adult health practice q
The nurse suspects "compartment syndrome" for a casted extremity. What characteristic symptoms would the nurse assess that would confirm these suspicions? (Select all that apply.) Decreased sensory function Capillary refill less than 3 seconds 2+ peripheral pulses in the affected distal pulse Loss of motion Excruciating pain
a d e
A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do? Tell the client that he will be asleep before he leaves for surgery. Encourage light ambulation. Place the bed in a low position with the side rails up. Take the client's vital signs every 15 minutes.
c
A client with Alzheimer's disease is admitted for hip surgery after falling and fracturing the right hip. The client's spouse tells the nurse about feeling guilty for letting the accident happen and reports not sleeping well lately because the spouse has been getting up at night and doing odd things. Which nursing diagnosis is most appropriate for the client's spouse? Relocation stress syndrome related to hospitalization Defensive coping related to diagnosis of Alzheimer's disease Risk for caregiver role strain related to increased client care needs Decisional conflict related to lack of relevant treatment information
c
A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal? Determine the stone type. Relieve the pain. Relieve any obstruction. Prevent nephron destruction.
b
The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting? Monitor bowel movements Monitor weight daily Monitor and record blood pressure daily Monitor and record radial pulses daily
b
an older adult client visits the clinic for a blood pressure (BP) check. The client's hypertension is not well controlled, and a new blood pressure medicine is prescribed. What is important for the nurse to teach this client about the blood pressure medicine? A severe drop in blood pressure is possible. A possible adverse effect of blood pressure medicine is dizziness when you stand. Take the medicine on an empty stomach. There are no adverse effects from blood pressure medicine.
b
Which is an accurate rationale for why older adults are more susceptible to serious infections? They are less aware of how to control infections. They have increased social contact. They have less efficient defense mechanisms. They do not have easy access to antibiotics.
c
Which is the most common presenting symptom of colon cancer? Fatigue Anorexia Change in bowel habits Weight loss
c
A nurse is presenting a safety program to a group of older adults at a continuing care retirement community. The nurse emphasizes measures to reduce the risk of falls based on the understanding that which type of fracture is the most common? Forearm Femur Ankle Hip
d
The nurse teaches a client scheduled for a colonoscopy. Which instruction should be included as part of the preparation for the procedure? a. Do not void for at least 30 minutes before the test. b. Spray or gargle with a local anesthetic. c. Consume at least 3 quarts of water 30 minutes before the test. d. Follow the dietary and fluid restrictions and bowel preparation procedures.
d
When fluid intake is normal, the specific gravity of urine should be 1.000. less than 1.010. greater than 1.025. 1.010 to 1.025.
d
A client realizes that regular use of laxatives has greatly improved his bowel pattern. However, the nurse cautions this client against the prolonged use of laxatives for which reason? The client's natural bowel function may become sluggish. The client may develop inflammatory bowel disease. The client may develop arthritis or arthralgia. The client may lose his appetite.
a
A client who had abdominal surgery 4 days ago reports that "something gave way" when he sneezed. The nurse observes a wound evisceration. Which nursing action is the first priority? Applying a sterile, moist dressing Putting the client on nothing-by-mouth (NPO) status Inserting a nasogastric (NG) tube Monitoring vital signs
a
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe? a. Older adults often lack the classic signs and symptoms of pneumonia. b. Older adults are not normally candidates for pneumococcal vaccination. c. Older adults often cannot tolerate the most common antibiotics used to treat pneumonia. d. Older adults have less compliant lung tissue than younger adults.
a
A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care? Monitor urine output hourly and report output less than 30 mL/hr. Turn the patient every 2 hours around the clock. Administer pain medication every 2 hours. Clean the stoma with soap and water after the patient voids.
a
After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output? It's an abnormal finding that requires further assessment. It's a normal finding associated with the client's nothing-by-mouth status. It's an abnormal finding that will correct itself when the client ambulates. It's a normal finding caused by blood loss during surgery.
a
An elderly client who lives in a retirement community is having a mild depressive episode over the past few weeks. The nurse intervenes by recommending Participation in a social activity Watching television in a darkened room Decreasing walking from 1 mile to 1/2 mile daily Taking an antidepressant medication
a
During a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. Which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? Receive vaccinations Exercise daily Drink six glasses of water daily Take all prescribed medications
a
The nurse is providing care for a client who has recently been diagnosed with COPD. When educating the client about exacerbations, the nurse should prioritize what topic? Identifying specific causes of exacerbations The relationship between activity level and exacerbations The importance of prone positioning during exacerbations Prompt administration of corticosteroids during exacerbations
a
Which drug is considered a stimulant laxative? Bisacodyl Magnesium hydroxide Psyllium hydrophilic mucilloid Mineral oil
a
Which of the following is a characteristic of an arterial ulcer? Border regular and well demarcated Edema may be severe Ankle-brachial index (ABI) > 0.90 Brawny edema
a
Which of the following is the most important nursing diagnosis for an elderly patient diagnosed with osteoporosis? Risk for injury related to fractures due to osteoporosis Acute pain related to fracture and muscle spasm Deficient knowledge about osteoporosis and the treatment regimen Risk for constipation related to immobility
a
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: 1.5 to 2.5 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control. 2.5 to 3.0 times the baseline control.
a ?
