AMS B

A nurse is performing a preoperative assessment for a client. The nurse should identify that an allergy to which of the following foods can indicate a latex allergy? Shellfish Peanuts Avocados Eggs

Avocados Clients who have an avocado allergy might have an allergic reaction or a sensitivity to latex. Allergies to certain fruits, such as strawberries and bananas, can also indicate latex allergy or sensitivity. Clients who have a shellfish allergy might have an allergic reaction to povidone-iodine. Clients who have a peanut allergy might have an allergic reaction to propofol. Clients who have an egg allergy might have an allergic reaction to propofol.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching? "I will take my iron with a glass of milk." "I will take an antacid with my iron." "I will limit my intake of red meat." "I will eat more high-fiber foods."

"I will eat more high-fiber foods." The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

FLAG A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? Check the client's blood glucose according to facility mealtimes. Contact the provider to clarify the prescription. Request for meals to be provided for the client. Hold the prescription until the client is no longer NPO.

Contact the provider to clarify the prescription. Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take? Document that depolarization has occurred. Increase the pacemaker's voltage. Decrease the pacemaker's sensitivity. Check the placement of the ECG leads.

Document that depolarization has occurred. When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching? Drink 240 mL (8 oz) of water after administration. Expect results in 4 to 6 hr. Take this medication before meals to increase appetite. Reduce dietary fiber intake to improve medication absorption.

Drink 240 mL (8 oz) of water after administration. The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving? Potassium 3.5 mEq/L pH 7.28 Glucose 272 mg/dL HCO3- 14 mEq/L

Glucose 272 A glucose reading less than 300 mg/dL indicates improvement in the client's status.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect? Painless ulcerations on the ankles Hair loss on the lower legs No extremity pain when resting Rubor with elevation of the extremity

Hair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.

A nurse is providing teaching to a client who has asthma about the use of a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching? Breathing in rapidly while administering the medication Washing the plastic case and cap of the inhaler in the dishwasher Holding breath for 10 seconds after inhaling Waiting 15 seconds between puffs, if two puffs are required

Holding breath for 10 seconds after inhaling The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect? PaCO2 56 mm Hg pH 7.38 HCO3- 24 mEq/L PaO2 90 mm Hg

PaCO2 56 mm Hg A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.

A nurse is caring for a client who has terminal cancer. The client tells the nurse, "I wish I could stop these treatments. I am ready to die." Which of the following statements should the nurse make? "Discontinuing with the treatments is your choice if it is your wish to do so." "Your daughter is named as your health care surrogate. I will ask her if you can stop them." "I will call your spiritual advisor to come in, so you can discuss this with them." "Next time you have an oncology appointment, you should ask the oncologist."

"Discontinuing with the treatments is your choice if it is your wish to do so." The nurse should recognize the client's right to refuse the treatments and inform the client of this right. The nurse should advocate for the client and offer to contact the provider for the client.

A nurse is providing discharge instructions to a client who has laryngeal cancer and is receiving radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? "I will wear a badge to measure how much radiation I am receiving." "I will remove the markings on my skin after each radiation treatment." "I will avoid direct exposure to the sun." "I will rinse my mouth with a commercial mouthwash."

"I will avoid direct exposure to the sun." The client should avoid exposure of irradiated skin areas to the sun for at least 1 year after completing radiation therapy. Skin in the radiation path is especially sensitive to sun damage.

A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? "This measures how much blood my heart is pumping." "This identifies if I have a defective heart valve." "This identifies if the pacemaker cells of my heart are working properly." "This measures the blood circulating to my heart muscle."

"This identifies if the pacemaker cells of my heart are working properly." Telemetry detects the ability of cardiac cells to generate a spontaneous and repetitive electrical impulse through the heart muscle.

A nurse is preparing to administer phenytoin 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is receiving report on a client who is postoperative following an open repair of Zenker's diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A )Neck

A nurse is teaching a client about the use of transcutaneous electrical nerve stimulation (TENS) for the management of bone cancer pain. The nurse should explain that applying a TENS unit to the painful area has which of the following effects? Electrically generated feelings of heat Cryotherapy for painful areas A tingling sensation replacing the pain Realignment of energy flow through meridians

A tingling sensation replacing the pain A TENS unit applies small electric currents to the painful area, with the client increasing the current until the "pins and needles" sensation overrides the pain.

A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

AdminiSTER o2 Initiate IV therapy Insert an NG tube Administer ranitidine

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate? Airborne Droplet Contact Protective environment

Airborne Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.

