CAS Adult Health
A nurse is completing d/c teaching w a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching? - Remain on bedrest for the first 24 hr. - Keep the leg in a dependent position. - Apply ice to the affected area. - Begin active range of motion.
Apply ice to the affected area.
A nurse is planning care for a client who has end stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? - Administer diuretics. - Restrict the client's intake of fluids. - Reduce the client's intake of protein. - Administer vitamin K.
Reduce the client's intake of protein.
A nurse is assessing a client who is receiving one unit packed RBC's to treat intraop blood loss. The client reports chills and back pain, and the client's bp is 80/64 mmhg. Which of the following actions should the nurse take first? - Stop the infusion of blood. - Inform the provider. - Obtain a urine specimen. - Notify the laboratory.
Stop the infusion of blood.
A nurse in the ED is caring for a client who has extensive partial and full thickness burns of the head, neck, and chest. While planning the clients care, the nurse should identify which of the following risks as the priority for the assessment and intervention? - Airway obstruction - Infection - Fluid imbalance - Paralytic ileus
Airway obstruction
A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? - Halitosis - Gingivitis - Xerostomia -Candidiasis
Candidiasis
A nurse is admitting a client who has active tuberculosis to a room on a med surg unit. Which of the following room assignments should the nurse make for the client? -A room with air exhaust directly to the outdoor environment -A room with another nonsurgical client -A room in the ICU -A room that is within view of the nurses' station
A room with air exhaust directly to the outdoor environment
A nurse is providing teaching to a client who has a new diagnosis of type 2 DM. the nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? SATA -Polyuria -Blurred vision -Polydipsia -Tachycardia -Moist, clammy skin
Blurred vision Tachycardia Moist, clammy skin
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? -Prevent aspiration. -Ensure adequate nutrition. -Promote oral hygiene -Relieve the client's pain.
Prevent aspiration.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which of the following products? - Recombinant -Packed RBCs -Prophylactic antibiotics -Fresh frozen plasma
Recombinant
A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? -The fourth heart sound (S4) -A friction rub -The third heart sound (S3) -A split second heart sound S2
The fourth heart sound (S4)
A nurse is caring for a client who has expressive aphasia following a CVA. Which of the following parameters should the nurse use first in order to assess the client's pain level? - pulse and blood pressure findings - behavioral indicators and effect - scheduled treatments and client illness - a self-report pain rating scale
a self-report pain rating scale
A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching? - "I will sit on the side of the tub and soak my right leg two times every day." - "I'll keep a heating pad on the calf of my right leg when I am lying down." - "I'll place my leg under a heat lamp every 3 hours." - "I'll wrap a warm, wet towel around my right calf every 4 hours."
"I'll wrap a warm, wet towel around my right calf every 4 hours."
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? - "It might help if I tried sleeping only on my back." - "I'll sleep better if I take a sleeping pill at night." - "I'll get a humidifier to run at my bedside at night." - "If I could lose about 50 pounds, I might stop having so many apneic episodes."
"If i could lose about 50 lbs, i might stop having so many apneic episodes"
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? SATA -Hypotension -Polyuria -Hyperthermia -Absence of bowel sounds -Weakened gag reflex
Hypotension Absence of bowel sounds Weakened gag reflex
A nurse is caring for a client who has a chest tube connected to a closed drainage system & needs to be transported to the x-ray dept. Which of the following actions should the nurse take? - Clamp the chest tube prior to transferring the client to a wheelchair. - Disconnect the chest tube from the drainage system during transport. - Keep the drainage system below the level of the client's chest at all times. - Empty the collection chamber prior to transport.
Keep the drainage system below the level of the client's chest at all times.
A nurse is caring for a client who is 5 hour postop following a TURP. The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? - Notify the provider. - Check the tubing for kinks. - Adjust the rate of the bladder irrigant. - Irrigate the catheter.
Check the tubing for kinks.
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should doc that the client has which of the following respiratory alterations? -Kussmaul respirations -Apneustic respirations -Cheyne-Stokes respirations -Stridor
Cheyne- stokes
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? -Check the tubing connections for leaks. -Check the suction control outlet on the wall. -Clamp the chest tube. -Continue to monitor the client's respiratory status.
