Contour of the abdomen when sitting

ABCE

The nurse is preparing a client who has chronic pancreatitis about how to prevent exacerbations of the disease. Which health teaching will the nurse include? (Select all that A. Avoid alcohol ingestion." B. Be sure and balance rest with activity.' C. Avoid cafteinated beverages." D. Avoid green, leafy vegelables." E. Eat small meals and high-calorie snacks."

ABCE

The nurse working with older clients understands age-related changes in the gastrointestinal system. Which changes does this include? (Select all that apply.) A. Decreased hydrochloric acid production B. Diminished sensation that can lead to constipation C. Fat not digested as well in older adults d. Increased peristalsis in the large intestine E. Pancreatic vessels become calcitied

ABCE

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) A. Hypokalemia-muscle weakness with respiratory depression b. Hypermagnesemia bradycardia and hypolension C. Hyponatremia-decreased level of consciousness D. Hypercalcemia-positive Trousseau and Chvostek Signs E. Hypomagnesemia-hyperactive deep tendon reflexes F. Hypernatremia weak pompheral pulses

ABCEF

nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) A sore that does not heal b. Changes in menstrual patterns C. Indigestion or trouble swallowing d. Near-daily abdominal pain E. Obvious change in a mole f. Frequent indigestion

ABCEF

A nurse is caring for clients on an in client surgical unit. Which clients does the nurse identify as having a risk for impaired immunity? SATA A. 86 y/o B. has type 2 DM C. taking prednisone D. has many allergies E. drinks a beer a day F. low socioeconomic status

ABCF

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) A. "Chemo" gloves b. Face mask C. Impervious gown d. N95 resnirator E. Shoe covers F. Eye protection

ABCF

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply) a. Dysuria B. Frequency c. Burning d. Fever E. Chills f. Hematuria

ABCF

A client has thrombocytopenia. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) A. Apply the client's shoes before getting the client out of bed. b. Assist the client with ambulation. C. Shave the client with a safety razor only. D. Use a lift sheet to move the client up in bed. E. Use a water pressure device be set on low for oral care.

ABD

A nurse revicws a clients laboratory results. which results from the clients urinalysis would the nurse identify as normal? (Select all that apply.) A. pH: 6 B. Specific gravity: 1.015 C. Protein: 1.2 mg/dL D. Glucose: negative E. Nitrate: small F. Leukocyte esterase: positive

ABD

Atter teaching a patient who has a permanent ilcostomy, a nurse assesses the client's understanding. Which dietary items chosen for dinner indicate that the client needs further teaching? (Select all that apply.) A. Corn B. String beans C. Carrots d. Wheat rice E. Sauash

ABD

The nurse assesses a client with ulcerative colitis. Which complications are paired correctly with their physiologic processes? (Select all that apply.) A. Lower gastrointestinal bleeding erosion of the bowel wall B. Abscess formation localized pockets of infection develop in the ulcerated bowel lining C. Toxic megacolon transmural inflammation resulting in pyuria and fecaluria d. Nonmechanical bowel obstruction -paralysis of colon resulting from colorectal cancer E. Fistula- dilation and colonic ileus caused by paralysis of the colon

ABD

The nurse is teaching a client who is taking an oral antibiotic for treatment of a sexually transmitted infection (STI). Which statements by the client indicate a correct understanding of the treatment? (Select all that apply.) A. I need to drink at least eight glasses of fluid each day with my antibiotic." B. I should read the instructions to see if I can take the medication with tood." C. Antacids should not interfere with the effectiveness of the antibiotic." D. I need to wait 7 days atter this injection to engage in intercourse." E. It should not matter if I skip a couple of doses of the antibiotic."

ABD

nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) A. How much water do you drink every day?" B. Do you take estrogen replacement therapy?? C. Does anyone in your family have a history of cystitis?* d. "Are you on steroids or other immunc-suppressing drugs?" E. Do you drink grapetruit juice or orange juice daily?"

ABD

nurse assists with the insertion of a central vascular access device. Which actions will the nurse ensure are completed to prevent a catheter-related bloodstream infection? (Select all that apply.) A. Include a review for the need of the device each day in the client's plan of care. B. Remind the primary health care provider to perform hand hygiene prior to insertion if he or she forgets. C. Cleanse the preferred site with alcohol and let it dry completely before insertion. D. Ask everyone in the room to wear a surgical mask during the procedure. E. Plan to complete a sterile dressing change on the device every day. f. Minimal client draping and barrier precautions as blood loss are minimal.

ABD

nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) A. Stress incontinence urine loss with physical exertion B. Urge incontinence-loss of urine upon feeling the need to void C. Functional incontinence urine loss results from abnormal detrusor contractions D. Overflow incontinence constant dribbling ot urine e. Reflex incontinence leakage of urine without lower urinary tract disorder

ABD

nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) A. Unique facility identifier b. Lot number related to the donor C. Name of the client receiving blood D. ABO group and Rh type of the donor e. Blood type of the client receiving blood f. Signature line for 2-person verification

ABD

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.) a. Red rash B. Shortness of breath C. Heart irregularity D. Chest tightness E. Anxiety f. Confusion

ABDE

The nurse is caring for a client who is diagnosed with celiac disease and preparing to start natalizumab. Which health teaching would the nurse include in the teaching? (Select all that apply.) A. Need to have druy administered by a primary health care provider. B. Need to avoid crowds and individuals who have infection. C. Need to report injection reactions such as redness and swelling. D. Awareness of a rare but potentially fatal drug complication. E. Need to report any signs and symptoms of infection immediately.

ABDE

The nurse is teaching an elderly client the risks of infection for older adults. Which of the following factors would the nurse include in the education? (Select all that apply.) a. Higher risk for respiratory tract and genitourinary infections. b. May not have a fever with severe infection C. Show expected changes in white blood cell counts. D. Should receive influenza, pneumococcal, and shingles vaccinations. E. Skin tests for tuberculosis may be falsely negative. f. Booster vaccinations are not likely needed as one ages

ABDE

The nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.) A. Appropriate drug B. Proper route ot administration C. Standardized peak levels d. Sufficient dose E. Sufficient length of treatment F. Appropriate trough levels

ABDE

nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a client diagnosed with both infections. Which items should be included in the client's teaching plan? (Select all that apply.) A. Expedited partner therapy B. Abstinence until therapy is completed C. Use of intrauterine devices D. Proper use of condoms E. Rescreening for infection f. Use of oral contraception

ABDE

The nurse in the emergency department would arrange to transter which burned clients to a burn center? (Select all that applv.) a. 15% partial-thickness burn B. Lightening injury C. 7% partial-thickness burn D. History of pulmonary edema e. Healthy 67 year old F. 4% partial-thickness burn to perineum

ABDEF

The nurse is educating a client with HIV-II and the partner on self-care measures to prevent infection when blood counts are low. What information does the nurse provide? (Select all that apply.) A. Do not work in the garden or with houseplants. b. Do not empty the kitty litter boxes. C. Clean your toothbrush in the dishwasher daily. D. Bathe daily using antimicrobial soap. e. Avoid people who are sick and large crowds F. Make sure meat, fish, and eggs are cooked well.

ABDEF

nurse cares for many clients with pressure injuries. What actions by the nurse are considered best practice? (Select all that apply.) A. Conduct ongoing assessments that include pain. b. Use normal saline to cleanse around the pressure injury. C. Soak eschar dailv unti it softens and can be removed. D. consult with a registered dietitian nutritionist. E. Use antimicrobial agents to clean wounds that are infected. f. Consider the use of adiuvant therapies for nonhealing wounds

ABDEF

A client has mucositis. What actions by the nurse will improve the client's nutrition? (Select all that apply.) A. Assist with rinsing the mouth with saline frequently. B. Encourage the client to eat room-temperature foods. c. Give the client hot liquids to hold in the mouth. D. Provide local anesthetic medications to swish and spit E. Remind the client to brush teeth gently after each meal. F. Offer the client fluids to drink each hour.