A nurse at an urgent care clinic is caring for a client who is experiencing an anaphylactic reaction. After ensuring a patent airway, which of the following nursing interventions is the priority? Applying oxygen via face mask Placing the client in Fowler's position Administering epinephrine Initiating an IV infusion of 0.9% sodium chloride

Applying oxygen via face mask

A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) EXHIBIT Blood pressure Prescribed medications Oxygen saturation BUN

BUN The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? The chest tube is draining serosanguineous fluid at 65 mL/hr. The client tolerates gentle milking of the tubing. Bubbling in the water seal chamber has ceased. There is tidaling in the water seal chamber.

Bubbling in the water seal chamber has ceased. Bubbling in the water seal chamber ceases when the lung re-expands.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first? Obtain the client's vital signs. Describe the blood transfusion procedure to the client. Check for the type and number of units of blood to administer. Initiate a peripheral IV line.

Check for the type and number of units of blood to administer According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client's medication administration record.

A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? Clean the wound daily with an antiseptic. Use a donut-shaped pillow when sitting in a chair. Change position every hour. Massage the area two times daily.

Change position every hour. Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.

A nurse in an emergency department is assessing an older adult client who has a fractured wrist following a fall. During the assessment, the client states, "Last week I crashed my car because my vision suddenly became blurry." Which of the following actions is the nurse's priority? Check the client's neurologic status. Document the client's statements. Prepare the client for a CT scan. Teach the client about using safety precautions for falls.

Check the client's neurologic status.

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider? The client's urinary output has increased. The client reports back pain. The client's urine color is red tinged. The client's BUN is 18 mg/dL.

Client reports back pain The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain? Set the wall suction to 80 to 100 mm Hg. Compress the drain reservoir after emptying. Allow the drainage to collect on a sterile gauze dressing. Position the drain below the bed to promote drainage.

Compress the drain reservoir after emptying. Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

FLAG A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload? Warm, moist skin Distended neck veins Dark amber, odiferous urine Orthostatic hypotension

Distended neck veins The nurse should identify distended neck and hand veins as indicators of fluid volume overload.

A nurse is planning care for a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse include in the plan? Encourage the client to take deep breaths after the procedure. Assist the client to hold their arms up during the procedure. Instruct the client to remain NPO after midnight prior to the procedure. Keep the client on bed rest for 8 hr following the procedure.

Encourage the client to take deep breaths after the procedure After a thoracentesis, the client should deep breathe to re-expand the lung.

A nurse is reviewing the medical record of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect? Facial butterfly rash Bradycardia Esophagitis Interstitial fibrosis

Facial butterfly rash A butterfly rash is a manifestation of SLE. It appears as a dry, red rash on the client's cheeks and nose and can disappear during times of remission.

A nurse is providing education to a client who has tuberculosis (TB) and their family. Which of the following information should the nurse include in the teaching? After 1 week of medication, TB is no longer communicable. Dispose of contaminated tissues in a paper bag. Airborne precautions are necessary in the home. Family members in the household should undergo TB testing.

Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse include? Flex the foot every hour when awake. Place a pillow under the knee when lying in bed. Lower the leg when sitting in a chair. Ensure the leg is abducted when resting in bed.

Flex the foot every hour when awake. The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (Select all that apply.) Follow a smoking cessation program. Maintain an appropriate weight. Eat a low-fat diet. Increase fluid intake. Decrease intake of complex carbohydrates.

Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate 80/min, blood pressure 130/70 mm Hg, respiratory rate 16/min, and temperature 36° C (96.8° F). Which of the following vital sign changes should alert the nurse that the client might be hemorrhaging? Heart rate 110/min Blood pressure 160/70 mm Hg Respiratory rate 14/min Temperature 38.4° C (101.1° F)

Heart rate 110/min One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make? "You should accept your body image change before discharge." "It is important for you to look at the incisional site when the dressings are removed." "I will refer you to community resources that can provide support." "The scar will remain red and raised for many years after surgery."

I will refer you to community resources that can provide support The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.

A nurse is providing discharge teaching to a client who is to self-administer heparin subcutaneously. Which of the following statements by the client indicates an understanding of the teaching? "I can expect to have blood in my urine during the first week of injections." "I will floss my teeth after each meal." "I will gently massage the site after I inject my medication." "I will use an electric razor to shave."