The nurse is providing instructions to a client scheduled for a gastroscopy. What should the nurse be sure to include in the instructions? Select all that apply. After gastroscopy, the client cannot eat or drink until the gag reflex returns (1 to 2 hours). The client must fast for 8 hours before the examination. The throat will be sprayed with a local anesthetic. The client must have bowel cleansing prior to the procedure. The health care provider will be able to determine if there is a presence of bowel disease.
a b c
A surgical client has been in the PACU for the past 3 hours. What are the determining factors for the client to be discharged from the PACU? Select all that apply. Adequate respiratory function Stable blood pressure Ability to tolerate oral fluids Sufficient oxygen saturation Absence of pain
a b d
A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply. Compression dressings Resting the affected extremity Corticosteroids Elevating the injured limb Massage Applying ice
a b d f
A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply. Smoking Physical inactivity Frequent upper respiratory infections Gallbladder disease Diabetes mellitus
a b e
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. To reduce stress on the myocardium To provide visual feedback to encourage the client to inhale slowly and deeply To provide adequate transport of oxygen in the blood To clear respiratory secretions To decrease the work of breathing
a c e
A client has experienced occasional urinary incontinence in the weeks since his prostatectomy. In order to promote continence, the nurse should encourage which of the following? Intermittent urinary catheterization Pelvic floor exercises Active range of motion exercises Reduced physical activity
b
A client reports urinary frequency, urgency, and dysuria. Which of the following would the nurse most likely suspect? Acute renal failure Infection Obstruction of the lower urinary tract Nephrotic syndrome
b
A patient has a serum study that is positive for the rheumatoid factor. What does the nurse understand is the significance of this test result? Specific for RA Suggestive of RA Diagnostic for SLE Diagnostic for Sjögren's syndrome
b
A patient informs the nurse that every time she sneezes or coughs, she urinates in her pants. What type of incontinence does the nurse recognize the patient is experiencing? Urge incontinence Stress incontinence Iatrogenic incontinence Functional incontinence
b
An older adult patient had a hip replacement. When should the patient begin with assisted ambulation with a walker? 72 hours 24 hours 1 week 2 to 3 weeks
b
It is important for the nurse to monitor serum electrolytes in a patient with acute diarrhea. Select the electrolyte result that should be immediately reported. Sodium of 136 mEq/L Potassium of 2.8 mEq/L Chloride of 100 mEq/L Calcium of 9 mg/dL
b
Students are preparing a class presentation on elder abuse. Which of the following would they include as the most common type of elder abuse? Emotional Neglect Sexual Financial
b
The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Intermittent positive-pressure breathing (IPPB) Incentive spirometry Positive end-expiratory pressure (PEEP) Bronchoscopy
b
The nurse is providing discharge instructions to a client with heart failure preparing to leave the following day. What type of diet should the nurse request the dietitian to discuss with the client? Low-potassium diet Low-sodium diet Low-cholesterol diet Low-fat diet
b
Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain. Venography reveals deep vein thrombosis (DVT). When assessing this client, the nurse is likely to detect: pallor and coolness of the left foot. left calf circumference 1" (2.5 cm) larger than the right. loss of hair on the lower portion of the left leg. a decrease in the left pedal pulse.
b
Which client requires immediate nursing intervention? The client who: presents with ribbonlike stools. presents with a rigid, boardlike abdomen. complains of anorexia and periumbilical pain. complains of epigastric pain after eating.
b
Which factor alters urinary elimination patterns in older adults? Decreased residual volume Decreased muscle tone Increased bladder capacity Active lifestyle
b
Which nursing instruction is correct to provide the client following a barium enema? An enema will be used to clear the bowel. The stools may be a white or clay colored. The client will maintain a low residue diet. Sips of fluid may be increased if tolerated.
b
Which principle applies to the client in traction? Weights should rest on the bed. Skeletal traction is never interrupted. Weights are removed routinely. Knots in the ropes should touch the pulley.
b
A nurse is applying an ostomy appliance to the ileostomy of a client with ulcerative colitis. Which action is appropriate? Cutting the faceplate opening no more than 2? larger than the stoma Gently washing the area surrounding the stoma using a facecloth and mild soap Scrubbing fecal material from the skin surrounding the stoma Maintaining wrinkles in the faceplate so it doesn't irritate the skin
b ?