ABDF

A nurse is planning interventions that regulate acid- base balance to ensure that the pH of a client's blood remains within the normal range. Which abnormal physiologic functions may occur if the client experiences an acid-base imbalance? (Select all that apply.) A. Reduction in the function of hormones B. Fluid and electrolyte imbalances C. Increase in the function ot selected enzymes D. Excitable cardiac muscle membranes E. Increase in the effectiveness of many drugs F. Changes in Gl tract excitability

ABDF

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) a. Infection B. Gi bleeding C. Irritable bowel syndrome d. Constipation E. Anemia f. Hypovolemia

ABDF

What statements about the complement system are correct? (Select all that apply.) a. Comprised of 20 types of inactive plasma proteins. B. Act as enzymes when activated to enhance innate immunity. C. Phagocytize foreign invaders quickly by destroying their membranes. D. Sticks to the antigen and forms a membrane attack complex. E. Maintain and prolong inflammation from non-self cells f. Is part of the innate immune system.

ABDF

Which findings are AIDS-detining characteristics? (Select all that apply.) A. CD41 cell count less than 200/mm' (0.2 × 10½L) or less than 14% B. Infection with P. jiroveci C. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) d. Presence of HIV wasting syndrome E. Taking antiretroviral medications F. Confusion, dementia, or memory loss

ABDF

A client has recurrent vulvovaginitis. Which statements by the client indicate a need for further teaching? (Select all that apply.) A. I can take a long. hot bath to relieve itching." B. I need to lake all ol' my antibiotics as prescribed." C. I should avoid having sex until my infection is gone." D. I should not douche or use feminine hygiene sprays." E. I should use antibacterial soon to clean the greg " f. "I should switch to wearing only cotton underwear.'

ABE

A nurse cares for a client who is recovering from a colonoscopy. Which actions would the nurse take? (Select all that applv.) A. Obtain vital signs every 15 to 30 minules until alert. B. Assess the client for rectal bleeding and severe pain. c. Administer prescribed pain medications as needed. d. Monitor the client's serum and urine glucose levels. E. Confirm the client has a ride home and plans to rest.

ABE

A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.) A. Choose a distal site on the clients nondominant arm. B. Verify that the prescription is appropriate for peripheral infusion. c. Place the venous catheter near an area of joint flexion. D. Wear a surgical mask during the catheter insertion procedure. E. Perform hand hygiene before inserting the catheter. F. Limit unsuccessful attempts by up to three clinicians to one attempt cach.

ABE

nurse cares for several clients on an inpatient unit. Which infection control measures will the nurse implement? (Select all that apply.) A. Wear a gown when contact of clothing with body fluids is anticipated. B. Teach clients and visitors respiratory hygiene techniques. C. Obtain powered air purifying respirators for all staff members. d. Do no use alcohol-based hand rub between cent contacts. e. Disinfect frequently touched surfaces in client-care areas.

ABE

nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. B. Leave the bathroom light on at night. C. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the assistive personnel (AP). E. Provide thorough perineal care after each voiding. F. Assess for urinary retention and urinary tract infection

ABEF

The nurse is teaching a client about medications for HIV-II treatment. What drugs are paired with the correct information? (Select all that apply.) A. Abacavir: avoid fatty and fried foods. B. Efavirenz: take 1 hour before or 2 hours after antacids. C. Atazanavir: check pulse daily and report pulse greater than 100 beats/min. d. Dolutegravir: do not take this medication if you become pregnant. E. Entuvirtide: teach client how to operate syringe infusion pump for administration. f. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

ABF

client has multiple lesions all over the body and a family history of skin cancer. The nurse teaches the client to perform a total skin self-examinations on a monthly basis. Which statements will the nurse include in this patient's teaching? (Select all that apply.) A. "Look for asymnactry of shape and iregular borders." B. "Assess for color variation within each lesion. C. "Examine the distribution ol'lesions over a section of the body." D. "Monitor for edema or swelling of tissues." E. "Focus your assessment on skin areas that itch." F. "Report any lesions that change over time in any way."

ABF

nurse assesses a client who has a peripherally inserted central catheter (PICC). For which common complications will the nurse assess? (Select all I that apply.) A. Phlebitis B. Pneumothorax C. Thrombophlebitis D. Excessive bleeding E. Extravasation f. Pneumothorax g. Infiltration

AC

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) A. Apply lotion to the client's dry skin areas." B. Use a basin with warm water to bathe the patient." C. For the patient's oral care, use a soft toothbrush." D. Provide clippers so the patient can trim the fingernails." E. Bathe with antibacterial and water-based soaps."

ACD

A client receiving chemotherapy has a white blood cell count of 1000/mm' (1 × 10°/L). What actions by the nurse are most appropriate? (Select all that apply) a. Assess all mucous membranes every 4 to 8 hours. B. Do not allow the client to eat meat or poultry. C. Listen to lung sounds and monitor for cough. D. Monitor the venous access device appearance hourly. E. Take and record vital signs every 4 to 8 hours. f. Encourage activity the client can tolerate.

ACDE

A nurse is studying the function of immunoglobulins. Which immunoglobulins are correctly matched to their function? (Select all that applv.) a. IgA: most responsible for preventing infection in the respiratory tracts, the GI tract, and the genitourinary tract. B. IgD: provides protection against parasite infestations, especially helminths. c. IgE: associated with antibody-mediated immediate hypersensitivity reactions. D. IgG: activates classic complement pathway and enhances neutrophil and macrophage actions. e. IgM: first antibody formed by a newly sensitized B-lymphocyte plasma cell.

ACDE

A nurse knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) A. Coal miner b. Electrician c. Metal worker d. Plumber E. Textile worker

ACDE

A nurse plans care for a client who has a wound that is not healing. Which focused assessments will the nurse complete to develop the patient's plan of care? (Select all that apply.) a. Height b. Allergies Alcohol use C. Prealbumin laboratory results D. Liver enzvme laboratory results f. Weight

ACDE

The nurse is learning about immunoglobulins.. Which principles does the nurse learn? (Select all that apply.) a. IgA is found in hich concentrations in secretions from mucous membranes. B. IgD is present in the highest concentrations in mucous membranes. C. IgE is associated with antibody-mediated hypersensitivity reactions. D. IgG comprises the majority of the circulating antibody population E. IgM is the first antibody formed by a newly sensitized B-cell.

ACDE

nurse understands that undernutrition can occur in hospitalized clients for several reasons. Which of the following factors are possible reasons for this complication to oceur? (Select all that apply) A. Cultural food preferences b. Family bringing snacks c. Increased need for nutrition d. Need for NPO status E. Staff shortages

ACDE

A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) A. Calculate pulse pressure with each blood pressure reading. B. Assess skin turgor using the back of the client's hand. C. Assess for pitting edema in dependent body areas. D. Monitor trends in the client's daily weights. E. Assist the client to change positions frequently. F. Teach client and family how to read food labels for sodium.

ACDEF

The nurse is caring for a client with peritonitis. What assessment findings would the nurse expect? (Select all that apply.) A. Nausea and vomiting B. Distended rigid abdomen C. Abdominal pain D. Bradycardia E. Decreased urinary output F. Fever

ACDEF

client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) A. Diuretic therapy B. Anorexia nervosa C. Stroke d. Dementia e. Arthritis f. Parkinson disease

ACDEF

nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) A. Ascites b. Weight gain C. Steatorrhea d. Jaundice E. Polydipsia F. Polyuria

ACDEF

A client receiving radiation therapy reports severe skin itching and irritation. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) A. Apply approved moisturizers to dry skin. B. Apply steroid creams to the skin. C. Bathe the client using mild soap. d. Help the client pat skin dry after a bath. E. Teach the client to avoid sunlight. f. Make sure no clothing is rubbing the site.

