AH Final Exam Prep (Exam Q's 3&4)

A highway construction worker is concerned about her cancer risks. She has been married for 18 years, has two children, smokes one pack of cigarettes a day, and drinks one to two beers each week. She is 30 lbs overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and and aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. Which of the following changes does the nurse encourage this patient to make to decrease her cancer risk (Select all that apply)? -Change her job to work inside. -Stop smoking. -Use sunscreen daily. -Decrease alcohol consumption. -Improve her nutrition. -Lose weight.

-Stop smoking. -Use sunscreen daily. -Improve her nutrition. -Lose weight.

Which laboratory results should the nurse report to the oncologist before the next does of chemotherapy is administered (Select all that apply)? -Hemoglobin of 14.5 g/dL -Temperature of 101.2 F -BUN of 12 mg/dL -Urine output of 60 mL for the last hour -Platelet count of 40,000/mm3 -White blood cell count of 2,300/mm3

-Temperature of 101.2 F -Platelet count of 40,000/mm3 -White blood cell count of 2,300/mm3

Bonus Question: A patient is to receive furosemide (Lasix) 60mg IVP now. The pharmacy gives you furosemide 40mg/2mL. How many mL will you administer (round to the nearest tenth)?

3mL

Bonus Question: A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority? A positive Western Blot test White blood cells of 6,000/mm3 CD4 count of 180 celles/mm3 Platelets of 175,000/mm3

CD4 count of 180 celles/mm3

The nurse is seeing clients in a clinic. Which of the following assessment findings prompts the nurse to assess further for cancer? Client with a 10-pound weight gain. Client whose mother died of lung cancer. Woman whose last mammogram was 3 years ago. Client with a cough that has lasted for 4 months.

Client with a cough that has lasted for 4 months.

After receiving change of shift report, which client does the nurse assess first? Client with breast cancer scheduled for external beam radiation. Client with xerostomia associated with laryngeal cancer. Client with neutropenia who has just been admitted with a possible infection. Client with leukemia who needs an antiemetic before chemotherapy.

Client with neutropenia who has just been admitted with a possible infection.

The nurse has completed an assessment on a client with a decreased cardiac output after an MI. Which finding should receive the highest priority? -Weight gain of 1 kg in 4 days, BP 130/80, mild dyspnea with exercise. -SpO2 93% on 2L of oxygen via nasal cannula, respirations 20, 1+ edema of bilateral lower extremities. -BP 110/62, atrial fibrillation with HR 82, bibasilar crackles. -Confusion, urine output 15 mL over the last 2 hours, orthopnea, cool extremities.

Confusion, urine output 15 mL over the last 2 hours, orthopnea, cool extremities.

The nurse is teaching a client who is receiving chemotherapy how to manage possible nausea and vomiting at home. The nurse should include information about: Eating small, frequent meals throughout the day. Eating only cold foods with strong flavors. Limiting the amount of fluid intake. Eating three normal meals a day.

Eating small, frequent meals throughout the day.

A client with acute chest pain is receiving IV morphine sulfate. Which of the following is not an intended effect of morphine in the treatment of chest pain: Decrease in respiratory rate. Reduction of myocardial oxygen demand. Reduction of circulating catecholamines. Reduction in pain.

Decrease in respiratory rate.

The emergency department nurse is assessing an 82 year old client for a potential myocardial infarction. Which clinical manifestations does the nurse monitor for? Right sided chest pain. Pain on inspiration. Numbness and tingling of the arm. Disorientation or confusion.

Disorientation or confusion.

The nurse is assessing a client who has a history of stable angina. The client describes a recent increase in the number of attacks and in the intensity of the pain. Which question does the nurse ask to assess the change in the client's condition? How many cigarettes do you smoke daily? Do you have abdominal pain or nausea? Do you have pain when you are resting? How frequently are you having chest pain?

Do you have pain when you are resting?

The nurse is assessing a client with anemia. Which clinical manifestation does the nurse expect to see in this client? Dyspnea with activity. Hypertension. Warm, flushed skin. Bradycardia.

Dyspnea with activity.