Continue to monitor the client's respiratory status
A nurse is assessing a client who is in skeletal traction. Which of the following findings should the nurse identify as an indication of infection at the pin sites? -Serosanguineous drainage -Mild erythema -Warmth -Fever
Fever
. A nurse is caring for a client who received a diagnosis of systemic scleroderma 5 years ago. The nurse plans to assess the client to document the disease progression. In addition to skin changes, which of the following findings should the nurse expect? -Periorbital edema -Excessive salivation -Finger contractures -Thinning of the skin
Finger contractures
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? -BP -Heart rate -Urine output -Weight
Heart rate
A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red tinged urine. Which of the following transfusion reactions should the nurse suspect? - Febrile - Allergic - Acute pain - Hemolytic
Hemolytic
A nurse on a med surg unit is caring for four clients who are 24 to 36 hr post op. Which of the following surgical procedures places the client at risk for DVT? -Myringotomy -Laparoscopic appendectomy -Hip arthroplasty -Cataract extraction
Hip arthroplasty
A nurse is teaching about risk factors of developing a stroke with a group of older adults clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching? -History of smoking -Obesity -History of hypertension -Race
Race
A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the ER confused, flushed and with acetone odor on the breath. Diabetes ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? -NPH insulin -Insulin glargine -Insulin detemir -Regular insulin
Regular insulin
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? - Review the client's electrolyte values. - Check the client's perianal skin integrity. - Investigate the client's emotional concerns. - Obtain a dietary history from the client.
Review the client's electrolytes values
A nurse is reviewing lab values for a client who has SLE. Which of the following values should give the nurse the best indication of the client's renal function? -Serum creatinine -Blood urea nitrogen (BUN) -Serum sodium -Urine-specific gravity
Serum creatinine
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? - Serum creatinine -Blood urea nitrogen (BUN) -Serum sodium -Urine-specific gravity
Serum creatinine
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the clients right nostril. Which of the following actions should the nurse take first? -Test the drainage for glucose. -Suction the nostril. -Notify the physician. -Ask the client to blow his nose.
Test the drainage for glucose
A nurse is in a client's room when the client begins having a tonic clonic seizure. Which of the following actions should the nurse take first? -Turn the client's head to the side. -Check the client's motor strength. -Loosen the clothing around the client's waist. -Document the time the seizure began.
Turn the client's head to the side
A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? -WBC 2300/mm3 -RBC 5 million/mm3 -Hemoglobin 12 g/dL -Platelets 155,000/mm3
WBC 2300/mm3
A nurse is caring for a client who has addison's disease and is at risk for addisonian crisis. Which of the following actions should the nurse take? -Provide a low-carbohydrate diet. -Weigh the client daily. -Administer oral corticosteroids. -Restrict fluid intake.
Weigh the client daily.
A nurse is assessing a client who is 48hr postop following abdominal surgery. Which of the following findings should the nurse report to the provider? -Blood pressure 102/66 mm Hg -Straw-colored urine from an indwelling urinary catheter -Yellow-green drainage on the surgical incision -Respiratory rate 18/min
Yellow-green drainage on the surgical incision
. A nurse is reviewing the ABG values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? - pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg - pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg - pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg - pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
A nurse is caring for a client who is scheduled to have a MRI scan. The client asks the nurse what to expect during the procedure, which of the following statements should the nurse take? - "An MRI scan is not distorted by movement, so you do not have to lie still." - "An MRI scan is a short procedure and should take no longer than 30 minutes." - "The MRI contrast dye contains iodine and can cause your skin to itch." - "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated & alone in this room." after acknowledging the client's feelings of loneliness, which of the following responses should the nurse provide? - "I will come and sit with you for 10 minutes each hour." - "Do you have a cell phone you can talk to friends and family on?" - "I'll ask the charge nurse to admit someone to your room for company." - "You're scheduled for discharge in 2 days so this isolation will be over soon."
"Do you have a cell phone you can talk to friends and family on?"
A nurse is teaching the partner of a client who had an acute MI about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzyme studies? - "These tests help determine the degree of damage to the heart tissues." - "Cardiac enzymes will identify the location of the MI." - "These tests will enable the provider to determine the heart structure and mobility of the heart valves." - "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."
"These test help determine the degree of damage to the heart tissues."
A nurse is caring for a client who is in the immediate postop period following a partial laryngectomy. Which of the following parameters should the nurse assess 1st? - Pain severity -Wound drainage -Tissue integrity - Airway patency
Airway patency
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have the following manifestations associated with early menopause? -Urinary retention -Decreased blood pressure -Dryness with intercourse -Elevation in body temperature above 37.8° C (100° F)
Dryness with intercourse
A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make? - Provide the client with articles from the Internet that explain colon cancer stages. - Assure the client that the provider will explain what has been planned. - Explain the various options available for treatment based on the cancer stage. - Encourage the client to write down questions to ask the provider.
Encourage the client to write down questions to ask the provider.
