adult health 2 hesi
which clinical finding supports the diagnosis of DKA? a. nervousness and tachycardia b. erythema toxicum rash and pruritus c. diaphoresis and altered mental state d. deep respirations and fruity odor to the breath
deep respirations and fruity odor to the breath
which medication taken by an older client who has been treated for rhinitis and pharyngitis may be causing the clients new onset confusion, dry mouth and constipation? a. chlorpheniramine b. acetaminophen c. ibuprofen d. guaifenesin
chlorpheniramine
which amount of time is the max amount the nurse would permit an older adult with a CVA to remain in one position? a. 1-2 hours b. 3-4 hours c. 15-20 minutes d. 30-40 minutes
1-2 hours
which factor in the history of a client who is a farmer with a large crusty patch of skin on the cheek that still bleeds easily and has not gotten better despite using different remedies, would cause the nurse to suspect skin cancer? a. exposure to radiation b. location of the lesion c. self treatment of lesions d. contact with soil contaminants
exposure to radiation
which initial response by the nurse is best when a client with lymphoma expresses discouragement during treatment because of chemo side effects? a. ask whether the client has considered antidepressants b. remind the client that positive thoughts can be therapeutic c. acknowledge that the adverse effects of treatment are difficult to endure d. offer information about the effectiveness of chemo for the lymphoma
acknowledge that the adverse effects of treatment are difficult to endure
which information would the nurse include when explaining the cause of TIAs to a client? a. genetic valvular heart disease b. atherosclerotic plaques within arteries c. developmental defects in arterial walls d. emboli ascending from the lower extremities
atherosclerotic plaques within arteries
which information will the nurse provide to minimize the risk for complications of pancytopenia as a result of chemo? a. avoid activities that risk traumatic injuries and exposure to infection b. perform frequent mouth care with firm toothbrush c. increase oral fluid intake d. report any unusual muscle cramps or tingling sensations in extremities
avoid activities that risk traumatic injuries and exposure to infection
which instruction will the home health nurse include when teaching a client with PAD? select all that apply a. avoid crossing your legs b. inspect feet daily c. change positions slowly d. do not use compression stockings e. avoid green leafy vegetables in your diet
avoid crossing your legs, inspect feet daily, do not use compression stocking
which nursing intervention is the priority when a client receiving chemo develop a temp of 102 when the temp 6hours ago was 99.2 a. assess the amount and color of urine; obtain a specimen for a urinalysis and culture b. administer the prescribed antipyretic and notify the primary healthcare provider of this change c. note the consistency of respiratory secretions and obtain a culture d. obtain vitals when rechecking temp in 1 you
administer the prescribed antipyretic and notify the primary healthcare provider of this change
which nursing intervention is approbate when. client is first admitted with HHNS? a. provide oxygen b. encouraging carbs c. administering fluid replacement d. teaching facts about dietary principles
administering fluid replacement
while assessing the skin of a client, the nurse notices that the skin does not return to normal position immediately after a gentle pinch. which conditions would be a cause of this? select all that apply a. aging b. cachexia c. liver failure d. dehydration e. sun exposure
aging, cachexia, dehydration
which assessment finding indicates that a client has had a stroke? select all that apply a. lopsided smile b. unilateral vision c. incoherent speech d. unable to raise right arm e. symptoms started 2 hours ago
all of the above
an older clients colonoscopy reveals the presence of extensive diverticulosis. which type of diet would the nurse encourage the client to follow? a. low fat b. high fiber c. high protein d. low carb
high fiber
the nurse is completing the health history of a client admitted to the hospital with osteoarthritis. which joint would the nurse expect the client to report as having been involved first? select all that apply a. hips b. knees c. ankles d. shoulders e. metacarpals
hips, knees
which instructions would the nurse give to an older adult with decreased perception of touch? select all that apply a. use a cane for support when walking b. hold on to handrails while ambulating c. look where your feet are placed while walking d. wear shoes that give good support while walking e. if you are unable to change your position frequently, request assistance
hold on to handrails while ambulating, look where your feet are placed while walking, wear shoes that give good support while walking, if you are unable to change your position frequently, request assistance
which collaborative action will the nurse anticipate a need to implement when a client with acute myelocytic leukemia who is receiving chemotherapy develops tumor lysis syndrome? a. offer analgesics frequently b. infuse large amounts of fluids c. administer antibiotic therapy d. give anticoagulant medication
infuse large amounts of fluids
which goal would the nurse include in the plan of care for a client who manifest right sided hemianopsia as a result of a CVA? a. correct the clients misuse of equipment b. instruct the client to scan surroundings c. teach the client to look at the position of the left extremities d. provide the client with tactile stimulation to the affected extremities
instruct the client to scan surroundings
which complication of diabetes would the nurse suspect when a healthcare provider prescribes one tube of glucose gel for a client with type 1 diabetes? a. diabetic acidosis b. hyperinsulin secretion c. insulin induced hypoglycemia d. idiosyncratic reactions to insulin
insulin induced hypoglycemia
a clients fasting plasma glucose levels are being evaluated. the nurse identifies that the client is considered to be diabetic if the results are within which range? a. 2.2-3.3 b. 4.5-5.5 c. 5.6-6.9 d. 7-7.8
7-7.8
which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency and dribbling at the end of urination with a digital rectal exam report indicating smooth, firm and enlarged prostate tissue surrounding the urethra? a. prostatitis b. paraphimosis c. prostate cancer d. BPH
BPH
which statement by the wife of a client receiving hemodialysis who undergoes surgery to create an arteriovenous fistula indicates that further teaching is required? a. I must touch the shunt several times a day to feel for the bruit b. I have to take his blood pressure every day in the arm with the fistula c. he will have to very careful at night not a lie on the arm with the fistula d. we really should check the fistula every day for signs of redness and swelling
I have to take his blood pressure every day in the arm with the fistula
the nurse provides education to a client about how to prevent constipation. the nurse concludes that the teaching is understood when the client makes which statements? select all that apply a. I can eat potatoes at dinner daily b. I should drink at least 6 glasses of water a day c. I should eat eggs for breakfast d. I can include bran muffins in my breakfast daily e. I will walk every day as part of my exercise regimen
I should drink at least 6 glasses of water a day, I can include bran muffins in my breakfast daily, I will walk every day as part of my exercise regimen
which heart problem history would increase an older adults risk for experiencing a CVA a. glaucoma b. hypothyroidism c. continuous nervousness, stress d. TIAs
TIAs
which possible dysrhythmia woulda nurse anticipate testing for after noting that a client in the clinic has an irregularly irregular pulse rhythm at a rate of 88 bpm? a. a fib b. v tach c. complete heart block d. supraventricular tachycardia
a fib
which clinical manifestation would the nurse associate with successful fluid replacement? a. a trended urinary output of at least 30 mL/h b. central venous pressure reading of 1.5 mmHg c. baseline pulse rate of 120 bpm decreased to 110 bpm in 15 minutes d. baseline blood pressure increasing
a trended urinary output of at least 30 mL/h
which assessment finding would the nurse associate with a client with diabetic ketoacidosis? select all that apply a. diaphoresis b. retinopathy c. acetone breath d. increased atrial bicarbonate level e. decreased arterial carbon dioxide level
acetone breath, decreased arterial carbon dioxide level