A client is taking furosemide (Lasix) for heart failure. What assessment finding requires immediate action by the nurse? Potassium of 2.9 mEq/L. Cough. Pulse of 60 bpm. Headache.

Potassium of 2.9 mEq/L.

The nurse is caring for a client with atrial fibrillation. What manifestation most alerts the nurse to the possibility of a serious complication from this condition? Dyspnea with activity. Fatigue. Sinus tachycardia. Speech alterations.

Speech alterations.

The nurse is assessing a client's skin for local signs of infection. Which signs does the nurse assess for (Select all that apply)? warmth fever elevated WBCs redness pain swelling

warmth redness pain swelling

A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client? -Void at least every 7-8 hours. -Avoid voiding immediately after sex. -Drink plenty of fluids each day. -Take hot baths daily to keep the perineal region clean.

"Drink plenty of fluids each day."

The nurse is teaching a client prescribed sublingual nitroglycerin for chest pain. Which statement indicates that the client needs further teaching? -I carry my medicine around in a clear plastic bag in my pocket so that I can get to it easily if I have chest pain. -Even if I have not used any of the nitroglycerin from one refill, I should get another refill one the other refill expires. -When my nitroglygerin tingles under my tongue, I know that it is strong enough to work. -If I have chest pain that isn't relieved by rest or nitroglycerin, I will call an ambulance.

"I carry my medicine around in a clear plastic bag in my pocket so that I can get to it easily if I have chest pain."

The nurse has identified risk for infection as a diagnosis for a patient diagnosed with leukemia. Which interventions should the nurse implement (Select all that apply)? -Assess the client's vital signs, including temperature, every 4 hours. -Ask the family to take the patient's fresh flowers home. -Place the client on droplet isolation. -Monitor the client's white blood cell count daily. -Ask that visitors with infections do not visit at this time. -Facilitate daily bone marrow biopsies.

-Assess the client's vital signs, including temperature, every 4 hours. -Ask the family to take the patient's fresh flowers home. -Monitor the client's white blood cell count daily. -Ask that visitors with infections do not visit at this time.

When teaching a client with heart failure about preventing complications and future hospitalizations, which problems stated by the client as reasons to call the physician would indicate to the nurse that the client has understood the teaching (Select all that apply)? -Becoming increasingly short of breath at rest. -Having to sleep sitting up in a reclining chair. -High intake of sodium for breakfast. -Weight loss of 2 pounds in 1 day. -Weight gain of 2 pounds or more in 1 day.

-Becoming increasingly short of breath at rest. -Having to sleep sitting up in a reclining chair. -Weight gain of 2 pounds or more in 1 day.

The nurse is assessing a client with left-sided heart failure. What conditions does the nurse assess for (Select all that apply)? -Crackles -Decreased oxygen saturation -Edema in lower extremities -Jugular Venous Distention -Dyspnea

-Crackles -Decreased oxygen saturation -Dyspnea

A client receiving chemotherapy is experiencing a low white blood cell count. The nurse should teach the client to avoid contact with which of the following family members? 9 year old grandchild with a recent exposure to chicken pox. 34 year old nephew with HIV infection. 31 year old daughter who is 4 months pregnant. 68 year old husband with a history of TB exposure as a child.

9 year old grandchild with a recent exposure to chicken pox.

The nurse is working on an orthopedic floor. Which client should the nurse assess first after receiving change of shift report? A 64-year old with a left total knee replacement and new onset confusion. An 84-year old in traction for a fractured femoral neck. A 50-year old post-op total knee replacement with a continuous passive motion (CPM) machine. An 88-year old post-op total hip replacement with an abduction pillow.

A 64-year old with a left total knee replacement and new onset confusion.

A client who is post percutaneous transluminal coronary angioplasty (PTCA) with stent placement reports severe chest pain. Which action does the nurse take first? Perform an immediate 12 lead ECG. Assess the vital signs and notify the healthcare provider. Administer the prescribed sublingual nitroglycerin. Administer the prescribed IV morphine.

Assess the vital signs and notify the healthcare provider.

The nurse notes the following rhythm on a client's telemetry monitor. How does the nurse interpret these findings? Atrial fibrillation. Sinus rhythm. Ventricular fibrillation. Asystole.