I will use an electric razor to shave Heparin is an anticoagulant that places the client at the risk for bleeding. Therefore, the nurse should instruct the client to use an electric razor when shaving to reduce the risk of cuts to the skin.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care? Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. Assist the client to start arm exercises 48 hr after surgery. Maintain the right arm in an extended position at the client's side when in bed. Place the client in a supine position for the first 24 hr after surgery.

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Remove the client's indwelling urinary catheter. Irrigate the indwelling urinary catheter. Clamp the indwelling urinary catheter. Apply traction to the indwelling urinary catheter.

Irrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Keep a lead-lined container in the client's room. Limit each visitor to 1 hr per day. Place a dosimeter badge on the client. Remove soiled linens from the client's room each day.

Keep a lead-lined container in the client's room. The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is caring for a client who is having a tonic-clonic seizure while in bed and has become cyanotic. Which of the following actions should the nurse take? (Select all that apply.) Restrain the client. Prepare to suction the client's airway. Insert a tongue blade in the client's mouth. Raise the head of the client's bed to a semi-Fowler's position. Loosen restrictive clothing on the client.

Loosen restrictive clothing on the client. Prepare to suction the client's airway.

A nurse is providing discharge teaching to a client who is postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include? Flex the affected arm when ambulating. Numbness can occur along the inside of the affected arm. Begin active range-of-motion exercises 1 day after surgery. Dress in clothing that fits snugly.

Numbness can occur along the inside of the affected arm The nurse should instruct the client that numbness can occur near the incision and along the inside of the affected arm due to nerve injury.

A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to the audio clip. (Click on the audio button to listen to the clip.)

Pericardial friction rub The nurse is hearing a pericardial friction rub, which is a scratchy, high-pitched sound associated with infection, inflammation, or infiltration and can be a manifestation of pericarditis. A pericardial friction rub is best heard with the diaphragm of the stethoscope.

A nurse is planning care for a client who is postoperative following a parathyroidectomy. Which of the following actions should the nurse identify as the priority? Use pillows to support the client's head and neck. Offer opioid medication. Place a tracheostomy tray at the bedside. Place the client in semi-Fowler's position.

Place tach tray at the bedside The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to place a tracheostomy tray at the client's bedside in case of airway obstruction.

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis? Conjugated estrogens Enalapril Prednisone Colchicine

Prednisone The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? 240 mL (8 oz) of orange juice 1 ampule of 50% dextrose IV bolus NPH insulin 60 units subcutaneous Regular insulin 20 units IV bolus

Regular insulin 20 units IV DKA is a complication of diabetes mellitus that results in dehydration, ketosis, metabolic acidosis, and elevated blood glucose levels. Management of DKA involves providing hydration, correcting acid-base imbalances, and decreasing blood glucose levels. Regular insulin is a fast-acting insulin that can be effective within 10 min when administered intravenously.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority? Report of sore throat Report of memory loss Alopecia Mucositis

Report of sore throat When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider? Temperature 37.2° C (99° F) Blood pressure 100/70 mm Hg Weight loss Restlessness

Restlessness Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.

A nurse is caring for a client who is 8 hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first? Document the client's intake and output. Scan the bladder with a portable ultrasound. Pour warm water over the client's perineum. Perform a straight catheterization.

Scan the bladder with a portable ultrasound. The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls when ambulating, the nurse should provide which of the following instructions to the client? "Wear an eye patch over one eye." "Make sure to have a staff member walk on your stronger side." "Scan the environment by turning your head from side to side." "Make sure to look at your feet while walking."

Scan the environment by turning your head from side to side." Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.

A nurse is reviewing the medical record of a client who has osteomyelitis and a prescription for gentamicin. Which of the following findings from the client's medical record should indicate to the nurse the need to withhold the medication and notify the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Serum creatinine A client who has an elevated serum creatinine level should not receive gentamicin because the medication is nephrotoxic.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Administer an antihistamine. Slow the infusion rate. Give the client a corticosteroid. Elevate the client's lower extremities.

Slow the infusion rate Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.

A nurse is providing discharge instructions to a client who has active tuberculosis (TB). Which of the following information should the nurse include in the instructions? Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. The contagious period generally lasts for 6 to 8 weeks after the initiation of medication therapy. Family members should follow airborne precautions at home. A follow-up tuberculosis skin test is necessary in 2 months.

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. After three negative sputum cultures, the client is no longer considered infectious.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should recognize that which of the following complications is associated with long-term mechanical ventilation? Elevated blood pressure Dehydration Stress ulcers Hypernatremia

Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority? Moderate serosanguinous drainage on the dressing Calcium 9.5 mg/dL Temperature 38.9° C (102° F) Decreased bowel sounds

Temperature 38.9° C (102° F) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.