which nursing action has specific gerontological implication the nurse must consider when caring for an older adult receiving chemo for cancer whose severe nausea and vomiting causes dehydration requiring hospital admission for rehydration therapy? select all that apply a. assessment of skin turgor b. documentation of vital signs c. assessment of intake and output d. administration of antiemetic medications e. replacement of fluid and electrolytes
assessment of skin turgor, administration of antiemetic medications, replacement of fluid and electrolytes
when would the nurse begin rehab planning for the client who is scheduled for a BKA? a. before surgery b. during convalescent phase c. discharge d. prosthesis fitting
before surgery
which intervention would be included in the plan of care of a client who underwent spinal surgery, reports pain at bony prominences and has skin breakdown and tears? select all that apply a. cleansing the ulcer with saline b. removing the loose bits of tissue c. measuring wound size every alternate week d. repositioning the client at least every 5 hours e. changing the old dressings daily if the ulcer is covered
cleansing the ulcer with saline, removing the loose bits of tissue, changing the old dressings daily if the ulcer is covered
which information about a client who is being discharged 3 days after having a STEMI and coronary artery stent placement indicates that a home health referral may be needed at discharge? a. ST segments have not yet returned to baseline b. troponin T and troponin I levels are still elevated c. client reports frequently forgetting to take medications d. pulse increases from 65 bpm to 75 bpm with exercise
client reports frequently forgetting to take medications
which client in the emergency department would the nurse assess first? a. client with chest pressure and ST segment elevation on the electrocardiogram b. client who reports a sharp chest pain with deep inspiration for the past week c. client who has history of HF with ascites and bilateral 4+ ankle swelling d. client with palpitations and paroxysmal a fib at a rate of 136 bpm
client with chest pressure and ST segment elevation on the electrocardiogram
when determining the main difference between type 1 and type 2 diabetes, the nurse recognizes which clinical presentation about type 1? a. onset of disease is slow b. excessive weight is a contributing factor c. complications are not present at the time of diagnosis d. treatment involves diet, exercise and oral meds
complications are not present at the time of diagnosis
which nursing action is most important for a client with urinary retention related to BPH who has a secondary diagnosis of delirium r/t urosepsis and a prescription for the insertion of an indwelling urinary retention catheter? a. secure a prescription for wrist restraints b. orient client to time, place and person c. involve family members in client care d. determine whether any unsafe behavior patterns exist
determine whether any unsafe behavior patterns exist
which assessment findings would the nurse identify in a client with clinical manifestations of RA? select all that apply a. obesity and symmetric joint disease b. development of antinuclear antibodies c. inflammatory disease pattern d. bilateral involvement of metacarpophalangeal joints e. disease process involving the distal interphalangeal joints f. disease in the weight bearing joints and hands
development of antinuclear antibodies, inflammatory disease pattern, bilateral involvement of metacarpophalangeal joints
which intervention by the home health nurse conforms to the use of safety competency while providing health care? a. ensures the furniture does not obstruct the clients movement b. updates the clients electronic health record after providing care c. coordinates with the local pharmacy to supply meds for client d. teaches family caregiver to assist the client with ROM
ensures the furniture does not obstruct the clients movement
which physiological change that occurs with aging causes stress incontinence? select all that apply a. estrogen deficiency b. prostatic enlargement c. decreased bladder capacity d. decreased sensory receptors e. unstable bladder contractions f. weakening of the urinary sphincter
estrogen deficiency, weakening of the urinary sphincter
which nursing action has the highest priority during the first 24 hours of a clients admission with right sided weakness, slight difficulty with speech and vital signs within normal limits? a. obtaining the clients temperature trends b. evaluating the clients motor status c. obtaining the clients urine for a urinalysis d. monitoring the clients blood pressure for hypertension
evaluating the clients motor status
which signs and symptoms are characters of Alzheimer dementia? select all that apply a. ambivalence b. forgetfullness c. flight of ideas d. loose associations e. expressive aphasia
forgetfullness, expressive aphasia
which complication of diabetes would the nurse assess for in a client with a long history of the disease? select all that apply a. leg ulcers b. lose of visual acuity c. increased creatinine clearance d. prolonged capillary refill in the toes e. decreased sensation in the lower extremities
leg ulcers, loss of visual acuity, prolonged capillary refill in the toes, decreased sensation in the lower extremities
the nurse is performing a skin assessment of a client. which findings may indicate a risk of skin cancer? a. lesion b. lumps c. rashes d. bruising e. dryness
lesion, lumps, rashes
which physiological change in the cardiovascular system is related to the aging process? select all that apply a. less sensitivity to B adrenergic drugs b. tachycardia when change position c. development of systolic murmurs d. shortening of the PR, QRS and QT intervals e. increase in systolic blood pressure
less sensitivity to B adrenergic drugs, development of systolic murmurs, increase in systolic blood pressure
which intervention would the nurse implement when a client with carotid atherosclerotic plaques who had a right carotid endarterectomy performed 2 hours ago begins to demonstrate clinical manifestations of progressive hypotension? a. notify healthcare provider immediately b. increase IV flow rate c. raise the head of clients bed d. place the client in the Trendelenburg position
notify healthcare provider immediately
which finding would be of most concern when the nurse assesses a client with emphysema? a. barrel chest b. oral cyanosis c. pursed lip expiration d. respirations 26 bpm
oral cyanosis
which intervention would the nurse include when developing a plan of care for an older client with dementia? a. explain to the client the details of the regimen b. demonstrate interest in the clients various likes and dislikes c. be firm when dealing with the clients attitudes and behaviors d. provide consistency in carrying out nursing activities for the client
provide consistency in carrying out nursing activities for the client
compromised nutrition during chemo can contribute to an increased risk of infection. which actions would the nurse take to offset this? a. provide oral supplements b. offer clients favorite foods c. restrict intake from diary products d. encourage client to drink low protein shakes
provide oral supplements
which rationale explains why IV potassium is prescribed in addition to regular insulin for clients in diabetic ketosis? a. potassium loss occurs rapidly from diaphoresis present during coma b. potassium is carried with glucose to the kidneys to excreted in the urine in increased amounts c. potassium is quickly used up during the rapid series of catabolic reactions stimulated by insulin and glucose d. serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment
serum potassium levels will decrease as potassium ions shift from the extracellular fluid to the intracellular fluid compartment
which information would the nurse include in the discharge teaching plan for a cline who sustained a CVA with residual hemiparesis and hemianopsia? a. necessity for bed rest at home b. use of oxygen therapy at home c. significance of a safe environment d. need for decreased protein in diet
significance of a safe environment
which info would the nurse include in the discharge teaching plan for a client who sustained a CVA with residual hemiparesis and hemianopsia? a. necessity for bed rest b. use of oxygen at home c. significance of safe environment d. decreased protein in the diet
significance of safe environment
which type of incontinence can be improved by teaching the client Kegel exercises? a. reflex b. stress c. overflow d. functional