Atrial fibrillation.

A client with heart failure is experiencing acute shortness of breath. What is the nurse's priority action? Perform nasotracheal suctioning of the client. Auscultate the client's heart and lung sounds. Place the client on a 1000 mL fluid restriction. Place the client in low fowler's position.

Auscultate the client's heart and lung sounds.

The nurse is caring for a client who has just returned from the ERCP removal of gallstones. The nurse should monitor the client for signs of what complications? Gangrene of the gallbladder Pain and drowsiness Bleeding and perforation of the hepatobiliary tract Acidosis and hypoglycemia

Bleeding and perforation of the hepatobiliary tract

A nurse is assessing a patient for risk factors known to contribute to osteoarthritis. What assessment finding would the nurse interpret as a risk factor? Age 58 years. Primary hypertension. Body mass index of 37. 30 pack-year history of smoking.

Body mass index of 37.

A client has been admitted with pyelonephritis. A review of the client's I&O records reveal that the client has been consuming between 3 and 3.5 Liters of oral fluid each day since admission. How does the nurse best respond to this finding? -Supplement the client's fluid intake with a high-calorie diet. -Emphasize the need to limit intake to 2 Liters of fluid daily. -Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. -Encourage the client to continue this pattern of fluid intake.

Encourage the client to continue this pattern of fluid intake.

The nurse is assisting with resuscitation of a client. What priority intervention does the nurse perform before defibrillating the client? Make sure the defibrillator is set to the synchronous mode. Deliver a precordial thump to the upper portion of the sternum. Ensure that all personnel are clear of contact with the patient and the bed. Test the equipment by delivering a smaller shock of 100 joules.

Ensure that all personnel are clear of contact with the patient and the bed.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray? Tapioca pudding Fried chicken Mashed potatoes Dinner roll

Fried chicken

The nurse is caring fora client admitted with a serious infection. The prescriber has ordered cultures and a broad-spectrum antibiotic. How should the nurse proceed? -Delay administration of the antibiotic until the culture results are available. -Obtain the culture samples, then administer the antibiotic. -Administer acetaminophen for fever. -Administer the antibiotic, then obtain the culture samples.

Obtain the culture samples, then administer the antibiotic.

The nurse is assisting a client to walk in the hall on the third day after an MI. Which clinical manifestation indicates to the nurse that the client is not ready to advance to the next level of activity? Onset of chest pain. Heart rate increase of 10 bpm at completion of the activity. Systolic BP increase of 10 mmHg at completion of the activity. Facial flushing.

Onset of chest pain.

The nurse is assessing the client who is postoperative for a total knee replacement. Which assessment data warrant immediate intervention? Pain and tenderness in the calf of the unaffected leg. Diffuse, crampy abdominal pain. T 99F, HR 80, RR 20 and BP 128/76 Intermittent bowel sounds in all four quadrants.

Pain and tenderness in the calf of the unaffected leg.

The registered nurse is assigning a practical nurse to care for a client who has leukemia. Which instruction does the registered nurse provide to the practical nurse when delegating this client's care? Assess the client's roommate for symptoms of infection. Wear a mask when entering the room. Evaluate the amount of protein the client eats. Perform effective hand hygiene frequently.

Perform effective hand hygiene frequently.

A patient with a productive cough, chills, and night sweats is suspected of having active tuberculosis. The most important initial intervention by the nurse would be: -Prepare the client to be discharged on bed rest. -Administer the PPD ordered by the physician. -Place the client on airborne isolation. -Administer the prescribed rifampin before discharge.

Place the client on airborne isolation.

The nurse is planning care for a client who has leukemia. Which intervention does the nurse include in the plan of care to prevent fatigue? Schedule for daily physicals and occupational therapy. Arrange for a family member to stay with the client. Plan care for times when the client has the most energy. Plan all activities to occur in the morning, allowing for afternoon naps.

Plan care for times when the client has the most energy.

A client with Crohn's disease has concentrated urine, decreased urinary output, dry skin, hypotension, and weak, thready pulse. What should the nurse do first? Provide IV rehydration as prescribed. Turn and reposition ever 2 hours. Encourage the client to drink at least 1 Liter of fluid a day. Monitor vital signs every shift.