ACDF

28-year-old client is diagnosed with uterine leiomyoma and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.) A. Teach nonpharmacologic comfort measures B. Discuss the high risk of infertility with this diagnosis. C. Relieve anxiety by relaxation techniques and education. d. Discuss in detail the side effects of laparoscopic surgery. E. RevIew complete blood count for possible iron deficiency anemia

ACE

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) A. Deep and fast respirations B. Decreased urine output C. Tachycardia d. Dependent pulmonary crackles e. Orthostatic nvnotension

ACE

A nurse is caring for a client who has been diagnosed with a small bowel obstruction. Which assessment findings would the nurse correlate with this diagnosis? (Select all that apply.) a. Serum potassium of 2.8 mEq/L (2.8 mmol/L) B. Loss of 15 lb (6.8 kg) without dieting C. Abdominal pain in upper quadrants d. Low-pitched bowel sounds E. Serum sodium of 121 mEq/L (121 mmolL)

ACE

A nurse is studying the functions of specific leukocytes. Which leukocytes are matched correctly with their function? (Select all that apply.) A. Monocyte: matures into a macrophage. B. Basophil: releases vasoactive amines during an allergic reaction C. Plasma cell: secretes immunoglobulins in response to the presence of a specific antigen. d. Cytotoxic T-cells: attacks and destroys ingested poisons and toxins. E. Natural killer cell: nonselectively attacks non-self cells. f. Regulator T-cells: become sensitized for sell-recognition in the bone marrow.

ACE

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of JU. (Select all that apply.) a. Colonoscopy every 10 years B. Endoscopy every 5 years C. Computed tomography (CT) colonography every 5 years D. Double-contrast barium enema every 1 years E. Flexible sigmoidoscopy every 5 years

ACE

The nurse is caring for a client who has perineal surgical wound. Which actions would the nurse take to promote comfort and wound healing? (Select all that apply.) A. Assist the client into a side-lying position. B. Use a rubber donut device when sitting up. C. Apply warm compresses three to four times a day. D. Instruct the client to wear boxer shorts. E. Place an absorbent dressing over the wound.

ACE

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) A. Registered dietitian nutritionist b. Nursing assistant C. Clinical pharmacist d. Certified herbalist E. Primary health care provider

ACE

A nurse cares for a client who reports discomfort related to eczematous dermatitis. Which nompharmacologic comfort measures would the nurse implement? (Select all that apply.) a. Cool, moist compresses B. Topical corticosteroids C. Heating pad d. Tepid bath with colloidal oatmeal E. Back rub with baby oil

AD

The nurse is planning health teaching for a client starting mirabegron for urinary incontinence. What health teaching would the nurse include? (Select all that apply.) A. Monitor blood tests carefully it you are prescribed warfarin. B. Avoid crowds and individuals with infection. C. Report any fever to your primary health care provider." D. Take vour blood pressure frequently at home." E. Report palpitations or chest soreness that may occur."

AD

client has dumping syndrome. What menu selections indicate the client understands the correct diet to manage this condition? (Select all that apply.) a. Apricots B. Coffee cake c. Milk shake d. Potato soup E. Steamed broccoli

AD

nurse assesses a client recovering from a cystoscopy. Which assessment findings would alert the nurse to urgently contact the primary health care provider? (Select all that apply.) a. Decrease in urine output B. Tolerating oral fluids C. Prescription for mettormin d. Blood clots present in the urine e. Burning sensation when urinating

AD

A cient with HIV- is hospitalized with P troveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated B. CD4+ cell count: 180/mm' C. Creatinine: 1.0 mg/dL (88 memol/L) d. Platelet count: 80,000/mm' (80 × 10°L) E. Serum sodium: 120 mEq/L (120 mmol/L) F. Serum potassium: 3.4 mEg/L (3.4 mmol/L)

ADE

The nurse is caring for a client who has a nasogastric tube (NGT). Which actions would the nurse take for client care? (Select all that apply.) A. Assess for proper placement of the tube every 4 hours or per agency policy. B. Flush the tube with water every hour to ensure patency. c. Secure the Al tube to the chent's can d. Disconnect suction when auscultating bowel peristalsis e. Monitor the client's skin around the rube site for irritation

ADE

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods would be included in the plan? (Select all that apply.) A. Annual mammogram B. Magnetic resonance imaging (MRI) C. Breast ultrasound D. Breast selt-awareness E. Clinical breast examination F. self-breast examination

ADE

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.) A. edema b. Pulselessness C. Pallor D. Redness E. Warmth F. Decreased function

ADEF

nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for diabetes? (Select all that apply.) A. A 56-year-old African-American male B. A 22-year-old female with a 30-Ib (13.6 kg) weight gain during pregnancy C. A 60-vear-old male with a history of liver trauma D. A 48-year-old female with a sedentary lifestyle E. A 50-year-old male with a body mass index greater than 25 kg/m? f. A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)

ADEF

nurse plans care for a client who is immobile. Which interventions would the nurse include in this client's plan of care to prevent pressure sores? (Select all that apply.) A. Place a small pillow between bony surfaces. B. Elevate the head of the bed to 45 degrees. C. Limit fluids and proteins in the diet. d. Use a lift sheet to assist with re-positioning. E. Re-position the client who is in a chair every 2 hours. f. Keep the client's heels off the bed surfaces. g. Use a rubber ring to decrease sacral pressure when up in the chair.

ADF

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects rclated to an acid-base imbalance would the nurse assess? (Select all that apply.) a. Positive Chostek sign b. Elevated blood pressure C. Bradycardia D. Increased muscle strength E. Anxiety and irritability F. Tetany

AE

A nurse assesses a client who presents with early koilonychias. Which assessments will the nurse complete next? (Select all that apply.) A. Review the client's health history for a diagnosis of iron deficiency anemia. B. Palpate the client's nail base for potential edemata and sponginess. C. Ask the client about prolonged contact with chemical irritants. D. Assess the client for signs of chronic obstructive pulmonary disease. E. Request a prescription to assess the client's hemoglobin Aic.

AE

After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for further teaching? (Select all that apply.) A. I will take the enzymes between mcals." B. The enteric-coated preparations cannot be crushed." C. Swallowing the tables without chewing is best." D. I will wipe my lips after taking the enzymes." E. Enzymes should be taken with high-protein foods."

AE

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) A. Reports of palpitations b. Slow, shallow respirations C. Orthostatic hypotension d. Paralytic ileus E. Skeletal muscle weakness f. Tall, peaked T waves on ECG

AEF

After treating several young women for urinary tract infections (UTIs), the college nurse plans an educational offering on reducing the risk of getting a UTI. What information does the nurse include? (Select all that apply.) a. Void before and after each act of intercourse. b. Consider changing to spermicide from birth control pills. c. Do not douche or use scented feminine products. d. Wear loose-fitting nylon panties. e. Wipe or clean the perineum from front to back.

ANS: A,E Woman can reduce their risk of contracting UTIs by voiding before and after intercourse, not douching or using scented feminine products, and wiping from front to back. If spermicides are currently used, the woman should consider another form of birth control. Loose-fitting cotton underwear is best.

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid base imbalance would the nurse assess? a. Agitation B. Kussmaul respirations C. Seizures d. Positive Chvostek sign

B

A nurse is caring for a client who has a seum calcium level of 14 mg/dL (3.5 mmol/L). Which primary HCP order does the nurse implement first? A. encourage oral fluid intake B. connect client to cardiac monitor C. assess urinary output D. admin oral calcitonin

B

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? a. Monitor intake and output. B. Provide a low-sodium diet. C. increase oral fluid intake. d. Weigh the patient dailv.

B

The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? a. 8:00 a.m. (0800) b. 4:00 p.m. (1600) C. 8:00 p.m. (2000) d. 11:00 p.m. (2300)

B

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority? A. admin high-ceiling (loop) diuretics B. assess lung sounds q2hrs C. place pressure-relieving overlay on the mattress D. weight client daily at same time on same scale

B

A client has been prescribed lorcaserin. What health teaching about the drug is appropriate for the nurse to provide? A. Increase the tiber and water in your diet to prevent diarrhea. B. Report any suicidal thoughts to your primary health care provider" C. Report dry mouth and decreased sweating. D. Do not take antibiotics or nay other anti-infective drugs."