stress
which nursing action would be in the plan of care of a client who had a CVA and now leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field? a. approaching the client from the left side b. keeping the clients head turned to the right c. teaching the client to use head movement to scan the left field of vision d. arranging furniture in the clients room so that the door is in the right visual field
teaching the client to use head movement to scan the left field of vision
which explanation would the nurse provide to a client about TIAs? a. temporary episodes of neurological dysfunction b. intermittent attacks caused by multiple small clots c. ischemic attacks that result in progressive neurological deterioration d. exacerbations of neurological dysfunction alternating with remissions
temporary episodes of neurological dysfunction
which behavior by a client who has a CVA begging to eat lunch indicates the client may be experiencing left hemianopsia? a. the client asks to have food moved to the left side of the tray b. the client drops the coffee cup when trying to use the right hand c. the client ignores food on the left side of the tray d. the client report not being able to use the right arm to help eat meals
the client ignores food on the left side of the tray
the client asks the nurse to recommend foods that might be included in a diet for diverticular disease. which foods would be correct to include in the teaching plan? select all that apply a. whole grains b. cooked fruits and veggies c. nuts and seeds d. lean red meats e. milk and eggs
whole grains, cooked fruits and veggies, nuts and seeds,milk and eggs
the nurse is assessing a client admitted with diabetic ketoacidosis. which statement made by the client indicates a need further education on sick day management? a. I will stop taking my insulin when I am ill because I am not eating b. I will check my urine for ketones when my blood sugar is over 250 c. I will alternate drinking gatorade and water throughout the day while ill d. I will continue all my insulin including my glargine when I am sick
I will stop taking my insulin when I am ill because I am not eating
the nurse is teaching an older client about proper medication use, which statement made by the client indicates further education? a. I will ask the pharmacist to give generic medications b. I will use OTC medicines along with prescribed meds c. I will continue my treatment by consulting a single health care provider d. I will know names and times of administration
I will use OTC medicines along with prescribed meds
which nursing intervention is appropriate to include in the plan of care for a client with diabetic ketoacidosis? a. IV administration of regular insulin b. administer insulin glargine subq at hour of sleep c. maintain nothing prescribed orally status d. IV administration fo 10% dextrose
IV administration of regular insulin
which medication is a beta adrenergic blocker used to reduce intraocular pressure? a. timolol b. travoprost c. carbachol d. apraclonidine
timolol
which response would the nurse offer when a client undergoing brachytherapy for breast cancer asks what precautions need to be observed? a. no restrictions b. all blood fluid is treated as radioactive c. you should maintain contact isolation d. visitors should be limited, particularly pregnancy women and children
visitors should be limited, particularly pregnancy women and children
which activity might cause chest pain in a client with stable angina? select all that apply a. deep breathing during meditation b. walking outside on a cold day c. sexual activity d. smoking a cigarette e. use of an oral decongestant
walking outside on a cold day, sexual activity, smoking a cigarette, use of an oral decongestant
which age related finding would the nurse expect to discover when assessing an older adult client a. big wide open eyes b. presence of facial hair c. a bruise on the elbow d. walking with neck bent forward
walking with neck bent forward
after presenting information about falls risk assessments to nursing staff, which participants statement needs review for corrective action? a. we will assess every admission to the unit b. we will implement a valid calls risk assessment tool c. we will apply yellow wrist bands to high risk clients d. we will use the admission fall assessment for the entire stay
we will use the admission fall assessment for the entire stay
which info would the nurse include when teaching a type 2 diabetic controlled with oral anti diabetic medications who is prescribed regular insulin when admitted for elective surgery? a. you will need a higher serum glucose level while on bed rest b. the stress of surgery may cause hypoglycemia c. with insulin, dosage can be adjusted to your changing needs during recovery from surgery d. the possibility of surgical complications is greater when client takes oral hypoglycemics
with insulin, dosage can be adjusted to your changing needs during recovery from surgery
which time indicates when the nurse would be alert to the possibility of a depressed client acting out suicidal thoughts? a. as the depression lifts b. if the depression is severe c. when the client has recovered from depression d. after client understands cause of depression
as the depression lifts
for a client arriving in the emergency department with a history of heart failure, which finding requires the most rapid action by the nurse? a. irregular apical pulse b. ox stat 86% c. crackles at both lung bases d. a fib on cardiac monitor
ox stat 86%
the nurse is assessing a client with a diagnosis of hemorrhoids. which factors int he clients history most likely played a role in the development of hemorrhoids? select all that apply a. constipation b. hypertension c. eating spicy foods d. bowel incontinence e. numerous pregnancies
constipation, numerous pregnancies
which information would the nurse include about future treatment and precautions when teaching a client who has glaucoma? a. avoidance of cholinergics b. surgical replacement of lens c. continuation of therapy for life d. prevention of high BP
continuation of therapy for life
which outcome is likely if the nurse palates a clients joints during an acute episode of RA? a. pain b. swelling c. nodule formation d. tophaceous deposits
pain
when a client with COPD reports a 5lb weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? a. polycythemia b. cor pulmonale c. compensated acidosis d. left ventricular failure
cor pulmonale
which skin damage is caused by chronic exposure to ultraviolet rays? select all that apply a. dryness b. photoaging c. vascular lesions d. wrinkling of skin e. benign neoplasma
photoaging, wrinkling of skin
which adverse effect will the nurse instruct the client to anticipate when prescribed albuterol to relieve severe asthma? select all that apply a. tremors b. lethargy c. palpitations d. bronchoconstriction e. decreased pulse rate
tremors, palpitations
which statement made by the caregiver about pressure injury care indicates need for further teaching? a. I will inspect clients skin daily b. I will manage the clients incontinence as quickly as possible c. I will properly dispose of clients contaminated dressings d. I will not worry about what the client eats
I will not worry about what the client eats
a 50 year old client has difficulty communicating because of expressive aphasia after a CVA. when the nurse inquired about the clients feelings, the spouse responds, which communication strategy would the nurse use to address this behavior? a. ask the spouse how they know the clients feelings b. instruct the spout to let the client answer c. when the spouse levels, return to speak with the client d. acknowledge the spouse, but look at the client for a response
acknowledge the spouse, but look at the client for a response
which information would support the nurses decision to arrange for a staff member to remain with a depressed client continuously? select all that apply a. refusal to eat b. inability to concentrate c. agitated pacing in hall d. history of suicide attempts e. statements that life is not worth living
agitated pacing in hall, history of suicide attempts, statements that life is not worth living
when a client is seen in the emergency department with sudden onset severe dyspnea, coughing and wheezes, which prescribed treatment would the nurse administer first? a. inhaled corticosteroid b. normal saline infusion c. albuterol via nebulizer d. IV methylprednisolone
albuterol via nebulizer