Provide IV rehydration as prescribed.

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? Inguinal region Neck or jaw Left upper chest Right shoulder

Right shoulder

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? Signs and symptoms of intra-abdominal complications. The need for blood glucose monitoring for the next week. Appropriate use of prescribed pancreatic enzymes. Management of fluid balance in the home setting.

Signs and symptoms of intra-abdominal complications.

The nurse is assessing the hospitalized client with his food selections for breakfast. The client is on a low-cholesterol diet. What recommendations are most appropriate for this client? Blueberry muffin, orange juice, decaffeinated coffee. Whole wheat french toast, a side of bacon, coffee. Skim milk, oatmeal, banana, orange juice, coffee. Cheese omelet, skim milk, whole wheat toast, coffee.

Skim milk, oatmeal, banana, orange juice, coffee.

What intervention does the nurse implement to provide for client safety during intradermal allergy testing? Apply oxygen by mask or nasal cannula before injecting the test agent. Cover the examination table and pillow with plastic or an ultrafine mesh. Pretreat the skin area to be tested with a cortisone-based cream. Stay with the client and ensure that emergency equipment is available .

Stay with the client and ensure that emergency equipment is available .

The nurse is teaching a client who has iron deficiency anemia. Which food choice indicates that the client correctly understands the teaching? Chicken Oranges Tomatoes Steak

Steak

The nurse is caring for a patient with an advanced stage of lung cancer. The nurse enters the room and finds the patient struggling to breathe and the nurse's rapid assessment reveals that the patient's jugular veins are distended and there is significant facial swelling. The nurse should suspect the development of what oncologic emergency? Superior vena cava syndrome (SVCS) Tumor Lysis Syndrome Increased intracranial pressure Spinal cord compression

Superior vena cava syndrome (SVCS)

The rehabilitation nurse is assisting a client with heart failure to increase activity tolerance. During ambulation of the client, identification of what symptom causes the nurse to stop the client's activity? Respiratory rate change from 20 to 26 breaths/min. Decrease in oxygen saturation from 98% to 95%. Increase in heart rate from 86 to 100 beats/min Systolic BP change from 136 to 96 mmHg.

Systolic BP change from 136 to 96 mmHg.

The nurse is caring for an HIV-positive client. What assessment finding assists the nurse in confirming progression of the client's diagnosis to AIDS? Generalized lymphadenopathy. Low-grade fever for the last 10 days. HIV-positive status for 8 years. Thick white patches on the client's tongue.

Thick white patches on the client's tongue.

A nursing assistant asks the nurse if respiratory isolation is needed for a client with pneumocystis jiroveci pneumonia. What is the nurse's best response? This type of pneumonia is an opportunistic infection, so the staff is not at risk. You are not at risk for this infection if you have had a vaccination. You should wear a mask and gown to provide care. Yes, please institute respiratory isolation because this is very contagious.

This type of pneumonia is an opportunistic infection, so the staff is not at risk.

The nurse is teaching a client who was recently diagnosed with thrombocytopenia. Which instruction does the nurse include in this client's discharge teaching? Avoid blowing your nose. Use a soft-bristled toothbrush. Use only aspirin when having pain. Drink at least 3 liters of fluid a day.

Use a soft-bristled toothbrush.

A client's radiation implant has become dislodged overnight, and the nurse finds it in the client's bed. What does the nurse do first? Don gloves and attempt to replace the implant. Assess the client's skin for radiation burns. Notify the safety officer and move the client to a different room. Use the tongs to put the implant into the radiation container.

Use the tongs to put the implant into the radiation container.

A client is at risk for acute pyelonephritis. The nurse should instruct the client about which health promotion behaviors that will be most effective in preventing pyelonephritis? -Treat fungal infections such as athlete's foot immediately. -Treat skin lesions with antibiotics, and cover any open lesions. -Wash the perineum with warm water and soap, cleaning from front to back. -Have a pneumonia immunization to prevent streptococcal infection.

Wash the perineum with warm water and soap, cleaning from front to back.