B

A client is awailing baratrie surgery in the morning. What action by the nurse is most important? a. Answering questions the client has about surgery B. Beginning venous thromboembolism prophylaxis C. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

B

A client is preparing to have a fecal occult blood test (FOBT). What health teaching would the nurse include prior to the (est? A. This test will determine whether vou have colorectal cancer." B. You need to avoid red meat and NSAIDs for 48 hours before the test.* C. You don't need to have this test because vou can have a virtual colonoscopy." d. "This test can determine your genetic risk for developing colorectal cancer

B

A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection. What health teaching related to bismuth would the nurse include? A. Report stool changes to your primary health care provider immediately." B. Do not take aspirin or aspirin products of any kind while on bismuth.' C. Take bismuth about 30 minules before each meal and at bedtime." D. Be aware that bismuth can cause frequent vomiting and diarrhea."

B

A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition? d. Auscultating the lungs B. assess ramucous memoranes C. Listening to bowel sounds d. Performing a neurologic examination

B

A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at this time? A. Have vou been using latex condoms?" B. "Are vou allergic to penicillin?" C. When was vour last sexual encounter?" D. Do you have a history of sexually transmitted infections?"

B

A nurse assesses a client and identifies that the client has pale conjunctivae. Which focused assessment will the nurse complete next? A. Partial thromboplastin time B. Hemoglobin and hematocrit C. Liver enzymes d. Basic metabolic panel

B

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO; 22 mE¢/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg B. pH 7.28, HCO; 18 mEg/L (18 minolL), PCO: 28 mm Hg. PO: 98 mm Hg C. pH 7.48, HCO:- 28 mEg/I. (28 mmol/I.), PCO2 38 mm lIg, PO= 98 mm ilg d. pH 7.32, HCO3- 22 mEg/L (22 minol/L), PCO2 58 mm Hg, PO: 88 mm Hg

B

A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client's right lower back. What action would the nurse take? a. Administer fresh-frozen plasma. B. Apply an ice pack to the site. C. Place the client in the prone position. D. Obtain serum coagulation test results

B

A nurse assesses clients on a medical-surgical unit, all of whom have stage 2 or 3 pressure injuries. Which client would the nurse evaluate further for a wound infection? a. WBC 9200 mm/L= (9.2 × 10*) B. Boggy feel to granulation tissue C. Increased size after debridement d. Requesting pain medication

B

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, Pa0298 mm HIg, PaCO2 28 mm He, and HCO: 22 mEg/L (22 mmol/L.). Which client condition does the nurse correlate with these results? a. Diarrhea and vomiting tor 36 hours B. Anxiety-induced hyperventilation C. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema

B

A nurse is assessing a client who has a recent diagnosis of melanoma for understanding of treatment choices. What statement by the client indicates good understanding of the information? a. "Dennabrasion or chemical peels can be done in the office." B. I may need lymph node resection during Mohs surgery." C. This needs only a small incision with local anesthetic D. After surgery I will need & weeks of radiation therapy.

B

A nurse is caring for a client who has the following arterial blood values: pl 7.12, Pa02 56 mm lIg, PaCO 65 mm lIg, and hICO: 22 mlq/l. (22 mmol/I.). Which clinical situation does the nurse correlate with these values? a. Diabetic ketoacidosis in a person with emphysema B. Bronchial obstruction related to aspiration of a hot dog C. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman

B

A nurse is caring for a client who is experiencing excessive diarrhea. The client's arterial blood gas values are pH 7.18. PaO: 98 mm Hg. PaCO, 45 mm Hg. and HCO: 16 mEg/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive? a. furosemide 40 mg B. Sodium bicarbonate C. Mechanical ventilation d. Indwelling urinary catheter

B

A nurse is caring for a client whose Braden Scale score is 9. What intervention demonstrates a lack of evidence-based knowledge? A. Requests a referral to a registered dietitian nutritionist B. Raises the head of the bed no more than 45 degrees. C. Performs perineal cleansing every 2 hours. d. Assesses the client's entire skin surface daily.

B

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? A. Administer topical lidocaine to the site. B. Place warm compresses on the site. C. Administer prescribed oral pain medication d. Massage the site with scented oils.

B

A nurse is planning care for a client who is hyperventilating. The client's arterial blood gas values are pH 7.52. PaO: 94 mm Hg. PaCO. 31 mm Hg. and HCO: 26 mEg/L (26 mmol/L). Which question would the nurse ask when developing this client's plan of care? A. "Do you take any over-the-counter medications?" B. "You appear anxious. What is causing your distress?" C. "Do you have a history of anxiety attacks?" D. "You are breathing fast. Is this causing you to feel light-headed?

B

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? A. Client with an albumin of 3.5 g/dL B. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) c. Client with a hemoglobin of 9.8 mg/dL, (98 mmol/L d. Client with a prealbumin of 28 mg/dL

B

A nurse is teaching a client who has itchy, raised red patches covered with a silvery white scale how to care for this disorder. What statement from the client shows a need for further information? A. At the next family reunion, I'm going to ask my relatives if they have anything similar." B. I will make sure To keep my lesions covered so I do not spread this to others." C. I must avoid large crowds and sick people while I am taking adalimumab. d. "I will buy a good quality emollient to put on my skin cach day."

B

A nurse is teaching a client with diabetes mellitus who asks. "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dl. (3.3 mmol/L.)?" How would the nurse respond? A. Glucose is the only fuel used by the body to produce the energy that it needs." B. Your brain needs a constant supply of glucose because it cannot store it." C. Without a minimum level of glucose, your body does not make red blood cells." d. "Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

B

A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse recognize as abnormal? A. pH of 5.6 B. Ketone bodies present C. Specific gravity of 1.020 D. Clear and yellow color

B

After delegating care to assistive personnel (AP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the Al's understanding. Which action indicates that the AP needs additional teaching? a. Toileting the client after breakfast B. Changing the client's incontinence brief when wet C. Encouraging the client to drink fluids d. Recording the client's incontinence episodes

B

After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates the client correctly understands the teaching? A. I must drink a quart (liter) of water or other liquids each day B. I will weight myself each morning before I eat or drink C. I will use a salt substitute when making and eating my meals D. I will not drink liquids after 6pm so I wont have to get up at night

B

Alter teaching a client who is prescribed adalimumab for severe ulcerative colitis (UC). the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. I will avoid large crowds and people who are sick." B. I will take this medication with my breakfast each morning." C. Nausea and vomiting are common side effects of this druy." D. I should wash my hands after I play with my dog.

B

The ED nurse is caring for 4 clients. Which client does the nurse assess for gas exchange abnormalities first? A. involved in MVC, has broken femur B. brought in unconscious by roommate after opioid overdose C. asthmatic client being discharged home after bronchodilator therapy D. Hx COPD, presents to ED after being bitten by dog

B

The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation. and an inability to void. Which question would the nurse ask first? A. Are you drinking plenty of walter?" B. What medications are vou laking?" C. Have you tried laxatives or enemas?" D. Hats this type of thing ever happened before?"

B

The nurse has provided postvasectomy discharge instructions to the client. What statement by the client demonstrates good understanding? A. We can have unprotected intercourse as soon as I have healed." B. An ice pack to my scrotum will help with the swelling." C. I need to report signs of infection, swelling, or bruising right away." d. "The stitches can be removed here in the office in 7 to 10 days."

B

The nurse is caring for a client who has a postoperative paralytic ileus following abdominal surgery. What drug is appropriate to manage this nonmechanical bowel obstruction? a. Alosetron b. Alvimopan C. Amitiptyline d. Amlodipine

B

The nurse is caring for a client who has been prescribed lubiprostone for irritable bowel syndrome (IBS-C). What health teaching will the nurse include about taking this drug? A. This drug will make you very dry because it will decrease your diarchca." B. Be sure to take this drug with food and water to help manage constipation. C. Avoid people who have infection as this drug will suppress your immune system." d. "Include high-liber foods in your diet to help produce more solid stools."

B

The nurse is caring for a client who is planning to have a laparoscopic colon resection for colorectal cancer tomorrow. Which statement b the client indicates a need for further teaching? A. I should have less pain after this surgery compared to having a large incision." B. I will probably be in the hospital for 3 to 4 days after surgery." C. I will be able to walk around a little on the same day as the surgery." d. "I will be able to return to work in a wock or two depending on how I do."