which fact would the nurse assess for a client report constipation? select all the apply a. diet b. fluid intake c. use of laxatives d. date of last bowel movement e. use of opioid pain medications
all of the above
which medication would the nurse anticipate administering to a client receiving cisplatin therapy who developed tumor lysis syndrome? a. mesna b. flavoxate c. allopurinol d. apreptiant
allopurinol
which sign or symptom would the nurse expect a client with hemorrhoids to report? select all that apply a. flatulence b. anal itching c. blood in stool d. rectal bulging e. pain when defecating
anal itching, blood in stool, rectal bulging, pain when defecating
which finding in a client with a diagnosis of stable angina is most important for the nurse to communicate to the health care provider? a. anginal symptoms are relieved by rest b. discomfort is described as chest pressure c. radiation of pain to the left arm and back occurs d. angina episodes are occurring more frequently
angina episodes are occurring more frequently
which data would the nurse to determine a clients score on the Braden Scale to predict a clients risk for developing pressure injuries? select all that apply a. age b. anorexia c. hemiplegia d. history of diabetes e. urinary incontinence
anorexia, hemiplegia, history of diabetes, urinary incontinence
which property would the nurse understands that the medication is being used primarily for when aspirin is prescribed on a regular scheduled for a client with RA? a. analgesic b. antipyretic c. anti inflammatory d. anti platelet
anti inflammatory
a client appears depressed and tense and reports various aches and pains since their spouses death 3 months ago. which intervention would the nurse first? a. ask the client to talk about the spouses death b. ask for specific description of pain c. ask provider about antidepressant use d. ask about participation in family activities
ask the client to talk about the spouses death
which action would the nurse take when a client returning to the unit after a transurethral vaporization of the prostate with an indwelling urinary catheter and continuous bladder irrigation reports thinned to urinate? a. encourage client to drink fluids b. review clients intake and output c. assess that the tubing attached to collection bag is patent d. explain that the balloon inflated in the bladder causes this feeling
assess that the tubing attached to collection bag is patent
during a fall risk assessment, which action would the nurse take after learning the client experienced a recent fall? a. apply restraints b. discontinue all medications to remove risk of polypharmacy c. assess the circumstances of the falling, including feelings and setting d. require family members to remain at the bedside to watch over the client
assess the circumstances of the falling, including feelings and setting
which assessment would the nurse complete after a client has an open reduction internal fixation of a fractured hip? a. assess femoral pulse b. assess toes for mobility c. check condition of the pin d. monitor range of motion of knee
assess toes for mobility
which action would the nurse implement first for a client whose serum potassium level has increased to 5.8 mEq/L a. assess vital signs b. call the lab to repeat the test c. informs the cardiac arrest team to place them on alert d. perform an electrocardiogram
assess vital signs
the nurse is planning care for an immobilized client who had a stroke with right sided hemiparesis. which activity would the nurse include in the plan of care? a. assess the clients lung sounds daily b. assist the client to perform ROM exercises every 1-2 hours c. allow the client to sit upright in the chair for as long as tolerated d. have the unlicensed nursing personnel reposition the client every 4 hours
assist the client to perform ROM exercises every 1-2 hours
which approach would the nurse use when managing the care of a client diagnosed with GAD? a. creating an anxiety free environment for the client b. assisting the client with development of health, adaptive coping mechanisms c. avoiding triggers that produce anxiety in the client d. providing reinforcement that the clients anxiety issues can be eliminated
assisting the client with development of health, adaptive coping mechanisms
which info would the nurse include in the teaching plan of a client who is receiving combo chemo for stage II Hodgkins disease and is at risk for stomatitis? a. rinse mouth 3 times a day with lemon juice b. brush the teeth once daily and use dental floss after each meal c. clean the mouth with a soft toothbrush or gentle spray d. gently clean the mouth with commercial mouthwash
clean the mouth with a soft toothbrush or gentle spray
the nurse provides education to a client with the diagnosis of bone cancer that a metastasis to the lung. which client statement indicates the need for further teaching related to the concept of metastasis? a. because my cancer has spread, my diagnosis now is lung cancer b. even though pain isn't experienced, a person can still have metastasis c. I can have metastases to other parts of my body d. I need to talk with my healthcare provider about possibility of more metastases
because my cancer has spread, my diagnosis now is lung cancer
when obtaining a clients health history, which factor would the nurse identify as predisposing the client to type 2 diabetes? a. having diabetes insipidus b. eating low cholesterol foods c. being 20 pounds overweight d. drinking a daily alcoholic beverage
being 20 pounds overweight
which medication prescribed for a client with an acute episode of heart failure would the nurse question? a. diuretic b. beta blocker c. long acting nitrate d. angiotensin receptor blocker
beta blocker
which test result would confirm the diagnosis of BPH a. digital rectal examination b. serum phosphatase level c. biopsy of prostatic tissue d. massage of prostatic fluid
biopsy of prostatic tissue
for a client with a hemorrhagic stroke secondary to a motor bike accident, which client finding requires immediate attention? a. glasgow coma score of 10 b. body temp 81.2 c. O2 state 90% d. BP 80 mmHg
body temp 81.2
the nurse is caring for a client admitted with peritonitis. which finding in the medical record is most likely the cause? a. gastritis b. hiatal hernia c. diverticulosis d. bowel obstruction
bowel obstruction
which manifestation would the nurse include when teaching a client about ketoacidosis? select all that apply a. confusion b. hyperactivity c. excessive thirst d. fruit scented breath e. decreased urinary output
confusion, excessive thirst, fruit scented breath
which finding in the older adult client is associated with a UTI? select all that apply a. dysuria b. urgency c. confusion d. incontinence e. slight rise in temperature
confusion, incontinence, slight rise in temperature
which common response do clients with cancer experience, regardless of the site of the cancer, that accounts for their cachexia? a. depression precipitates anorexia b. changes in taste and food aversions c. decreased salvia impedes chewing and swallowing d. decreased GI absorption of nutrients
changes in taste and food aversions
the nurse identifies that which type of care is removed when patient is placed in hospice? select all that apply a. chemo b. repositioning c. regular oral care d. blood transfusions e. radiation
chemo, blood transfusions, radiation
which sign or symptom supports the nurses suspicion that a client has overflow incontinence? a. constant dribbling of urine b. abrupt and strong urge to void c. loss of urine with physical exertion d. large amount of urine loss with each occurrence
constant dribbling of urine
which point requires correction regarding wellness promotion in the older adult? select all that apply a. older adults need to prevent injuries when promoting wellness b. curing diseases or other illnesses completely is essential to promote wellness in the older adult c. it is important to assess the level of fear of falling and provide support accordingly when caring for older adults d. it is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries e. an older adult should live in social isolation to prevent stress
curing diseases or other illnesses completely is essential to promote wellness in the older adult, it is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries, an older adult should live in social isolation to prevent stress
which clinical manifestation would the nurse observe in an older client diagnosed with major depressive disorder? select all that apply a. loss of memory b decreased appetite c. neglect of personal hygiene d. I don't know answer to questions e. I can't remember answer to questions