A nurse is preparing to provide care for a client whose exacerbation of ulcerative colitis has required hospital admission. During an exacerbation of this health problem, the nurse would expect that the client's stools will have what characteristics? Watery with blood and mucous Hard or black and tarry Dry and streaked with blood Loose with visible fatty streaks

Watery with blood and mucous

A client with a history of heart failure is being discharged. Which priority instruction will assist the client in the prevention of complications associated with heart failure? -Weigh yourself at the same time each day in the same amount of clothing. -When you feel short of breath, take an additional diuretic. -Eat six small meals daily instead of three larger meals. -Avoid drinking more than 3 quarts of liquids each day.

Weigh yourself at the same time each day in the same amount of clothing.

An older adult client with heart failure state, "I don't know what to do. I don't want to be a burden to my daughter, but I can't do it alone. Maybe I should die." What is the nurse's best response? Would you like to talk about this some more? You must feel as though you are a burden. You're lucky to have such a devoted daughter. Would you like an antidepressant medication?

Would you like to talk about this some more?

A client comes in for his yearly PPD. Which statement by the nurse is best made to the client who returns to the clinical 48 hours later with a 16 mm area of redness and induration: -You will need to have a second PPD. -Your PPD is negative. No follow-up is necessary. -You will need to have titers drawn. -You will need to be evaluated further.

You will need to be evaluated further.

The nurse is caring for a postoperative client following a total left hip replacement the previous day. During the assessment, the nurse notes that the client's left leg is cool, with weak pedal pulses. What is the nurse's first action? Assess circulatory status of the right leg. Check for bilateral Homan's signs. Notify the surgeon immediately. Measure leg circumference at the calf.

Assess circulatory status of the right leg.

The nurse is instructing a client with heart failure about energy conservation. Which is the best instruction? -Pull rather than push or carry items heavier than 5 pounds. -Gather everything you will need to complete a task before you begin. -Take a walk after dinner every day to build up your strength. -Walk until you become short of breath then walk back home.

Gather everything you will need to complete a task before you begin.

The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? Get a wheelchair and have the client sit down. Assist the client when ambulating. Apply oxygen via nasal cannula. Assess the client's lungs.

Get a wheelchair and have the client sit down.

The nurse is caring for a patient diagnosed with pneumonia. The nurse should perform with of the following interventions to help loosen thick secretions: -Administer antibiotics as ordered. -Place the patient in the prone position. -Have the patient use the incentive spirometer every hour while awake. -Limit fluids to prevent fluid overload.

Have the patient use the incentive spirometer every hour while awake.

Which intervention is most important for the nurse to teach the client who is recovering from an anaphylactic reaction to a bee sting? Avoiding contact with the allergen. How to use and Epi Pen. Wearing a medical alert bracelet. Keeping diphenhydramine (Benadryl) available.

How to use and Epi Pen.

The nurse is providing care for a client whose inflammatory bowel disease has necessitated hospital treatment. Which of the following would most likely be included in the client's medication regimen? Vitamin B12 injections to prevent pernicious anemia. Antiemetics on a PRN basis. Give an antidiarrheal medication 30 minutes before a meal. Beta blockers to increase bowel motility.

Give an antidiarrheal medication 30 minutes before a meal.

What is the best way for the nurse to decrease the risk of ventilator-associated pneumonia (Select all that apply)? -Perform chest percussion frequently. -Daily breaks from sedation to assess readiness for extubation. -Maintain good hand hygiene. -Provide frequent oral care -Administer prophylactic antibiotics -Keep the head of the bed elevated.

-Daily breaks from sedation to assess readiness for extubation. -Maintain good hand hygiene. -Provide frequent oral care -Keep the head of the bed elevated.

The nurse administers 650mg of aspirin every 4 hours to a client with pneumonia. The nurse should evaluate the outcome of administering the drug by assessing the client for which desired outcomes (select all that apply)? -Decreased pain when breathing. -Prolonged clotting time. -Thickened respiratory secretions. -Increased respiratory rate. -Decreased temperature.

-Decreased pain when breathing. -Decreased temperature.