A nurse is assessing a client while suctioning the client's tracheostomy tube. Which of the following findings should indicate to the nurse the client is experiencing hypoxia? The client starts to cough. The client's heart rate increases. The client is diaphoretic. The client's blood pressure decreases.

The client's heart rate increases. Hypoxia related to suctioning can cause the client's heart rate to increase. If this occurs, the nurse should discontinue the suctioning and manually oxygenate the client with 100% oxygen. The nurse should instruct the client to take three or four deep breaths prior to suctioning to reduce the risk for hypoxia.

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

This image depicts glossitis, which can indicate pernicious anemia. Glossitis, a smooth red tongue, is also a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid.

A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction (MI)? Creatine kinase (CK-MB) 85 units/L High-density lipoprotein (HDL) 65 mg/dL Alanine aminotransferase (ALT) 28 units/L Troponin I 8 ng/mL

Troponin I 8 ng/mL Troponins are proteins present in skeletal and cardiac muscle that are involved with muscle contraction. The elevation of either troponin T or troponin I is an indication of cardiac injury. The client's laboratory value is above the expected reference range for troponin I, indicating an MI has occurred. CK-MB is found in the heart, skeletal muscle, and brain tissue, and is elevated within 6 hr after an injury occurs. An elevated CK-MB indicates a significant MI has already occurred; however, a CK-MB level of 85 units/L is within the expected reference range.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care? Secure the straps firmly around the boot. Remove the device before showering. Use crutches with rubber tips. Adjust the screws to maintain alignment.

Use crutches with rubber tips. Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicates a potential complication? RBC count 5.2 million/mm3 WBC count 2,000/mm3 Platelets 380,000/mm3 Potassium 4 mEq/L

WBC count 2,000 A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is providing education to a client who is at risk for osteoporosis. Which of the following instructions should the nurse include? Begin taking glucosamine supplements. Walk for 30 min four times per week. Jog for 15 min two times per week. Avoid taking over-the-counter calcium supplements.

Walk for 30 min four times per week. Weight-bearing exercises promote bone mass. Therefore, walking can help the client prevent osteoporosis.

A nurse is providing teaching to a client who has stage II cervical cancer and is scheduled for brachytherapy. Which of the following instructions should the nurse include? "You will have an implant placed twice each month for the duration of the treatment." "You should remain at least 6 feet away from others between treatments." "You should expect to have blood in your urine for a few days after treatment." "You will need to stay still in the bed during each treatment session."

You will need to stay still in the bed during each treatment session." The nurse should instruct the client that they will need to remain on bed rest with very limited movement because excessive movement can cause the radioactive source to become dislodged.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? "Ginkgo biloba relieves nausea for people who have vertigo." "Taking ginkgo biloba will help relieve your joint pain." "Ginkgo biloba can cause an increased risk for bleeding." "Taking ginkgo biloba decreases the risk of migraine headache."

"Ginkgo biloba can cause an increased risk for bleeding." Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following information should the nurse include in the teaching? "Take this medication on an empty stomach." "Eczema is an immediate expected adverse effect of this medication." "Increase fiber intake to avoid constipation." "Monitor your blood pressure monthly."

"Increase fiber intake to avoid constipation."

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain? Increase intake of foods containing calcium. Alternate application of heat and cold to the affected joints. Keep the affected extremities elevated. Limit movement of the affected joints.

Alternate application of heat and cold to the affected joints. The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse is providing discharge teaching about infection prevention to a client who has AIDS. Which of the following statements by the client indicates understanding of the teaching? "I will eat a salad at least once each day to increase my intake of vitamin K." "I can work in my flower garden as long as I wear gardening gloves to cover my skin." "I will no longer floss my teeth after brushing my teeth." "I can sip on a glass of juice for at least 2 hours before I should discard it."

"I will no longer floss my teeth after brushing my teeth." The nurse should instruct the client to avoid flossing teeth to prevent gum inflammation, which could create the opportunity for infection.

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching? "I should clean my toothbrush in the dishwasher once a month." "I should eat more fresh fruit and vegetables." "I will avoid drinking a glass of cold liquid that has been standing for 30 minutes." "I will take my temperature once a day."