decreased appetite, neglect of personal hygiene, I don't know answer to questions, I can't remember answer to questions
a client reports diminished sensations of pain, touch and temperature on the skin. the nurse touches the skin and finds it cool. which skin changes would he nurse relate tot he clients findings? a. degenerated elastic fibers b. decreased blood flow to the skin c. increased melanocytes in basal layer d. decreased activity of the apocrine glands
decreased blood flow to the skin
which age related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? a. atrophy of the sweat glands b. decreased subcutaneous fat c. stiffening of the collagen fibers d. degeneration of elastic fibers
decreased subcutaneous fat
when assessing a client with right ventricular heart failure, the nurse would expect which finding? select all the apply a. dependent edema b. swollen hands and fingers c. collapsed neck veins d. right upper quadrant discomfort e. oliguria
dependent edema, swollen hands and fingers, right upper quadrant discomfort
which assessment finding is associated with cranial nerve dysfunction after carotid endarterectomy? a. labored breathing b. edema of the neck c. difficulty in swallowing d. alteration in blood pressure
difficulty in swallowing
a client admitted with a history of emphysema and a diagnosis of acute respiratory failure with respiratory acidosis has oxygen at 3L/min nasal cannula. four hours after admission, the client exhibits increased restlessness and confusion followed by a decreased respiratory rate and lethargy. which intervention would the nurse implement at this time? a. question the client about the confusion b. change the method of oxygen delivery c. percuss and vibrate the clients chest wall d. discontinue or decrease the oxygen flow rate
discontinue or decrease the oxygen flow rate
which question asked by the nurse would help confirm the diagnosis in a client who is suspected of having candidiasis? select all that apply a. do you have interdigital scaling and maceration b. do you have experience scaliness user the distal nail plate c. do you have cheesy plaques in the mouth resembling milk curds d. do you have red rashes with satellite lesions around the affected area e. do you have white patches in the groin area with increased vaginal discharge
do you have cheesy plaques in the mouth resembling milk curds, do you have red rashes with satellite lesions around the affected area, do you have white patches in the groin area with increased vaginal discharge
which assessment finding indicates to the nurse that a client with COPD who is receiving oxygen is retaining CO2? select all that apply a. anxiety b. drowsiness c. irregular pulse d. mental confusion e. increased respirations
drowsiness, irregular pulse, mental confusion
when would the nurse observe a client to assess their level of functioning? select all that apply a. during mealtime b. when talking about pain c. when preparing medication d. during the assessment interview e. when administering insulin
during mealtime, when preparing medication, when administering insulin
which instruction regarding nutrition will the nurse give a client discharged after a short hospitalization for an epidote of an TIA related to hypertension who is on a regimen that includes cholorthiazide? a. eat more dark green leafy vegetables b. substitute a potassium based salt sub for table salt c. return to previous eating habits d. increase intake of diary produces
eat more dark green leafy vegetables
the nurse recommends that, when in bed, a client who has osteoarthritis should lie in the supine or prone position, the client states that these positions are uncomfortable for the knees and hips. which action would the nurse take? a. encourage the client to maintain extension for specific periods of time b. urge the client to lie in whatever position is most comfortable c. insert a pillow under the clients knees to relieve discomfort d. place the client in semi fowler position
encourage the client to maintain extension for specific periods of time
which intervention would the nurse implement after determining that a client, who sustained a CVA, needs assistance with eating for optimum nutrition? a. request that the clients food be pureed b. feed the client to conserve the clients energy c. have a family member assist the client with each meal d. encourage the client to participate in the feeding process
encourage the client to participate in the feeding process
a client is hospitalized for an exacerbation of emphysema. the client is experiencing a fever, chills and difficulty breathing on exertion. which is an important nursing action? a. checking for capillary refill b. encouraging increased fluid intake c. suctioning secretions from the airway d. administering a high concentration of oxygen
encouraging increased fluid intake
the nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. which interventions would the nurse include to decrease the risk of complications? select all that apply a. examine feet daily b. wear well fitting shoes c. perform regular exercise d. powder the feet after showering e. visit the primary health care provider weekly f. test bathwater with the toes before bathing
examine feet daily, wear well fitting shoes, perform regular exercise
for which prescription would the nurse seek clarification when reviewing the plan of care for the geriatric client with less than adequate nutritional intake? a. have client sit in a chair for meals to prevent aspiration of food/liquid into the lungs b. provide 6 small feeding in 24 hours and whenever requested by the client c. give on can of diet supplement at 8am with breakfast and at 4pm before evening meal d. encourage the clients family members to bring food from home
give one can of diet supplement at 8am with breakfast and at 4pm before evening meal
which nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom a. instructing the client to be quiet b. allowing the client to act on until fatigue sets in c. immediately guiding the client from the room d. giving the client one simple direction at a time in firm voice
giving the client one simple direction at a time in firm voice
an older client who has been taking lorazepam for several years is scheduled for a procedure that requires the client to be away for the duration. the client has a history of violence and hypotension. which antipsychotic medication is approbate to administer the client during the procedure? select all the apply. a. loxapine b. risperidone c. haloperidol d. perphenazine e. olanzapine IM f. cholopromazine
haloperidol, perphenazine
which explanation would the nurse provide about the clients behavior when family members of a client who has CVA ask why the client cries easily and without provocation? a. has little control over this behavior b. is making an attempt to get attention c. feels guilty about the demands being made on the family d. has selective memory from the pasts, especially sad events
has little control over this behavior
when a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? a. giving flu vaccine to client b. having suction available during meals c. assisting the client to take deep breaths d. teaching about incentive spirometer use
having suction available during meals
which adverse effect of warfarin will the nurse identify as a reason for a client with a partial occlusion of the left common carotid artery to seek medical attention? select all that apply a. hematuria b. hemoptyisis c. delayed clotting d. bleeding from gums e. vomiting coffee ground emesis
hematuria, hemoptysis, vomiting coffee ground emesis
which disease is caused by the virus that causes chickenpox? a. athletes foot b. herpes zoster c. German measles d. infectious hepatitis
herpes zoster
which skin infection does the nurse expect to observe in the electronic medical record of an older adult client with postherapeutic neuralgia who reports deep tissue pain a. cellulitis b. candidiasis c. herpes zoster d. herpes simplex
herpes zoster
which technique would the nurse reinforce when teaching a client how to self administer eyedrops cataract surgery? a. placing the drops on the cornea of the eye b. raising the upper eyelid with gentle traction c. holding the dropper tip above the conjunctival sac d. squeezing the eye shut
holding the dropper tip above the conjunctival sac
which health care system focuses on palliative care? a. hospice b. rehab c. assisted living d. extended care facilities
hospice