Which interventions should be included in the discharge teaching of a client who had a total hip replacement (Select all that apply)? -Instruct the client not to take any medication before ambulating. -Explain the importance of increasing activity gradually. -Tell the client to ambulate barefooted for comfort. -Request that the client demonstrate use of assistive devices. -Discuss the client's weight-bearing limitations.

-Explain the importance of increasing activity gradually. -Request that the client demonstrate use of assistive devices. -Discuss the client's weight-bearing limitations.

The nurse is caring for a hospitalized client who has AIDS and is severely immune compromised. Which interventions are used to help prevent infection in this client (Select all that apply)? -Use sterile gloves and gowns whenever staff is in contact with the client. -Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only. -Request that family take home the fresh flowers that are at the client's bedside. -Use N95 respirator masks anytime staff is in the client's room. -Assist the client with good oral care after meals and at bedtime. -Provide an incentive spirometer to encourage coughing and deep breathing.

-Keep a blood pressure cuff, thermometer, and stethoscope in the client's room for his or her use only. -Request that family take home the fresh flowers that are at the client's bedside. -Assist the client with good oral care after meals and at bedtime. -Provide an incentive spirometer to encourage coughing and deep breathing.

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan (Select all that apply)? -Keep the client from bathing on a daily basis. -Wear an N95 respirator mask and shoe covers at all times when with the client. -Prohibit visitors who have active infections. -Dispose of all linen in the trash after use. -Instruct the client to eat well cooked meats.

-Prohibit visitors who have active infections. -Instruct the client to eat well cooked meats.

Which of the following should be included in the teaching plan for a client with cancer who is experiencing thrombocytopenia (Select all that apply)? -Report bleeding to your health care provider immediately. -Use a soft-bristled toothbrush. -Use aspirin for pain control. -Monitor temperature daily. -Floss aggressively every day. -Use an electric razor.

-Report bleeding to your health care provider immediately. -Use a soft-bristled toothbrush. -Use an electric razor.

The clinic nurse is caring for an oncology patient complaining of extreme fatigue and weakness after the first week of radiation therapy. Which response by the nurse would best reassure the patient? -These symptoms usually result from radiation therapy, however, we will continue to monitor your lab and X-ray results. -Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy. -Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying. -These symptoms are part of your disease and unfortunately an inevitable part of living with cancer.

-These symptoms usually result from radiation therapy, however, we will continue to monitor your lab and X-ray results.

The nurse is planning a community health promotion program for cardiovascular disease. Which risk factors of coronary artery disease (CAD) does the nurse include in the education (Select all that apply)? -obesity -smoking -hypertension -depression -insomnia

-obesity -smoking -hypertension

Which client is at greatest risk of coronary artery disease: -A 43 year old with a family history of CAD and a total cholesterol of 150. -A 65 year old who is obese with an LDL of 200 -A 32 year old with mitral valve prolapse who quit smoking 10 years ago. -A 56 year old with an HDL of 63 who takes simvastatin (Zocor).

A 65 year old who is obese with an LDL of 200

The nurse is assessing clients in the emergency department (ED). Which client is at highest risk for developing septic shock? -An 82-year old who is taking antihypertensive medication. -A 68-year old who is being treated with chemotherapy. -A 25-year old who has irritable bowel syndrome. -A 37-year old who is 20% above ideal body weight.

A 68-year old who is being treated with chemotherapy.

The nurse works in a long-term care facility. Which resident does the nurse assess most carefully for manifestations of infection? A resident with long-standing dementia. A resident who eats a diet high in carbohydrates. A resident with both fecal and urinary incontinence. A resident whose family won't allow a pneumonia vaccine.

A resident with both fecal and urinary incontinence.

The nurse is caring for a client who has sepsis. After administering oxygen, what is the priority intervention for this client? -Administer a diuretic -Initiate a heparin drip -Administer IV fluids -Administer a vasoconstrictor

Administer IV fluids

An elderly patient developed pneumonia. The nurse is aware that the initial symptom the patient may manifest is: Pleuritic chest pain and cough. Fever and chills. Altered mental status Hemoptysis and dyspnea.