B

The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? A. Clamp the nasogastric tube. B. Place the patient in semi-Fowler position. C. Assess vital signs once every shift d. Provide oral rehydration

B

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? A. A low-protein diet will help the liver rest and will restore liver function." B. Less protein in the diet will help prevent confusion associated with liver failure." C. Increasing dietary protein will help the patient gain weight and muscle mass."* D. Low dietary protein is needed to prevent fluid from laking into the abdomen."

B

The nurse knows that a client with prolonged prothrombin time (PT) values (not related to medication) probably has dysfunction in which organ? a. Kidneys B. Liver C. Spleen d. Stomach

B

The nurse plans care for a client with Crohn disease who has a heavily draining fistula. Which intervention would be the nurse's priority action'? A. Low-fiber diet B. Skin protection c. Antibiotic administration d. Intravenous glucocorticoids

B

client has a platelet count of 9800/mm? (9800 × 10'/L). What action by the nurse is most appropriate? A. Assess the client for calf pain, warmth, and redness. B. Instruct the client to call for help to get out of bed. C. Obtain cultures as per the facility's standing policy. d. Place the client on protective Isolation Precautions.

B

client has an external percutaneous transhepatic biliary catheter inserted for a biliary obstruction. What health teaching about catheter care would the nurse provide for the client? A. Cap the catheter drain at night to prevent leakage and skin damage." B. Position the drainage bag lower than the catheler insertion site." C. Irrigate the catheter with an ounce of saline every nicht." d. *Pierce a hole in the top of the drainage bag to get rid of odors."

B

client has recently been diagnosed with type II endometrial cancer and will be treated with brachytherapy. What statement by the client indicates a need for further education on this treatment? A. each treatment will take only 20 to 30 minutes." B. I have to be alone in the room during treatment so I don't expose others." C. I can get up and walk around or read in a chair during the treatments. D. I need to report any heavy vaginal bleeding or severe diarrhea."

B

client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Five hours after the operation, the nurse notes the drainage is bright red with clots What action should the nurse take first? A. Review the most recent hemoglobin and hematocrit. B. Take vital signs and begin immediate irrigation with sterile water. C. Notify the primary health care provider immediately. d. Remind the client not to pull on the catheter.

B

client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? A. You do not need to worry about lymphedema since you did not have radiation therapy." B. Be careful not to injure that arm or get any infection in that arm." C. Numbness, tingling, and swelling are common sensations afler a masteclomy." d. *The risk for lymphedema is a real threat and can be very self-limiting."

B

client is preparing to have a laparoscopic restorative proctocolectomy with ileo pouch-anal anastomosis (RCA-IPAA). Which preoperative health teaching would the nurse include? A. You will have to wear an appliance for your permanent ileostomy." B. You should be able to have better bowel continence after healing occurs. C. You will have a large abdominal incision that will require irrigation." D. This procedure can be performed under general or regional anesthesia."

B

client with long-standing heart failure being treated for cancer has received a dose of ondansetron for nausea. What action by the nurse is most important'? A. Assess the client for a headache or dizziness. b. Request a prescription for cardiac monitoring C. Instruct the client to change positions slowly D. Weigh the client daily before eating.

B

new nurse care for several client after radical prostatectomies for prostate cancer. What action by the nuse indicates a need to review care measures for this type of client? a. Delegates emplying and recording contents of the drainage devices. B. Administers a suppository to the chent who reports constiation. C. Removes the sequential compression stockings on ambulatory clients. d. Discusses long-term complications such as erectile dysfunction.

B

nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nurse decrease? A. Carbohydrates B. Proteins C. Fats d. Total calories

B

nurse evaluates the following data in a client's chart: Admission Note Laboratory Results A 66-year-old male with a White blood cell count: 8000/mm health history of a cerebral (8 × 109/L) vascular accident and Prealbumin: 15.2 mg/dL (152 left-side paralysis mg/L) Albumin: 4.2 mg/dL (42 mg/L) Lymphocyte count: 2000/mm' (2 x 109/L) Based on this information, which action would the nurse take? A. Perform a neuromuscular assessment. B. Request a dietary consult. C. Initiate Contact Precautions. D. Assess the client's vital signs.

B

nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? A. Redness at the catheter insertion site b. Report of headache and stiff neck C. Temperature of 100.1° F (37.8° C) d. Pain rating of 8 on a scale of 0-10

B

nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has "a shill to the left" on the white blood cell count. What action by the nurse is most important? a. Document findings and continue monitoring. B. Notify the primary health care provider and request antibiotics. C. Place the client in protective isolation. d. Tell the client this signifies inflammation.

B

nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment Laboratory Results Medications Blood pressure: 90/62 mm Ily Serum potassium: 2.6 Potassium chloride 40 Pulse: 120 beats/min mEq/L (2.6 mmol/L) mEg/L (40 mmol/L) IV Respiratory rate: 28 breaths/min bolus STAT Urine output: 20 mL/hr via Increase IV fluid to 100 catheter mL/hr what action would the nurse take? A. Administer the potassium and then consult with the primary health care provider about the fluid prescription. B. increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. C. Administer the potassium first before increasing the infusion flow rate for the client. D. Increase the intravenous how rate before administering the potassium to the client.

B

nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? a. "Change positions slowly when you get out of bed." B. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." C. If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication it you devclop a urinary infection."

B

A nurse is caring for a woman who had hysteroscopic surgerv for uterine leiomvomas. On initial assessment, the nurse notes the following: pulse: 114 beats/min, respiratory rate: 20 breaths/minute, crackles in bilateral lung bases. What action by the nurse takes priority? a. Assess the client for pain. B. Call the Rapid Response Team. C. Obtain an oxygen saturation. d. Delegate a temperature

B The drainings can fall into uterine cavity

A nurse is assessing clients on a medsurg unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? A. client taking furosemide B. anxious client who has tachypnea C. client who is on fluid restrictions D. client who is constipated with abdominal pain

B insensible water loss is through skin, lungs, and stool

The nurse caring for a client with malnutrition assesses which lab value as priority? A. albumin B. prealbumin C. prothrombin time D. serum sodium

B prealbumin changes more rapidly with decreased nutrition compared to albumin

A nurse is caring for a client who is acidotic. The nurse asks the charge nurse why the client is breathing rapidly. What response by the charge nurse is best? A. anxiety is causing the client to breathe rapidly B. the client is trying to get rid of extra body acids C. the rapid respirations cause buildup of bicarbonate D. an increased respiratory rate is due to increased metabolism

B resp system is trying to compensate for build up of extra acid

A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) A. Demonstrating breast self-examination methods to women b. Instructing people on the use of chemoprevention C. Providing vaccinations against certain cancers d. Screening teenage girls for cervical cancer E. Teaching teens the dangers of tanning booths f. Educating adults about healthy eating habits

B, C, E, F

The nursing is teaching a client diagnosed with gastrosophageal reflux disease (GERD) who is planning to have an endoscopic radiofrequency (Stretta) procedure. What preprocedure health teaching would the nurse include? (Select all that apply.) A. You will need to be on a liquid diet for the first week after the procedure b. Avoid taking any NSAIDs like ibuprofen for 10 davs before the procedure. " C. Contact the primary health care provider after the procedure if you have increased pain." D. You will need a nasogasitic lube for a few daws after the procedure " E. You will have a small incision in your stomach area that will have a wound closure

BC

A nurse is planning care for a client who is lethargie and confused. The client's arterial blood gas values are pH 7.30. PaOs 96 mm Hy, PaCOs 43 mun Hy, and HCO: 19 mEg/L (19 mmol/L). Which questions would the nurse ask the client and spouse when developing the plan of care? (Select all that apply.) A. "Are you laking any antacid medications?" B. "Is your spouse's current behavior typical?" C. "Do you drink any alcoholic beverages?" D. "Have you been participating in strenuous activities ?" E. "Are you experiencing any shortness of breath?"