"I will take my temperature once a day." A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? "Older adult clients might require up to 6 grams of acetaminophen over 24 hours for effective pain control." "Ibuprofen can cause gastrointestinal bleeding in older adult clients." "Meperidine is the medication of choice for older adult clients experiencing severe pain." "Older adult clients taking oxycodone are at risk for diarrhea."

"Ibuprofen can cause gastrointestinal bleeding in older adult clients." A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

A nurse is evaluating the plan of care for four clients after 2 days of hospitalization. The nurse should identify the need to revise the plan for which of the following clients? A client who is taking potassium supplements, has a potassium level of 3.2 mEq/L, and reports constipation A client who has Alzheimer's Disease (AD), has a room near the nurse's station, and is agitated A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A client who has a conductive hearing loss, speaks softly, and is scheduled for a cerumen removal

A client who is postoperative following abdominal surgery and reports feeling that something "popped" when they coughed A feeling of something popping or loosening with coughing might indicate a wound dehiscence. This client will need to have revisions to the plan of care, which can include management of the dehiscence, prevention of evisceration, or possible surgical repair of an evisceration if one occurs.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect? Constipation Insomnia Tachycardia Diaphoresis

Constipation A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.

A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Anorexia and jaundice Bronchospasm and urticaria Hypertension and bounding pulse Low back pain and apprehension

Low back pain and apprehension Hemolytic transfusion reactions result from the infusion of incompatible blood products and create a systemic inflammatory response. Manifestations include low back pain, hypotension, tachycardia, and apprehension.

A nurse is caring for a client who has breast cancer and tells the nurse that they would like to have acupuncture because it provides greater relief than pain medication. Which of the following statements should the nurse make? "Acupuncture is not an approved treatment for cancer pain." "I can speak to the provider about incorporating acupuncture into your treatment plan." "I will ask the provider to prescribe a stronger medication to help ease your pain." "I can contact a family member or spiritual advisor for you to speak with."

"I can speak to the provider about incorporating acupuncture into your treatment plan." The nurse should serve as an advocate for the client by acting on behalf of the client and offering to speak with the provider. The client has the right to make choices and decisions about their treatment and the nurse should support these decisions and assist the client to carry them out.

A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? Potassium 4.8 mEq/L Magnesium 1.7 mEq/L BUN 34 mg/dL Hematocrit 45%

BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has a positive culture for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following actions should the nurse take? Obtain a sputum specimen to determine if there is colonization. Bathe the client using chlorhexidine solution. Place the client in droplet isolation. Restrict visits from the client's friends and family.

Bathe the client using chlorhexidine solution. The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is providing teaching to a client who is perimenopausal and has a prescription for hormone replacement therapy. For which of the following adverse effects should the nurse instruct the client to notify the provider? (Select all that apply.) Night sweats Calf pain Vaginal dryness Numbness in the arms Intense headache

Calf pain Numbness in the arms Intense headache Night sweats is incorrect. Night sweats are a manifestation of menopause and do not require notification of the provider.Calf pain is correct. Calf pain is an indication of deep-vein thrombosis. The client should report this finding to the provider immediately.Vaginal dryness is incorrect. Vaginal dryness is an expected finding of menopause.Numbness in the arms is correct. Numbness in the arms can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately.Intense headache is correct. An intense headache can indicate a cerebrovascular accident, which is an adverse effect of hormone replacement therapy. The client should report this finding to the provider immediately.

A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? Take a calcium antacid before meals and at bedtime. Consume at least 30 g of fiber daily. Take a stimulant laxative daily. Consume no more than 1,000 mL of water per day.

Consume at least 30 g of fiber daily. Irritable bowel syndrome is a gastrointestinal disorder characterized by abdominal pain, bloating, and either constipation or diarrhea or a mixture of both. Consuming a diet high in dietary fiber helps produce bulky, soft stools and establish regular bowel patterns.

A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. Which of the following findings should the nurse report to the provider as an adverse effect of this medication? Decreased heart rate Crackles heard on auscultation Increased urinary output Decreased deep tendon reflexes

Crackles heard on auscultation Mannitol is an osmotic diuretic that prevents the reabsorption of water in the kidneys, thus increasing urinary output. With the exception of the brain, mannitol can leave the vascular system at the capillary site, which can result in edema. The nurse should identify crackles as a manifestations of pulmonary edema and notify the provider. Other manifestations include dyspnea and decreased oxygen saturation.