Altered mental status

Which person is at greatest risk of developing a community-acquired pneumonia? -An older adult with exercise-induced wheezing. -An older adult who smokes and has a substance abuse problem. -Young adult who eats a vegetarian diet. -Middle-aged teacher who eats a diet of Asian foods.

An older adult who smokes and has a substance abuse problem.

You are making a home visit to a client receiving external radiation therapy. Further teaching is necessary when you observe the client doing which of the following? Protecting the skin with soft, loose clothing. Washing the site with plain water and patting it dry. Regularly inspecting the skin for damage. Applying perfumed lotion to the irritated site.

Applying perfumed lotion to the irritated site.

Before discharge, the nurse confirms that the client understands antibiotic therapy for a wound infection by which statement? If my temperature elevates, I should increase my dose of antibiotic. If my drainage is clear, I do not need the antibiotic. I need to take the medication until the prescription is finished. I should take the antibiotic until my temperature is normal.

I need to take the medication until the prescription is finished.

A client states that he is "allergic" to poison ivy. Which statement by the client indicates a good understanding of this type of sensitivity? I should carry diphenhydramine (Benadryl) with me at all times. I will always wear a medical alert bracelet for this allergy. Drinking 3 liters of water a day will prevent kidney damage. I need to try to avoid coming into contact with poison ivy.

I need to try to avoid coming into contact with poison ivy.

A patient with HIV will be receiving care in the home setting. What aspect of self-care will the nurse emphasize during discharge education to prevent infection? Importance of personal hygiene. Strategies for adjusting antiretroviral medications. Appropriate use of prophylactic antibiotics. Signs and symptoms of wasting syndrome.

Importance of personal hygiene.

The nurse and an unlicensed assistive personnel are caring for a group of clients. Which intervention should the nurse perform? Measure the client's output from the indwelling catheter. Refill the water pitcher for the patient with dehydration. Instruct the client on appropriate fluid restrictions. Record the client's intake and output on the I&O sheet.

Instruct the client on appropriate fluid restrictions.

A client is ready to go home after a myocardial infarction (MI). The client is asking questions about his medications and wants to know why metoprolol (Lopressor) was prescribed. The nurse's best response would be which of the following? Metoprolol helps to increase blood flow to the heart by dilating the coronary arteries. Your heart was beating too slowly, and metoprolol increases your heart rate. It slows your heart rate and decreases the amount of work it has to do so it can heal. The medication makes your heart beat stronger to supply more blood to your body.

It slows your heart rate and decreases the amount of work it has to do so it can heal.

A client returns to the medical-surgical unit after a total hip replacement with a large wedge-shaped pillow between his legs. The client's daughter asks the nurse why the pillow is in place. What is the nurse's best response? It will prevent climbing out of bed if he becomes confused. It will help keep the new hip from becoming dislocated. It will help prevent pressure ulcers from developing. It will help prevent nerve damage and foot drop.

It will help keep the new hip from becoming dislocated.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? -Irrigate the catheter once each shift. -Replace the catheter every three days. -Keep the catheter tubing free of kinks and/or dependent loops. -Clean the perineal area with hot water daily.

Keep the catheter tubing free of kinks and/or dependent loops.

A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections (UTI) among older adults. What action has the greatest potential to prevent UTIs in this population? -Toilet immobile residents on a scheduled basis. -Encourage frequent mobility and repositioning. -Limit the use of indwelling urinary catheters. -Administer prophylactic antibiotics.

Limit the use of indwelling urinary catheters.

Which nursing intervention is most important in preventing sepsis and septic shock? -Administering IV fluid replacement as prescribed. -Obtaining vital signs every 4 hours for every client. -Maintaining asepsis of indwelling urinary catheters. -Monitoring red blood cell (RBC) counts for elevation.

Maintaining asepsis of indwelling urinary catheters.

Which is the highest priority goal to set for a client with pneumonia? -Absence of cyanosis. -Ability to walk 20 feet three times a day. -Maintenance of oxygen saturation of 95% or higher. -Absences of confusion.

Maintenance of oxygen saturation of 95% or higher.