BCD

A nurse assesses a client who is recovering from an open traditional Whipple surgical procedure. Which assessment findings) alert(s) the nurse to a complication from this surgery? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain C. Shortness of breath D. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

BCDE

A nurse is providing education about HIV risks at a health fair. What groups would the nurse include as needing to be tested for HIV on an annual basis? (Select all that apply.) a. Anyone who received a blood product in 1989 B. Couples planning on getting married C. Those who are sexually active with multiple partners D. Injection drugs users E. Sex workers and their customers f. Adults over the age of 65 years

BCDE

The nurse is teaching a client who had a descending colostomy 2 days ago about the ostomy stoma. Which changes in the stoma would the nurse teach the client to report to the primary health care provider? (Select all that apply.) a. Stool consistency is similar to paste. b. Stoma becomes dark and dull. C. Skin around the stoma becomes excoriated. D. Skin around stoma becomes protruded. E. stoma becomes retracted into the abdomen.

BCDE

client with HIV-IlI is in the hospital with severe diarrhea. What actions does the nurse delegate to assistive personnel (AP)? (Select all that apply.) A. Assessing the client's fluid and electrolyte status B. Assisting the client to get out of bed to prevent falls C. Obtaining a bedside commode if the client is weak d. Providing gentle perianal cleansing after stools e. Reporting an perianal abnormalities

BCDE

nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the nurse learn? (Select all that apply.) a. Basophils are only involved in the general inflammatory process. B. Eosinophils increase during allergic reactions and parasitic invasion. C. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. E. Neutrophils can only take part in one episode of phagocytosis.

BCDE

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select al that apply.) A. Hypomagnesemia-kidney failure B. Hyperkalemia -salt substitutes C. Hyponatremia heart lailure D. Hypernatremia hyperaldosteronism E. Hypocalcemia_-diarrhea f. Hypokalemia - loop diuretics

BCDEF

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) A. Sodium: 160 mEq/L (mmol/L): Overhydration B. Potassium: 5.4 mEq/L (mmol/L): Dehydration C. Osmolarity: 250 mOsm/L: Overhydration d. Hematocrit: 68%: Dehydration E. BUN: 39 mg/dI.: Overhydration F. Magnesium: 0.8 mg/dL: Dehydration

BCDF

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.) a. Weight gain b. Rectal bleeding C. Anemia d. Change in stool shape E. Electrolyte imbalances F. Abdominal discomfort

BCDF

The nurse is teaching a client about side effects and adverse reactions of a PDE5 inhibitor. What information does the nurse include? (Select all that apply.) a. Refrain from eating citrus fruit within 24 hours of taking the medication. B. Stop using this drug if your primary health care provider prescribes a nitrate. C. Do not drink alcohol before having sexual intercourse D. Muscle cramps, nausea, and vomiting are possible if you take more than I pill a day. E. Take this medication within 30 to 60 minutes of having sexual intercourse. f. Change positions slowly especially if you also take an anti-hypertensive drug.

BCDF

client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.) a. "You will need to be hospitalized during this therapy." B. Your skin needs to be inspected daily for any breakdown." C. It is not wise to stay out in the sun for long periods of time." D. The perincal area may become damaged with the radiation." E. The technician applies new site markings before each treatment." F. You will not be radioactive or pose any danger lo anyone else."

BCDF

A nurse assesses a patient who has celiac disease. Which signs and symptoms would the nurse expect? (Select all that apply.) a. Weight gain B. Anorexia C. Constipation d. Anal fistula E. Abdominal pall

BCE

A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired with the acid- base imbalance? (Select all that apply.) A. Metabolic alkalosis -young adult who is prescribed intravenous morphine sulfate for pain b. Metabolic acidosis older adult who is following a carbohydrate-free diet c. Respiratory alkalosis client on mechanical ventilation at a rate of 28 breaths/min d. Respiratory acidosis postoperative client who received 6 units of packed red blood cells E. Metabolic alkalosis older client prescribed antacids for gastrosophageal reflux disease

BCE

The nurse is doing home care teaching for a client who has undergone cryotherapy. Which statements by the client indicate a correct understanding of the instructions? (Select all that apply.) A. I can resume mv weight-lifing exercise class tomonow." B. I should not use tampons, douche. or have sexual activity.' C. I should shower rather than toke a tub bath " D. There may be a lot of bleeding for a few davs." E. There should be litle or ma discomfort

BCE

client's small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are appropriate? (Select all that apply.) A. Attempt to dissolve the clog by instilling a cola product. b. Determine if any of the medications come in liquid form. C. Flush the tube before and after administering medications. D. Mix all medications in the formula and use a feeding pump е. Try to flush the tube with 30 mL. of water and gentle pressure

BCE

nurse plans care for a client who is at risk for infection. Which interventions will the nurse implement to prevent infection? (Select all that apply.) A. Administer prophylactic antibiotics. b. Monitor white blood cell count and differential. C. Screen all visitors for infections. d. Implement Transmission-Based Precautions. E. Promote sufficient nutritional intake.

BCE

A client with HIV-IlI has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) A. Apply oral anesthetic gels before meals. b. Assist the client with oral care ever 2 hours C. Offer the client frequent sips of cool drinks. d. Provide the client with alcohol-based mouthwash E. Remind the client to use only a soft toothbrush F. Offer the client soft foods like gelatin or pudding.

BCEF

A client with an infection has a fever. What actions by the nurse help increase the client's comfort? (Select all that apply.) a. Administer antipyretics around the clock. B. Change the client's gown and linens when damp. C. Offer cool fluids to the client frequently. d. Place ice bags in the armpits and groin E. Provide a fan to help cool the client. f. Sponging the client with tepid water

BCF

The nurse working with clients who have gastrointestinal problems knows that which laboratory values are related to which organ functions or dysfunctions? (Select all that apply.) A. Alanine aminotransferase: biliary system B. Ammonia: liver C. Amylase: liver D. Lipase: pancreas E. Urine urobilinogen: stomach

BD

A nurse cares for a patient who has a chronic inflammatory bowel disease. Which actions would the nurse take to prevent skin excoriation? (Select all that apply.) A. Cleanse the perineum with an antibacterial soap. B. Use medicated wipes instead of toilet paper. C. Identify foods that decrease constipation. D. Apply a thin coat of aloe cream to the perineum E. Gently pat the perineum dry after cleansing.

BDE

The nurse is caring for a client with a long history of peptic ulcer disease. What assessment findings would the nurse anticipate if the client experiences upper gastrointestinal (GI) bleeding? (Select all that apply.) A. Decreased heart rate B. Decreased blood pressure C. Bounding radial pulse d. Dizziness E. Hematemesis F. Decreased urinary output

BDEF

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.) A. Urine output of 25 mL/hr B. Serum potassium level of 5.4 mEq/L (5.4 mmol/L) C. Urine specific gravity of 1.02 g/mL D. Serum sodium level of 128 mEq/L (128 mmol/L) E. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

BE

nurse assesses a client who has cirrhosis of the liver. Which laboratory findings would the nurse expect in clients with this disorder? (Select all that apply.) A. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) C. Decreased serum globulin levels D. Decreased serum alkaline phosphatase E. Elevated serum ammonia F. Elevated prothrombin time (PT)

BEF

nurse assesses a client who presents with an increase in psoriatic lesions. Which questions would the nurse ask to identify a possible trigger for worsening of this client's psoriatic lesions? (Select all that apply.) A. Have you eaten a large amount of chocolate lately?" B. Have you heen under a lot of stress lately?" C. Have vou recently used a public shower?" D. Have you been out of the country recently?" E. Have you rocently had any other health problems?" F. Have you changed any medications recently?"

BEF

The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.) A. Warm, dry skin B. Nervousness C. Rapid deep respirations d. Dehydration E. Ketoacidosis F. Blurred vision

BF

A client is receiving rituximab and asks how it works. What response by the nurse is best? A. "It causes rapid lysis of the cancer cell membranes ." B. "It destroys the enzymes needed to create cancer cells " C. "It prevents the start of cell division in the cancer cells " D. "It sensitizes certain cancer cells to chemotherapy."

C

A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? a. It blocks the release of luteinizing hormone. B. Il interferes with cancer cell division. C. It selectively blocks estrogen in the breast. D. It inhibits DNA synthesis in rapidly dividing cells.