with which condition would the nurse associate the response of diaphoresis, weakness and pallor at 3:30pm in a client with type 1 diabetes who receives 30 units of NPH insulin at 7am? A. diabetic coma b. HHNS c. DKA d. hypoglycemic reaction
hypoglycemic reaction
which response would the nurse give to a client taking ibuprofen for rheumatoid arthritis who asks the nurse if acetaminophen can be substituted? a. yes, both are antipyretics and have the same effect b. acetaminophen irritates the stomach more than ibuprofen does c. acetaminophen is the preferred treatment for RA d. ibuprofen has anti-inflammatory properties and acetaminophen does not
ibuprofen has anti-inflammatory properties and acetaminophen does not
which initial action would the nurse take for a nursing home resident with moderate Alzheimer disease who beings to engage in numerous acting out behaviors? a. assess clients LOC b. identify stressors that precipitate the clients behavior c. observe the clients performance of ADLs d. monitor side effects of medications
identify stressors that precipitate the clients behavior
which finding is important to communicate to the healthcare provider when the nurse assesses a client who has had a carotid endarterectomy? a. poor appetite b. impaired swallowing c. decreased neck range of motion d. slight swelling along the incision
impaired swallowing
what info from a clients history would the nurse identify as risk factors for the development of colon cancer? select all that apply a. hemorrhoids b. increased age c. high fiber diet d. ulcerative colitis e. low hemoglobin level
increased age, ulcerative colitis
which lab value supports the presence of diabetic ketoacidosis in a client with type 1 diabetes? a. decreased serum glucose levels b. decreased serum calcium levels c. increased blood urea nitrogen levels d. increased serum bicarbonate levels
increased blood urea nitrogen levels
which age related change would the nurse consider when formulating a plan of care for an older adult? select all that apply a. difficulty in swallowing b. increased sensitivity to heat c. increased sensitivity to glare d. diminished sensation of pain e. heightened response to stimuli
increased sensitivity to glare, diminished sensation of pain
which lab value supports the presence of diabetic ketoacidosis? a. increased serum lipids b. decreased hematocrit level c. increased serum calcium levels d. decreased blood urea nitrogen level
increased serum lipids
which conditions can precipitate delirium? select all that apply a. infection b. dementia c. dehydration d. urine retention e. medications
infection, dehydration, urine retention, medications
which factor explains why a client who experiences an acute episode of RA has swollen finger joints? a. urate crystals in the synovial tissue b. inflammation in the joints synovial lining c. formation of bony spots on the joint surfaces d. deterioration and loss of articular cartilage joints
inflammation in the joints synovial lining
which finding for an 85 year old client would be of concern to the nurse? a. distant heart tones b. irregularly irregular pulse c. fatigue after walking in hallway d. tortuous veins on lower legs
irregularly irregular pulse
which info will the nurse emphasize when teaching skin care to a client scheduled to receive irradiation to the chest wall after a tumor was removed from the lung? a. keep the skin dry to protect it from excoriation b. using lotion twice daily c. massage skin four times a day d. washing area frequently
keep the skin dry to protect it from excoriation
which term would the nurse to document a client experiencing urinary incontinence via involuntary loss of small amounts of urine from an over distended bladder? a. urge incontinence b. stress incontinence c. overflow incontinence d. functional incontinence
overflow incontinence
the nurse is teaching pursed lip breathing to a client with COPD. the client asks about the benefit of exercises. which explanation would the nurse give? a. prevents complications that are associated with COPD b. relieves SOB by increasing the breath rate c. increases the amount of air that the client can inhale with each breath d. keeps the airway open longer to decrease the work that goes into breathing
keeps the airway open longer to decrease the work that goes into breathing
the nurse is teaching pursed lip breathing to a client with COPD. the client asks about the benefit of the exercises. which explanation would the nurse give? a. prevents complications of COPD b. receives SOB by increasing breath rate c. increased the amount of air that the client can inhale with each breath d. keeps the airway open longer to decrease the work that goes into breathing
keeps the airway open longer to decrease the work that goes into breathing
which unique response is associated with DKA that is not exhibited with HHNS? a. fluid loss b. glycosuria c. kussmaul respirations d. increased blood glucose level
kussmaul respirations
a client has a stroke that involves the right cerebral cortex and cranial nerves. which area of paralysis would the nurse expect fo find upon assessment. select all that apply a. left arm b. left leg c. right leg d. right arm e. left side of face
left arm, left leg, left side of face
normal findings during regular checkup of older adult? select all that apply a. loss of turgor b. urinary incontinence c. decreased night vision d. decreased mobility of ribs e. increased senstivity to odors
loss of turgor, decreased night vision,decreased mobility of ribs
the nurse is teaching a client newly diagnosed with type 1 diabetes about self care. which is the primary long term goal? a. maintaining normoglycemia b. complying with diabetic diet c. adhering to an exercise program d. developing a nonstressful lifestyle
maintaining normoglycemia
which risk factors regarding fall prevention and safest for older adults would the nurse manage include in a presentation to a group of nurses? select all that apply a. medications b. visual changes c. urinary retention d. decreased appetite e. orthostatic hypotension
medications, visual changes, orthostatic hypotension
which skin growth would require healthcare provider follow up evaluate for possible skin cancer? a. mole that is solid black b. mole with equal borders c. mole that is 12 mm wide d. mole of symmetrical size
mole that is 12 mm wide
which nursing intervention would be the highest priority when caring for patient with suspected TB a. move the client to an airborne isolation unit b. emphasize hadn't washing after handling soiled tissues c. inform the client about adherence with the prescribed regimen d. report the clients condition to the primary health care provider
move the client to an airborne isolation unit
which precipitating factor for depression would be common in the older adult without neurocognitive problems? select all that apply a. dementia b. multiple losses c. declines in health d. milestone birthday e. traumatic injury
multiple losses, declines in health
after instructing an older clients adult child about age related immune system changes and associated care measures, which statement indicates a need for further instruction? a. my parent has a private room at home b. my parent has received the pneumococcal vaccination recently c. my parents comes in for checkups only when experiencing a fever d. my parent has been given s second dose of the pertussis vaccination
my parents comes in for checkups only when experiencing a fever
which explanation will the nurse provide to a client with cancer who develops pancytopenia during the course of chemo and asks the nurse why this occurred? a. the medications used for chemo interacted with other meds you are taking b. lymph node activity is depressed by the radiation therapy used before chemo c. noncancerous cells are also susceptible to the effects of chemotherapeutic medications d. dehydration caused by nausea, vomiting and diarrhea results in hemoconcentration
noncancerous cells are also susceptible to the effects of chemotherapeutic medications
which information will the nurse share about alopecia characteristics to a client who is to receive chemotherapy after surgery for cancer a. rare b. not permanent c. frequently prolonged d. usually preventable
not permanent
which nursing action is most approbate to help reduce the likelihood of an older adult falling during the night? a. moving the clients bedside table closer to the bed b. encouraging the client to take an available sedative c. instructing the client to call the nurse before going to the bathroom d. assisting the client to telephone home to say goodnight to spouse
nstructing the client to call the nurse before going to the bathroom