The nurse is working with a client who has AIDS-related dementia and will soon be discharged to the care of family members. What teaching topic is best for the nurse to include in the discharge plan to help with the client's confusion? Remove locks from bathroom and bedroom doors. Do not allow the client to smoke when he is alone. Feed the client when she will not do it herself. Make sure that a clock and calendar are easily visible.

Make sure that a clock and calendar are easily visible.

A client with tachycardia is experiencing clinical manifestations. Which manifestation requires immediate intervention by the nurse? Mid-sternal chest pain. T wave touching the P wave. Mild orthostatic hypotension. Increased urine output.

Mid-sternal chest pain.

A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE). The nurse should recognize the need for further teaching when the client identifies which of the following as a factor that can exacerbate SLE? Infection Sunlight Stress Moderate exercise

Moderate exercise

What is the rationale that supports multidrug treatment for clients with tuberculosis? -Multiple drugs potentiate the drugs' actions. -Multiple drugs reduce undesirable adverse effects. -Multiple drugs reduce development of resistant strains of the bacteria. -Multiple drugs allow reduced dosages to be given.

Multiple drugs reduce development of resistant strains of the bacteria.

The nurse is assessing a client admitted to the cardiac unit. What statement made by the client alerts the nurse to the possibility of right-sided heart failure? I wake up coughing every night. My shoes fit really tight lately. I have trouble catching my breath. I sleep on four pillows at night.

My shoes fit really tight lately.

A client is scheduled for an intravenous pyelogram. Before the procedure, the nurse learns that the client has an allergy to shellfish. What should the nurse do next? -Keep the client on nothing-by-mouth (NPO) status. -Administer an antiflatulent to relieve gas -Administer a laxative to empty the colon. -Notify the healthcare provider.

Notify the healthcare provider.

The nurse is providing care for a client admitted to the hospital with reports of chest pain. After receiving a total of three nitroglycerin sublingual tablets, the client states, " The pain has not gotten any better." What does the nurse do next? Administer IV nitroglycerin. Place the client in a semi-Fowler's position. Notify the healthcare provider. Begin supplemental oxygen at 5 L/min.

Notify the healthcare provider.

Which of the following nursing diagnoses would be a priority for the teenage male client with acute leukemia? Risk of activity intolerance related to fatigue. Risk for injury related to thrombocytopenia. Risk for ineffective coping related to disease process. Risk for impaired skin integrity related to purpura.

Risk for injury related to thrombocytopenia.

A client admitted with inflammatory bowel disease asks the nurse for help with menu selections. What menu selection is most likely to be the best choice for this client? Multigrain bagel Fresh blueberries Salmon Raw spinach

Salmon

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? Urine-specific gravity Serum creatinine Blood urea nitrogen (BUN) Serum sodium

Serum creatinine

The nurse notices that the client's heart rate is 50 bpm on the telemetry monitor. Which of the following should the nurse do first? Auscultate for abnormal heart sounds. Take the client's blood pressure. Administer 0.5 mg of atropine IV push. Prepare for transcutatneous pacing.

Take the client's blood pressure.

The nurse is planning discharge education for a client after coronary artery bypass graft (CABG) surgery. Which instruction does the nurse include in this client's teaching? Remember to drink at least 3 liters of fluid daily. You should abstain from sexual activity for 6 months. Stop taking your antihyperlipidemic medication at this time. Take your pulse before, midway through, and after exercising.

Take your pulse before, midway through, and after exercising.

The nurse is interested in primary prevention for cancer. Which activity will allow the nurse to provide this level of prevention? -Teaching junior high school students the impact of using tobacco on the body. -Distributing fecal occult blood test kits to people at the shopping mall. -Educating adolescent girls about getting an annual Pap smear. -Arranging transportation volunteers for clients undergoing radiation therapy.

Teaching junior high school students the impact of using tobacco on the body.

A client who is receiving antiretroviral therapy tells the nurse, "The doctor said that my viral load is reduced. What does this mean?" What is the nurse's best response? The antiretroviral medications are working well right now. You are developing an opportunistic infection. You are not as contagious are you were before. Your HIV infection is becoming resistant to your medications.

The antiretroviral medications are working well right now.