A nurse is teaching a family about the care of a parent who has a new diagnosis of Alzheimer's disease. Which of the following information should the nurse include in the teaching? Position tabletop clocks with multi-colored backgrounds throughout the home. Explain how to complete a task while having the client do the task. Place a calendar on the wall with days and weeks included. Create complete outfits and allow the client to select one each day.

Create complete outfits and allow the client to select one each day The family should place completed outfits on hangers and allow the client to select which one to wear each day.

A nurse is assessing a client who has advanced lung cancer and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer? Dyspnea Hemoptysis Mucus production Dysphagia

Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? Extremity cool upon palpation Serosanguineous drainage on the dressing Capillary refill of 2 seconds Client report of discomfort when moving toes

Extremity cool upon palpation The nurse should report indicators of reduced circulation, such as pallor, cool temperature, or paresthesia of the client's extremity. These findings can indicate that the client is at risk for developing acute compartment syndrome.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? Temperature 38.9° C (102° F) Systolic blood pressure 70 mm Hg Heart rate 52/min Respiratory rate 8/min

Heart rate 52/min A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.

A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? Kidney donation must come from a living donor. Immunosuppressive therapy is necessary until the donated kidney begins producing urine. Hemodialysis is sometimes required following surgery. Kidney transplant recipients can resume their regular diet following surgery.

Hemodialys is something required following surgery When a kidney comes from a deceased donor, it might not function immediately, requiring the recipient to continue hemodialysis postoperatively.

A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of clients? Multiple sclerosis Skin cancer Urolithiasis Hypertension

Hypertension

A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? INR 1 INR 2.5 aPTT 45 seconds aPTT 90 seconds

INR 2.5 Clients receive warfarin therapy to decrease the risk of stroke, myocardial infarction (MI), or pulmonary emboli (PE) from blood clots. Since warfarin is an anticoagulant, the medication must be monitored to ensure the anticoagulation is within the therapeutic range and prevent hemorrhage (high levels of anticoagulation) or stroke, MI, or PE (low levels of anticoagulation). An INR of 2.5 is within the targeted therapeutic range of 2 to 3 for a client who has atrial fibrillation.

A nurse is caring for an older adult client who has dementia and requires acute care for a respiratory infection. The client is agitated and is attempting to remove their IV catheter. Which of the following actions should nurse take to avoid restraining the client? Check on the client every 2 hr. Provide a quiet environment with no distractions. Turn on the television in the client's room. Keep the client occupied with a manual activity.

Keep the client occupied with a manual activity. The nurse should provide the client with a manual activity such as a puzzle or an art project. This can help to distract the client from the IV catheter.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Low urine specific gravity Hypertension Bounding peripheral pulses Hyperglycemia

Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? "I will need to take antibiotics for 1 year." "My partner will need to take an antiviral medication." "My joints ache because I have Lyme disease." "I bruise easily because I have Lyme disease."

My joints ache because I have Lyme disease Lyme disease is a vector-borne illness transmitted by the deer tick. The disease course occurs in three stages beginning with joint and muscle pain in stage I. If left untreated, these symptoms continue throughout stage II and, by stage III, become chronic. Other chronic complications include memory problems and fatigue.

A nurse is assessing for compartment syndrome in a client who has a short leg cast. Which of the following findings should the nurse identify as a manifestation of this condition? Bounding pedal pulse Capillary refill less than 2 seconds Pain that increases with passive movement Areas of warmth on the cast

Pain that increases with passive movement The nurse should identify that a client who has compartment syndrome experiences pain that increases with passive movement. Compartment syndrome results from a decrease in blood flow in the extremity caused by a decrease in the muscle compartment size due to a cast that is too tight.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? Explain procedures as they occur to the client. Place personal items, such as pictures, at the client's bedside. Orient the client to their location once a shift. Encourage the family members to remain home until the client has adjusted.

Place personal items, such as pictures, at the client's bedside. The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following laboratory values is a manifestation of osteomyelitis and should be reported to the provider? Sedimentation rate Hematocrit Calcium Acid phosphatase

Sedimentation rate An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

A nurse is caring for a client following extubation of an endotracheal tube 10 min ago. Which of the following findings should the nurse report to the provider immediately? Stridor Oral secretions Hoarseness Sore throat

Stridor Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should report the finding immediately and implement an intervention.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider? Hydrocodone Bupropion Lactulose Warfarin

Warfarin Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take? Flush the line before administering antibiotics. Position the client in Trendelenburg to obtain measurements. Have the client bear down when readings are obtained. Place a pressure bag around the flush solution.

place a pressure bag around the flush solution The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.