which action would the nurse instruct an older client to implement to ensure antibody mediated immunity? select all that apply a. obtain shingles vaccination b. receive a tetanus booster injection c. obtain the pneumococcal vaccination d. receive annual testing for tuberculosis e. receive an annual influenza vaccination f. avoid obtaining the pertussis vaccination
obtain shingles vaccination, receive a tetanus booster injection, obtain the pneumococcal vaccination, receive an annual influenza vaccination
which reason for a decrease in height is common in older females? a. older adults have lower levels of growth hormone b. older adults are not active enough, so they lose bone mass c. older adults have poor posture, so they are shorter d. older adults may have osteoporosis-related height changes
older adults may have osteoporosis-related height changes
which client has the greatest risk for a completed suicide? a. young adult who acutely psychotic b. adolescent who was recently sexually abused c. older single man diagnosed with pancreatic cancer d. middle aged woman experiencing dysfunctional grieving
older single man diagnosed with pancreatic cancer
a client with left sided weakness is learning how to use a cane. the nurse would demonstrate proper use of the cane by holding it where? a. on alternating sides b. on the right side c. on the side with weakness d. one the side of clients choice
on the right side
when teaching a client about their disease process, which term would the nurse use to describe bone loss greater than normal but less than that caused by osteoporosis? a. osteopenia b. osteomyelitis c. osteomalacia d. osteoarthritis
osteopenia
which nursing action is essential when client experiences hemianopsia as the result of a left ischemic stroke? a. place objects within the visual field b. teach passive range of motion exercises c. instill artificial teardrops into the affected eye d. reduce time client is positioned on the left side
place objects within the visual field
which action indicates the need for additional teaching when the nurse is educating a client on the use of heat and cold for OA pain? a. places ice pack on skin b. uses ice pack for 20 minutes c. applies lightweight heating pad d. tests water before getting into shower
places ice pack on skin
a child with a diagnosis of acute renal failure has additional blood drawn for lab testing. which serum level requires immediate intervention? a. sodium 125 mEq/L b. bilirubin 0.3 mg/dL c. creatinine 1.3mg/dL d. potassium 6.1 mEq/L
potassium 6.1 mEq/L
which information about bPH is important for the nurse to consider when caring for a client with that condition? a. it is a congenital abnormality b. a malignancy usually results c. predisposes to hydronephrosis d. prostate specific antigen decreases
predisposes to hydronephrosis
which goal is the nurse trying ti achieve with continuous bladder irrigations of a client who has undergone a suprapubic prostatectomy for cancer of the prostate? a. stimulate continuous formation of urine b. facilitate the measurement of urinary output c. prevent the development of clots in the bladder d. provide continuous pressure not he prostatic fossa
prevent the development of clots in the bladder
which purpose would potassium chloride added to the IV solution of ancient with diabetic ketoacidosis serve? a. treats hyperpnea b. prevents flaccid paralysis c. prevents hypokalemia d. treats cardiac dysrhythmias
prevents hypokalemia
which interventions would the nurse perform while caring for an actively dying patient? select all that apply a. admit the client in hospice b. perform aggressive lab tests c. provide client and family reassurance d. keep client undisturbed for long periods of time e. offer symptom management to the client
provide client and family reassurance, offer symptom management to the client
which nursing intervention would help an older adult experiencing urinary incontinence? select all that apply a. provide nutritional support b. provide voiding opportunites c. avoid indwelling catheterization d. provide beverages and snacks frequently e. promote measures to prevent skin breakdown
provide voiding opportunites, avoid indwelling catheterization, promote measures to prevent skin breakdown
which purpose would the nurse associate with respite care? a. assisting the client with meals and personal care b. providing short term relief to the family care giver c. providing skilled nursing interventions for the client d. providing counseling and treatment for behavioral problems
providing short term relief to the family care giver
how can the nurse best manage a common side effect of chemotherapy? a. restricting fluid intake b. insinuating contact precautions c. keeping the hair closely cropped d. provoding meticulous oral hygiene
provoding meticulous oral hygiene
a client with COPD is breathing rapidly and using accessory muscles of respiration. the nurse osculates the lungs and hears crackles and wheezes. which action would the nurse take? a. encourage the client to take slow deep breaths and administer 5L oxygen per nasal cannula b. place the client in side lying position and performs test physiotherapy c. raise head of the bed to high fowler, administer 2L/min oxygen per nasal cannula d. assist the client in assuming a position of comfort and perform postural drainage
raise head of the bed to high fowler, administer 2L/min oxygen per nasal cannula
which characteristic mental change occurs with delirium and differentiates it from dementia? a. daytime sleepiness b. rapid onset confusion c. lasts several years d. progressive deterioration
rapid onset confusion
which color would the nurse anticipate when assessing a clients skin tears? a. red b. gray c. black d. yellow
red
which action would the nurse implement to assist a clients development of independence, after experiencing a CVA 2 weeks ago? a. establish long range goals for the client b. reinforce success in tasks accomplished c. point out error in performance on which to focus d. explain ways the client can regain independence in activities
reinforce success in tasks accomplished
which pain characteristic would the nurse expect to observe when a client is experiencing anginal pain? a. unchanged by rest b. precipitated by light activity c. described as a knifelike sharpness d. relieved by sublingual nitroglycerin
relieved by sublingual nitroglycerin
which manifestations are seen in an older adult with the diagnosis of dementia? select all that apply a. resistance to change b. inability to recognize familiar objects c. preoccupation with personal appearance d. inability to concentrate on new activities e. tendency to dwell on the past
resistance to change, inability to recognize familiar objects, inability to concentrate on new activities, tendency to dwell on the past
which clinical manifestation is expected for a client with moderate dementia? select all that apply a. restless b. pessimism c. short attention span d. disordered reasoning e. impaired motor activités
restless, short attention span, disordered reasoning, impaired motor activities
which finding of a client several hours after removal of a catheter inserted a week prior after pelvic surgery indicates a need for reinsertion of the catheter? a. anuria b. polyuria c. retention d. incontinence
retention
which eye problem is the leading cause of blindness in clients with diabetes? a. cataracts b. glaucoma c. retinopathy d. astigmatism
retinopathy
which dinging for a client who has a diagnosis of paroxysmal atrial fibrillation is most important to report quickly to the healthcare provider? a. irregular heartbeat b. right arm weakness c. client report of palpitations d. client report of lightheadedness
right arm weakness
which action would the nurse perform when administering fluticasone propionate to a client with asthma? a. assessing heart rate and rhythm b. monitoring liver function blood tests c. rinsing the oral cavity with water after use d. obtaining blood glucose levels before meals
rinsing the oral cavity with water after use
which information is most important to include when the nurse is teaching a client who has had an STEMI about the purpose of salt restriction? a. low salt intake helps prevent ankle swelling b. salt intake increases the work of the heart c. decreasing salt intake will lower blood pressure d. salt intake prevents diuretics from being effective
salt intake increases the work of the heart
