Adult Health

TThe nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath?

"Do you have any allergies?"

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement?

"Fresh foods such as fruits and vegetables are high in sodium."

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure?

"The uterus weighs about 2 ounces."

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client?

"You will need to talk to your primary health care provider (PHCP) before using an herbal substance."

The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply.

- "I will not sleep lying on my left side." - "I will sit at the table to eat breakfast." - "I will sit in my recliner with my feet elevated." - "I will not lift anything heavier than 10 pounds."

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, which foods would the nurse tell the client are best to include in the diet for this disorder? Select all that apply.

- Apples - Whole-grain bread

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions? Select all that apply.

- Collect data to determine factors for fall risk. - Instruct the client to ask for assistance when getting up to walk.

A licensed practical nurse (LPN) is preparing to assist a registered nurse (RN) with removing a nasogastric (NG) tube from the client. Which interventions would be included in the procedure? Select all that apply.

- Explain the procedure to the client. - Ask the client to take a deep breath and hold. - Pull the tube out in one continuous steady motion. - Remove the device or tape securing the tube from the nose.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points would be included in the instructions? Select all that apply.

- The client leans over a bedside table. - The client should sit on the edge of the bed. - A time-out is performed before the procedure. - A local anesthetic is administered before the procedure.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings would the nurse expect to observe because of meningeal irritation? Select all that apply.

- The client reports stiffness and soreness in the neck area. - The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. - The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions would the nurse provide? Select all that apply.

- Use sunscreen when participating in outdoor activities - Wear a hat, opaque clothing, and sunglasses when in the sun. - Examine your body monthly for any lesions that may be suspicious.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury? Fill in the blank.

36

The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? Refer to the Figure.

A

A client arrives at the emergency department and has experienced frostbite to the right hand. What would the nurse expect to find when inspecting the client's hand?

A white color of the skin that is insensitive to touch

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

Cheese

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing?

Chicken breast, broccoli, strawberries, and milk

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate?

Continue to monitor.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially?

Determine the client's ability to follow verbal commands.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client?

Fat-free beef broth

While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur?

Gentle, blowing or swooshing noise

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse would place the client in which position for insertion?

High-Fowler's position

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?

Limit bleeding from the biopsy site

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method would be used to monitor the client for crepitus?

Palpating the skin around the chest and neck for a crackling sensation

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What would the nurse expect to find when checking the client's sacral area?

Partial-thickness skin loss of the epidermis

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of an NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach?

Placement is verified on x-ray.

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?

Positive culture results

Which intervention would be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones.

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding would the nurse note if this disorder is present?

Silvery-white scaly lesions

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention would be implemented initially?

Stand in front of the client.

The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse would plan to maintain bed rest for this client in which position?

Supine with head elevation no greater than 30 degrees

The nurse is preparing to assist the primary health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done?

Testing the six cardinal positions of gaze

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a modified left lateral recumbent position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs would the nurse expect to note in the health record when collecting data related to the respiratory system for this client?

Wheezes and use of accessory muscles

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching?

"I need to avoid sun exposure before 10:00 am and after 4:00 pm."

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet?

Baked turkey

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse would expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply.

- Lesion has a waxy border - An irregularly shaped lesion

The nurse is helping perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which would the nurse include for this type of data collection? Select all that apply.

- Listening to lung sounds - Obtaining the client's temperature - Obtaining information about the client's respirations

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply.

- Notify the RN. - Discontinue suctioning until the client is stabilized.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply.

- Semi-Fowler's position - With the foot of the bed flat

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings would the nurse expect to note? Select all that apply.

- 50 mL of drainage in the drainage-collection chamber - The drainage system is maintained below the client's chest. - An occlusive dressing is in place over the chest-tube insertion site. - Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply.

- Acute otitis media with effusion - A physical obstruction to the transmission of sound waves

Which would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?

The return of distal pulses

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?

Tinnitus

The licensed practical nurse (LPN) in the emergency department is caring for a client who was assaulted and sustained blunt force injuries to the chest and abdomen. Which priority client data would the LPN immediately report to the registered nurse (RN)?

Tracheal deviation to the left