C

A client presents to the emergency department reporting vomiting, severe lower abdominal pain, and a tender mass above one testis. What action by the nurse is most important? a. Have the client rate pain using the 0-10 scale. B. Prepare to administer an IV opioid analgesic. C. Determine when he last ale or drank anything D. Assess risk factors for testicular cancer.

C

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time'? A. Listen to the client's bowel sounds. B. Call the Rapid Response Team. c. Take the client's vital signs. d. Contact the primary health care provider.

C

A client with HIV-IlI asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? A. Gabapentin can be used as an antidepressant too. B. "I have no idea why you would be taking this drug." C. This drug helps treat the pain from nerve irritation." D. You are at risk for seizures duc to fungal infections."

C

A client with genital herpes has painful blisters on her vulva. After teaching the client self-care measures, which statement indicates the need for further education? A. Pouring water over my genitals will decrease the pain of urinating." B. I will wash my hands carefully after applying ointment." C. When I don't have lesions. I am not contagious to my sexual partner." D. I should increase my fluid intake when I have open lesions."

C

A new nurse reads a client has a wound "healing by second intention" and asks what that mcans. Which description by the charge nurse is most accurate? A. The wound edges have been approximated and stitched together." B. The wound was stapled together aller an infection was cleared up." C. The wound is an open cavity that will fill in with granulation tissue." D. "The wound was contaminated by debris and can't be closed at all."

C

A nurse assesses a client who has ulcerative colitis and severe diarrhea. Which assessment would the nurse complete first. A. inspection of oral mucosa B. Recent dietary intake C. Heart rate and rhythm d. Percussion of abdomen

C

A nurse cares for a client who has serum potassium of 6.5 and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? A. prepare to admin patiromer by mouth B. provide heart healthy low potassium diet C. prepare to admin dextrose 20% and 10 units of regular insulin IV push D. prepare client for hemodialysis treatment

C

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states. "My pain has suddenly increased from a 3 to a 10 on a scale of 0-10." Which action would the nurse take first? a. Reposition the client on the operative side. B. Administer the prescribed opioid analgesic. C. Assess the client's pulse rate and blood pressure d. Examine the color of the chent's urine

C

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take? a. Contact the primary health care provider to recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Encourage the client to drink more fluids. d. Obtain a suction device and implement seizure precautions.

C

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse make in this client's teaching? A. have your spouse watch for irritability and anxiety B. notify the clinic if you notice muscle twitching C. call your PCP if you experience diarrhea D. bake or grill your meat rather than frying it

C

A nurse teaches a client who is prescribed a central vascular access device and is transferring to a skilled facility for long-term treatment. Which statement will the nurse include in this client's teaching? A. You will need to wear a sling on your arm while the device is in place." B. There is no risk of infection because sterile technique will be used during insertion C. Ask all providers to vigorously clean the connections prior to accessing the device " d. You will not he able to take a bath with this vascular access device."

C

After providing discharge teaching, a nurse assesses the client's understanding regarding increased risk for metabolic alkalosis Which statement indicates that the client needs additional teaching? A. "I don't drink milk because it gives me gas and diarrhea." B. "I have been taking digoxin every day for the last 15 years." C. "I take sodium bicarbonate after every meal to prevent begitburg." D. "In hot weather, I sweat so much that I drink six glasses of water cach day."

C

After teaching a client who expressed concern about a rash located beneath her breast, a nurse assesses the client's understanding. Which statement indicates the client has a good understanding of this condition? A. "This rash is probably due to fluid overload." B. "I need to wash this daily with antibacterial soap." C. "can use powder to keep this area dry. D. "I will schedule a mammogram as soon as I can."

C

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. I cannot drink any alcohol at all anymore. B. I should not take over-the-counter medications." C. I need to avoid protein in my diet. D. I should cal small, frequent, balanced meals."

C

After teaching a client who has diverticulitis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching. A. I'll ride my bike or take a long walk at least three times a week. B. I must try to include at least 25 g of tiber in my diet every day." C. I will take a laxative nichtly at bedtime to avoid becoming constipated." D. I should use my legs rather than my back muscles when I lilt heavy objects."

C

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the chent's understanding. Which statement made by the client indicates a need for additional teaching? a. "I should increase my intake of vegetables with higher amounts of dietary fiber." b. "My intake of saturated fats should be no more than 10% ol my total caloric c. "I should decrease my intake of protein and eliminate carbohydrates from my diet." d. "My intake of' water is not restricted by my treatment plan or medication regimen.

C

After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client's understanding. Which statement made by the clicat indicates a correet understanding of the teaching? A. I will not take this drug with food or milk." B. I will have my partners tested for ST'ls." C. An orange color in my urine should not alan me.' D. I will drink two glasses of cranberry juice daily."

C

During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? a. Hematemesis B. Pain when eating c.Melena d. Weight loss

C

Four clients are receiving tyrosine kinase inhibitors (TKIs). Which of these four clients would the nurse assess first? A. Dry, itchy, peeling skin b. Serum calcium of 9.2 mg/dL (2.3 mmol/L) C. Serum potassium of 2.8 mEq/L (2.8 mmol/L) D. Weight gain of 0.5 lb (1.1 ky) in 1 day

C

The assistive personnel note that a client had a dark stool. What stool test would the nurse obtain for this client. A. Culture and sensitivity b. Parasites and ova C. Occult blood test d. Total fat content

C

The murse is working with a male client who has gynecomastia. What action by the nurse is most appropriate? a. Teach the client to perform self-breast examination. B. Review the plan for chemotherapy after surgery. C. Educate him on the side effects of tamoxifen. D. Assess his usual daily alcohol intake.

C

The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? a. Urinary retention B. Urinary incontinence c. Painless hematuria d. Difficulty urinating

C

The nurse assesses a client who is hospitalized with an exacerbation of Crohn disease. Which assessment finding would the nurse expect? A. Positive Murphy sign with rebound tenderness to palpitation B. Dull, hypoactive bowel sounds in the lower abdominal quadrants C. High-pitched, rushing bowel sounds in the right lower quadrant D. Reports of abdominal cramping that is worse at night

C

The nurse documents the vital signs of a client diagnosed with acute pancreatitis Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? A. Electrolyte imbalance b. Pleural effusion C. Internal bleeding D. Pancreatic pseudocyst

C

The nurse is caring for a client diagnosed with oral cancer. What is the nurse's priority for client care? A. Encourage fluids to liquefy the client's secretions. B. Place the client on aspiration Precautions. C. Remind the client to use an incentive spirometer. d. Manage the client's pain and inflammation.

C

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? a. Blacks b. Asian/Pacific Islanders c. Latinos d. French

C

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor'? a. Large bowel obstruction B. Dyspepsia c. Upper gastrointestinal (Gl) bleeding d. Castric cancer

C

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? A. Assess the client's blood glucose level. B. Monitor the client's urinary oulput ever hour. C. Establish intravenous access to provide fluids. D. Give regular insulin per agency policy.

C

The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess. a. Intermittent diarrhea b. Cholecystitis C. Aspiration Pneumonia d. Peptic ulcer disease

C

The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching? A. Be sure to take the drug once a day before breakfast." B. Take the drug every evening before bedtime." C. Give your drug injection the same day every week." d. "Take the drug with dinner at the same time each day

C

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect? A. Decreased potassium level B. Increased sodium level C. Elevated leukocyte count D. Decreased thrombocyte count

C

client has been treated for syphilis with IM penicillin. The next day the client calls the clinic to report fever, chills, achy muscles, and a worsening rash. What statement by the nurse is most appropriate? A. You must be allergic to penicillin; over the counter antihistamines will help." B. Please go to the nearest emergency department if you develop shortness of breath C. You can take acetaminophen or ibuprofen for the pain and achiness." d. "I thnk you should come in to the chnic either today or tomorrow and be checked."

C

client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The client reports headache and dizziness. What action by the nurse is most appropriate? A. Consider starting a blood transfusion. B. Slow the bladder irrigation down. C. Report the findings to the surgeon immediately. d. Take the vital signs every 15 minutes.