which behavior would the nurse include when teaching a family what to expect from a client who experienced a stroke on the left side of the brain? select all that apply a. impaired judgement b. spatial perceptual deficits c. slow performance and caution d. impaired speech/language aphasias e. tendency to deny or minimize problems f. awareness of deficits with depression and anxiety
slow performance and caution, impaired speech/language aphasias, awareness of deficits with depression and anxiety
which physiological change of the musculoskeletal system would the nurse associate with aging? select all that apply. a. slowed movement b. cartilage degeneration c. increased bone density d. increased range of motion e. increased bone prominence
slowed movement, cartilage degeneration, increased bone prominence
which rationale describes the nurses behavior for sitting with a severely depressed client and making no demands on the client? a. nurses are required to spend time with assigned clients b. environmental stimulation helps depressed clients feel more worthwhile c. nurses are expected to initiate one on one interactions on an acute care unit d. spending time with depression client demonstrates that they are worthy of attention
spending time with depression client demonstrates that they are worthy of attention
which action would the nurse take for an older client with Alzheimer who has intermittent episodes of urinary incontinence? a. point out behavior to the client b. obtain incontinence pads for the client c. take the client to the bathroom at regular intervals d. encourage the client to call for help when there is an urge to urinate
take the client to the bathroom at regular intervals
which action would the nurse take first after obtaining a radial pulse of 136 bpm in a client with chronic a fib? a. ask about any new stressors in the clients life b. take the clients apical pulse for a full minute c. notify the health care provider about the heart rate d. ask whether prescribed medications have been taken
take the clients apical pulse for a full minute
which statement by a client who had an endarterectomy that is prescribed clopidogrel would cause the nurse to conclude that teaching was effective? a. clopidogrel will limit inflammation around my incision b. taking this medication will help prevent further clogging of my arteries c. the medication will lower the slight fever I have had since surgery d. I will take this medication to reduce the discomfort I feel at the surgical incision
taking this medication will help prevent further clogging of my arteries
which action oft he student nurse my have resulted in an increase in the risk for skin tear when caring for a client who's dermal epidermal junction is flattened? a. taping the clients skin b. encouraging the client to take vitamin D supplements c. assisting the client to change positions at 4 hour intervals d. avoiding the removal of the clients adhesive wound dressings
taping the clients skin
which action would be used to decrease risk for post op respiratory complications in an older client with decreased vital capacity? a. give prescribed IV antibiotic b. administer oxygen per nonrebreather mask c. teach the client coughing and eep breathing exercises d. keep the client on the mechanical ventilation for several days
teach the client coughing and eep breathing exercises
the nurse is educating the client newly diagnosed with type 2 diabetes on oral anti diabetic medications. which instruction would the nurse include in the teaching plan? select all that apply a. the client should obtain a finger stick blood glucose before each meal b. the client does not need to follow a specific diet until insulin is required c. the teaching plan should include signs and symptoms of hypoglycemia d. the teaching plan should include how to administer regular insulin e. the teaching plan should include sick day rules
the client should obtain a finger stick blood glucose before each meal, the teaching plan should include signs and symptoms of hypoglycemia, the teaching plan should include sick day rules
which difference between the two methods of access with nursing consider in planning care for a client with end stage renal disease who has an internal arteriovenous fistula in one arm and an external arteriovenous shunt in the other arm? a. the graft is more subject to hemorrhage, clotting and infection than the fistula is b. blood pressure readings can be taken in the arm with fistula but not shunt c. IV fluids can be administered in the arm with the shunt d. fistula should have a light dressing
the graft is more subject to hemorrhage, clotting and infection than the fistula is
an older adult is hospitalized for weight loss and dehydration due to nutritional deficit. which factor would the nurse consider when planning care for this client? a. financial resources usually are unrelated to nutritional status b. an older adults daily fluid intake must be increased c. the clients diet should be high in carbohydrates and low in proteins d. the nutritional needs of an older adult are basically unchanged except for a decreased need for calories
the nutritional needs of an older adult are basically unchanged except for a decreased need for calories
which focus would the nurse associate with hospice care? a. to ease the pain from illness b. to provide curative treatment c. to assist with activities of daily living d. to adopt to the limitations due to an illness
to ease the pain from illness
which approach would the nurse take for an older adult client who is confused, does not recognize family members and often soils clothing with feces and urine? a. toileting the client every 2 hours b. placing the client in orientation therapy c. supervising the clients bathroom activities closely d. explaining to the client how offensive the behavior is to others
toileting the client every 2 hours
which result would the nurse expect to find when assessing the lab values of a client with type 2 diabetes? a. ketones in the blood but not in the urine b. glucose in the urine but not in the blood c. urine and blood glucose and ketones d. urine negative for ketones and positive glucose in the blood
urine negative for ketones and positive glucose in the blood
which info would the nurse provide an older adult and caregivers regarding medication safety? select ask that apply a. use a pill organizer b. read all medication labels c, place pills in unlabeled bottles d. review medications with pharmacist e. empty medicine cabinet every 2 years
use a pill organizer, read all medication labels, review medications with pharmacist
which factor may have led to the development of flexion contractors in a client with OA a. wearing shoes without insolues b. elevating the legs 8-12 inches c. using large pillows under the knees or head d. placing a small pillow under the head in the supine position
using large pillows under the knees or head
the nurses assess for which client symptoms that indicate hyperthermia? select all that apply a. vasodilation b. dry and flushed skin c. pale and cyanotic skin d. decreased capillary refill e. decreased urinary output
vasodilation, dry and flushed skin, decreased urinary output
which activates would the nurse initiate for a client with Alzheimer disease who is admitted to a long term facility? select all that apply a. weighing the client once a week b. having specialized rehabilitation equipment available c. keeping the client in pjs and robe most of the day d. establishing a schedule with periods of rest e. reviewing clients weekly budget and use of community resources d. setting up a plan for weekly entertainment through a senior citizens travel group
weighing the client once a week, having specialized rehabilitation equipment available, establishing a schedule with periods of rest
which specific instruction would the nurse provide to a client with urinary incontinence who is prescribed amitriptyline? a you should avoid dehydration b. you should monitor your urine output c. you should rise slowly when getting up from a sitting or lying position d. you should periodically check your blood pressure
you should rise slowly when getting up from a sitting or lying position
which response will the nurse provide when a client taking a loop diuretic asks the nurse why changing positions slowly is necessary? a. your high blood pressure may case headaches with position change b. you will experience potassium fluctuations that will affect your balance c. you will need to rush to the bathroom while on the diuretic and we want to ensure you are safe d. your blood pressure may drop with position changes, leading to dizziness and risk of falling
your blood pressure may drop with position changes, leading to dizziness and risk of falling