Which intervention should the nurse implement with the client who has an external fixator? Select all that apply. Turn the clamps by one-half every day. Perform pin care as ordered. Supervise the client during transfers. Perform neurovascular assessment. Inspect pin sites for signs of infection.
b c d e
A client is scheduled for a transurethral rescection of the prostate (TURP). Which statement demonstrates that the expected outcome of "client demonstrates understanding of the surgical procedure and aftercare" has been met? "The surgeon is going to remove the entire prostate gland." "I'll have to stay in the hospital for about 3 to 4 days after the surgery." "I'll have a small incision on my lower abdomen after the procedure." "The surgeon is going to insert a scope through my urethra to remove a portion of the gland."
d
A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Face tent Non-rebreather air mask Tracheostomy collar Venturi mask
d
A nurse caring for a patient with regional enteritis knows to assess for this most serious systemic complication. What is that complication? Nephrolithiasis Megacolon Pyelonephritis Small bowel obstruction
d
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation? Suggestion to take tub baths instead of showers Importance of urinating every 4 to 6 hours while awake Need to wear underwear made from synthetic material Need to urinate after engaging in sexual intercourse
d
A registered nurse who is responsible for coordinating and documenting client care in the operating room is a anesthetist. scrub nurse. anesthesiologist. circulating nurse.
d
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? a. Promote more efficient and controlled ventilation and to decrease the work of breathing b. Promote the strengthening of the client's diaphragm c. Promote the client's ability to take in oxygen d. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
d
The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? "You need to perform weight-bearing exercises twice a week." "Use your continuous passive motion machine (CPM) 2 hours each day." "You need to limit the amount of protein and calcium in your diet." "You will receive IV antibiotics for 3 to 6 weeks."
d
The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? Inform the surgeon of this finding. Encourage the client to perform active ROM exercises with the residual limb. Transfer the client to a sitting position. Explain the risks of flexion contracture to the client.
d
What abnormal postoperative urinary output should the nurse report to the physician for a 2-hour period? Between 100 and 200 mL Between 75 and 100 mL >200 mL <30 mL
d
With a severe degree of peripheral arterial insufficiency, leg pain during rest can be reduced by: Elevating the limb over the heart level. Massaging the limb after application of cold compresses. Placing the limb in a plane horizontal to the body. Lowering the limb so that it is dependent.
d
You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia? Offer nutritious snacks 2 times a day. Give antibiotics as ordered. Place client on bed rest. Encourage increased fluid intake.
d
A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery? Leg exercises improve circulation and prevent venous thrombosis. Leg exercises increase the client's muscle mass postoperatively. Leg exercise help increase the client's level of consciousness after surgery. Leg exercises help to prevent pressure sores to the sacrum and heels.
a
An age-related change associated with the cardiovascular system is decreased cardiac output. thinner heart valves. increased compliance of heart muscle. decreased blood pressure.
a
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? Stress Functional Urge Overflow
c
A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? Avoiding airplanes, buses, and other crowded public places Adhering to the treatment regimen in order to cure the disease Setting realistic short- and long-term goals Taking prophylactic antibiotics as prescribed
c
An 84-year-old client has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The client is oriented to name only. The client's family is very upset because, before having surgery, the client had no cognitive deficits. The client is subsequently diagnosed with postoperative delirium. What should the nurse explain to the client's family? This problem is self-limiting and there is nothing to worry about. Delirium involves a progressive decline in memory loss and overall cognitive function. Delirium of this type is treatable and her cognition will return to previous levels. This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.
c
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." "What concerns you most about Alzheimer disease?" "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." "Alzheimer disease can be a great burden on the family. What community resources do you know about?"
c
Based on a client's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility? Work with the family to promote healthy conflict resolution. Confront the suspected perpetrator. Report the findings to adult protective services. Gather evidence to corroborate the abuse.
c
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention? Respiratory rate of 12 breaths per minute Blood pressure of 94/62 mm Hg Oxygen saturation of 82% Urine output of 60 ml/hr
c
The nurse teaches the client which intervention to avoid hip dislocation after replacement surgery? Bend forward only when seated in a chair Avoid placing a pillow between the legs when sleeping Never cross the affected leg when seated Keep the knees together at all times
c
The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? Decrease the intake of vitamins A and D Reduce stress Walk or perform weight-bearing exercises Increase fiber in the diet
c
The wife of a patient who was admitted 3 days ago with an exacerbation of chronic obstructive pulmonary disease (COPD) states that she is worried about her husband because he appears to be breathing "really hard." The nurse performs a respiratory assessment. Which of the following findings would indicate a need for further interventions? (Select all that apply.) a. BP 122/82, HR 102, R 24, noted barrel chest b. Pale, paper-thin skin, O2 at 2L/min via nasal cannula c. BP 122/80, HR 116, R 24, pale and clammy skin, temp 101.3 degrees F d. Patient states, "It always seems like I just can't catch my breath."
c
The surgical nurse is preparing to send a client from the presurgical area to the OR and is reviewing the client's informed consent form. What are the criteria for legally valid informed consent? Select all that apply. Consent must be notarized. Consent must be signed on the day of surgery. Consent must be freely given. Signature must be witnessed by a professional staff member. Consent must normally be obtained by a physician.
c d e
A client is admitted to the hospital with systolic left-sided heart failure. The nurse knows to look for which assessment finding for this client? Jugular venous distention Nausea Pedal edema Pulmonary congestion
d
A client asks about the purpose of withholding food and fluid before surgery. Which response by the nurse is appropriate? It prevents overhydration and hypertension. It decreases the risk of elevated blood sugar and slow wound healing. It prevents aspiration and respiratory complications. It decreases urine output so that a catheter will not be needed.
c