C

nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond? A. Red blood cells produce erythropoietin, which increases blood flow to the kidneys." b. Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density. C. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow. d. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood "

C

nurse is assessing a client who presents with a scaly rash over the palms and soles of the leet and the leching ol muscle aches and malarse. Which action by the nurse is most appropriate? a. Reassure the client that these lesions are not infectious. B. Assess the client for hearing loss and generalized weakness. C. Don gloves and further assess the client's lesions. d. Take a history regarding any cardiovascular symptoms

C

nurse is learning the difference between normal cells and benign tumor cells. What information does this include? A. Benign tumors grow through invasion of other tissue. B. Benign tumors have lost their cellular regulation from contact inhibition. C. Growing in the wrong place or time is typical of benign lumors. D. The loss of characteristics of the parent cells is called anaplasia.

C

The nurse is teaching a client how to avoid the formation of hemorrhoids. What lifestyle change would the nurse include? a. Avoiding alcohol B. Quitting smoking C. Decreasing fluid intake d. Increasing dietary fiber

C I think it's keyed wrong but he will probably go with the answer they got so C

After administering potassium chloride, a nurse evaluates the client's response. Which signs and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) A. Respiratory rate of 8 breaths/min B. Absent deep tendon reflexes C. Strong productive cough D. Active bowel sounas E. U waves present on the electrocardiogram (ECG)

CD

The nurse assesses a client who has possible gastritis. Which assessment finding(s) indicate(s) that the client has chronic gastritis? (Select all that apply.) A. Anorexia b. Dyspepsia C. Intolerance of fatty foods D. Pernicious anemia E. Nausea and vomiting

CD

The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her primary health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.) A. Constipation for 3 days b. Temperature of 99° F (37.2° C) C. Abdominal pain d. Visible blood in the urine E. Heavy vaginal bleeding f. Urinary retention

CDE

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the client's behavior, which statement by the nurse would be the most appropriate? A. The urine incontinence should not prevent you from socializing." B. You scem depressed and should seck more pleasant things to do." C. It is common for men at your age to have changes in mood." D. "Nocturia could cause interruption of your sleep and cause changes in mood."

D

A nurse assesses a client who is prescribed furosemide for hypertension. For which acid base imbalance does the nurse assess to prevent complications of this therapy? a. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis d. Metabolic alkalosis

D

A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? A. Apply cold compresses to the IV site. B. Blevate the extremity on a pillow. C. Flush the catheter with normal saline. d. Stop the infusion of intravenous fluids.

D

A nurse is assessing a client with glioblastoma. What assessment is most important? A. Abdominal palpation B. Abdominal percussion C. Lung auscultation d. Neurologic examination

D

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? A. assesses the client's Chvostek and Trousseau signs B. keeps clients room quiet and dimly lit C. moves client carefully to avoid fracturing bones D. admin bisphosphonates as prescribed

D

A nurse is evaluating a client being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? A. increased RR from 12 to 22 breaths/min B. decreased skin turgor on the client's posterior hand and forehead C. increased urine specific gravity from 1.012 to 1.030 D. decreased orthostatic changes when standing

D

A nurse plans care for a client with overflow incontinence. Which intervention does the nurse include in this client's plan of care to assist with elimination? A. Stroke the medial aspect of the thigh. B. Use intermittent catheterization. C. Provide digital anal stimulation. d. Use the Vasalva manenver

D

A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? A. Lower the extremity below the level of the heart. b. Apply warm compresses to the extremity. C. Tap the skin lightly and avoid slapping. d. Place a washcloth between the skin and tourniguet.

D

A nurse teaches a client who has pruritus. Which statement by the client shows a need to review the information? A. "I will shower daily using a super-fattod soap." B. "I can try taking a bath with colloidal oatmeal." C. "I will pat my skin dry instead of rubbing it with a towel." D. "I will be careful to keep my nails filed smoothly."

D

A nurse teaches a client with type I diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 L a day." b. "Animal organ meat is high in insulin." C. Limit your carbolydrate intake to 80 g a day." d. *Walk at a moderate pace for I mile daily."

D

After teaching a patient with diverticular disease, a nurse assesses the client's understanding. Which menu selection indicates the client correctly understood the teaching. a. Roasted chicken with rice pilaf and a cup of coffee with cream B. Spaghetti with meat sauce, a fresh fruit cup, and hot tea C. Garden salad with a cup of bean soup and a glass of low-fat milk d. Baked fish with steamed carrots and a glass of apple juice

D

After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? A. I'll take this medicine during cach of my meals." B. I must take this medicine in the morning when I wake." C. I will take this medicine before I go to bed." d. "I will take this medicine immediately before I eat."

D

During dressing changes, the nurse assesses a client who had breast reconstruction. Which finding would cause the nurse to take immediate action? a. Slightly reddened incisional area b. Blood pressure of 128/75 mm Hg c. Temperature of 99° F (37.2° C) d. Dusky color of the breast flap

D

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? A. Musculoskeletal assessment B. Neurologic assessment C. Mental health assessment d. Cardiovascular assessment

D

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? A. Have the client sign the informed consent form. B. Get the patient into a chair before the procedure. c. Help the client lie flat in bed on the right side. D. Assist the client to void before the procedure.

D

The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? A. Diabetic ketoacidosis (DKA) B. Severe hypoglycemia c. Chronic kidney disease (CKD) D. Hyperglycemic-hyperosmolar state (HHS)

D

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy What health teaching would the nurse include? a. "Follow up on all appointments to monitor your lab values." B. Do not take amiodorone at any time while on this drug." C. Monitor for jaundice, rash, and itchy skin while on this drug.* D. Report any changes in urinary climination while on this drug."

D

The nurse is teaching a client who has been treated for acute gastritis. What statement by the client indicates a need for further teaching? A. I need to cut down on drinking martinis every might." B. I should decrease my intake of caffeinated drinks, especially coffee." C. I will only take ibuprofen once in a while when I really need it." d. *I can continue smoking cigarettes which is better than chewing tobacco."

D

The nurse teaches a client about how to prevent transmission of gastroenteritis. Which statement by the nurse indicates a need for further teaching: A. I won't let anyone use my dishes or glasses B. I'll wash my hands with antibacterial soar c. "I'll keep my bathroom extra clean." d. I'll cook all the meals for my family."

D

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunitv is the problem? a. CD4+ cells B. Cytotoxic T-cells C. Natural killer cells d. Regulator T-cells

D

The outpatient clinic nurse has assessed a woman who reports a month-long history of feeling full, urinary frequency, and bloating. What action by the nurse is best? a. Obtain a clean catch urine specimen. B. Instruct the client on a 3-day diet history. C. Facilitate having a pelvic ultrasound. d. Teach the woman about CA-125 test.

D

Which of these client assessment findings is typically associated with oral cancer? A. Dry sticky oral membranes b. Increased appetite c. Itchy rash in oral cavity d. Painless red or raised lesion

D

client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best? A. Suggest increasing vitamins and supplements daily. B. Discuss the value of a balanced diet and exercise. C. Reinforce that weight gain may be inevitable. d. Teach that estrogen cream inserted vaginally may help.

D

nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? A. Allergic reaction B. Bowel obstruction C. Catheter lumen occlusion d. Infection

D

nurse cares for a client who has a stage 3 pressure injury with copious exudate. What type of dressing does the nurse use on this wound? A. Wet-to-damp saline moistened gauze B. None, the wound is left open to the air C. A transparent film d. Multi-fiber superabsorbent dressing

D

nurse cares for a client who has kidney stones from gout ricemia. Which medication does the nurse anticipate administering? A. Phenazopyridine B. Doxycyline c. Tolterodine d. Allopurinol

D

nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent A. Examine your feet using a mirror every day." B. Rotate your insulin injection sites every week." C. Check vour blood glucose level before each meal" d. "Use a bath thermometer to test the water temperature

D

nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? A. You must clean around your catheter daily with soap and water." B. You will need to be on your drug therapy for life." C. Operations to repair your bladder are available, and you can consider those." d. "You might want to get pants with elastic waisthands

D