A nurse is assessing a client who is admitted with hyperthyroidism. the client reports a weight loss of 5/4 kg (12lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. which of the following actions should the nurse take to prevent a thyroid crisis? -Provide a quiet, low-stimulus environment. -Administer aspirin as prescribed for any sign of hyperthermia. -Keep the client NPO. -Observe the client carefully for signs of hypocalcemia.
Provide a quiet, low-stimulus environment.
A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse take to maintain privacy for the client? - Close the door to the client's room. - Pull the curtains around the client's bed. - Ask family members to leave the room. - Use sterile drapes to cover the client.
Pull the curtains around the client's bed.
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor? -Confusion -Weakness -Increased intracranial pressure -Increased urinary output
Weakness
A client who has a history of MI is prescribed aspirin 325 mg. The nurse recognizes that the aspirin is given due to which of the following actions of the medication? -analgesic -anti-inflammatory -antiplatelet aggregate -antipyretic
antiplatelet aggregate
A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?
hemorrhagic stroke
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was -dysphagia -hoarseness. -dyspnea. -weight loss
hoarseness
A nurse is caring for a client who is 9 days post op following a total laryngectomy. The nurse removes the client's NG tube and initiates oral feedings. Which of the following statements should the nurse make? - "Tuck your chin when you swallow so you won't choke." - "It is no longer possible for you to choke on or aspirate food." - "You should have no trouble swallowing fluids." - "I will add a thickener to your liquids to prevent aspiration."
"It is no longer possible for you to choke on or aspirate food."
A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a RAST completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result? -Immunoglobulin G (IgG) -Immunoglobulin A (IgA) - Immunoglobulin E (IgE) -Immunoglobulin M (IgM)
-Immunoglobulin E (IgE)
A nurse is caring for a client who has HIV. Which of the following lab values is the nurse's priority? Positive Western blot test CD4-T-cell count 180 cells/mm3 Platelets 150,000/mm3 WBC 5,000/mm3
CD4-T-cell count 180 cells/mm3
A nurse is providing d/c teaching for a client who is postop following a simple mastectomy. The client is to begin outpt radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? - Do not apply heat to the area of irradiation. - Do not wash the area of irradiation. - Use an antibiotic ointment to treat skin breakdown. - Lubricate the skin lubricated with hypoallergenic lotion.
Do not apply heat to the area of irradiation
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? -Large incisions will be made in the eschar to improve circulation -This procedure involves placing the client into a shower and removing the dead tissue. -A piece of healthy skin will be removed from an unburned area and grafted over the burned area." -Dead tissue will be non-surgically removed
Large incisions will be made in the eschar to improve circulation
A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following lab values? -Thyroid stimulating hormone (TSH) -Free T4 -Serum T4 -Serum T3
Thyroid stimulating hormone (TSH)
A nurse is caring for a client who has chemotherapy - induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms? -Extremities that turned blue when exposed to cold -Tingling feeling in the extremities -Jerking movements of the extremities -Spasms of the extremities
Tingling feeling in the extremities
A nurse is caring for an adult client who has dementia and handles anxiety by confabulating. The nurse should recognize confabulation when the client - displays compulsive and ritualistic behaviors. - reminisces about the past. -makes up stories when he is unable to remember actual events. -refuses to leave home to see a provider.
makes up stories when he is unable to remember actual events.
A nurse is instructing a client who is newly diagnosed with pulmonary TB about the use of antitubercular meds. Which of the following info should the nurse include in the teaching? - Medications will need to be taken for the rest of the client's life, even if the client feels better. - Medications will need to be taken until the Mantoux test is negative. - A typical course of treatment involves 6 to 9 months of consistent medication use. - The client's family will also need to take medications to prevent infection.
A typical course of treatment involves 6 to 9 months of consistent med use
A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? -Tell the client to expect dark stools following chemotherapy. -Have the client floss 4 times daily. -Have the client swish with commercial mouthwash before therapy. -Administer an antiemetic prior to the procedure.
Administer an antiemetic prior to the procedure.
A nurse is reviewing the lab data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of the following values? - Calcium - RBC count - Magnesium - Amylase
Amylase
A nurse is reviewing d/c instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? -Sleep on the abdomen to facilitate wound healing. -Bend at the waist to pick objects up from the floor. - Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week -Notify the surgeon if white drainage develops on the eyelids.
Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week
During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? -Squamous cell carcinoma -Basal cell carcinoma -Malignant melanoma -Actinic keratosis
Basal cell carcinoma
A nurse is reviewing the lab findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following lab findings should the nurse expect? -Decreased serum calcium level -Decreased level of serum lipids -Decreased erythrocyte sedimentation rate (ESR) - Increased platelet count
Decreased serum calcium level
A nurse is caring for a client who has parkinson's disease is taking diphenhydramine 25 mg po tid. Which of the following therapeutic outcomes should the nurse expect to see? - Delay in disease progression - Improved bladder function - Relief of depression - Decreased tremors
Decreased tremors
A nurse is assessing a client who has diabetes insipidus, which of the following findings should the nurse expect? - Dehydration -Polyphagia -Hyperglycemia -Bradycardia
Dehydration
. A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? - A history of pelvic inflammatory disease (PID). - Abdominal bloating starting several days before menses. - An atypical Papanicolaou smear at her last clinic visit. - Dysmenorrhea that is unresponsive to NSAIDs.
Dysmenorrhea that is unresponsive to NSAIDs.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a peripherally inserted central catheter (PICC) line. When assessing the client, the nurse notes that the client's arm seems swollen above the PICC insertion site. Which of the following actions should the nurse take first? -Measure the circumference of both upper arms. -Notify the provider who inserted the PICC line. -Remove the PICC line. -Apply a cold pack to the client's upper arm.
Measure the circumference of both upper arms
A nurse is caring for a client following an abdominal surgery. The client has a prescription for dressing changes every 4 hr & prn. Which of the following objects should the nurse use to reduce skin irritation around the incision area? - Montgomery straps -Enzymes -Alcohol swabs -A transparent dressing
Montgomery straps
A nurse is assessing a client who has a pneumothorax w a chest tube in place. For which of the following findings should the nurse notify the Dr? - Movement of the trachea toward the unaffected side -Bubbling of the water in the water seal chamber with exhalation -Crepitus in the area above and surrounding the insertion site -Eyelets are not visible
Movement of the trachea toward the unaffected side
A nurse is providing instructions for a 52- year old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate? - "Don't worry; most clients dislike the prep more than the procedure itself." - "Before the examination, your provider will give you a sedative that will make you sleepy." - "I know you're anxious, but this procedure is recommended for people your age." - "After you have signed the consent form, we can talk more about this."
"Before the examination, your provider will give you a sedative that will make you sleepy."
A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the clients provider? - "My eye really itches, but I'm trying not to rub it." - "I need something for the pain in my eye. I can't stand it." - "It's hard to see with a patch on one eye. I'm afraid of falling." - "The bright light in this room is really bothering me."
"I need something for the pain in my eye. I can't stand it."
. A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? - Abnormally prominent U wave - Elevated ST segment - Wide QRS - Inverted P wave
Abnormally prominent U wave
A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize which of the following are manifestations of Cushing's syndrome? SATA - Alopecia -Tremors - Moon face - Purple striations - Buffalo hump
- Alopecia - Moon face - Purple striations - Buffalo hump
A nurse is caring for a client who has cushing's syndrome. Which of the following interventions should the nurse expect to perform? (SATA) -Assess blood glucose level -Assess for neck vein distention -Monitor for an irregular heart rate -Monitor for postural hypotension -Weigh the client daily
- Assess blood glucose level - Assess for neck vein distention - Weigh the client daily
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (SATA) - Increased heart rate - Increased blood pressure - Increased respiratory rate -Increase hematocrit -Increased temperature
- Increased heart rate - Increased blood pressure - Increased respiratory rate
A nurse is caring for an older adult client who had surgery for intestinal obstruction and has NG tube to wall suction. which intervention should nurse include in postop plan of care -Discontinue suction when assessing for peristalsis -Irrigate the NG tube with 0.9% sodium chloride irrigation solution. -Place sequential compression devices on the bilateral lower extremities. -Reposition the client from side to side every 2 hr. -Encourage the use of an incentive spirometer every 2 hr while the client is awake.
-Discontinue suction when assessing for peristalsis -Irrigate the NG tube with 0.9% sodium chloride irrigation solution. -Place sequential compression devices on the bilateral lower extremities. -Reposition the client from side to side every 2 hr.
A nurse is teaching a female client who has a new diagnosis of systemic lupus erythematosus (SLE) about factors that can trigger an exacerbation of SLE. The nurse should determine that the client needs more teaching when she identifies which of the following as a factor that can exacerbate SLE? -Sunlight -Pregnancy -Infection -Exercise
Exercise
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor? - Hypocalcemia - BMI less than 25 - Family history - Diuretic use
Family history
Nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations? -Sensitivity to cold -Constipation -Frequent mood changes -Weight gain of 10lbs in 3 weeks
Frequent mood changes.
A nurse is conducting a primary survey of a client who has sustained life threatening injuries due to a mvc. Identify the sequence of the actions the nurse should take.
Open the airway using a jaw thrust maneuver. Determine effectiveness of ventilator efforts Establish iv access Perform a glasgow coma scale assessment Remove clothing for a thorough assessment
A nurse is admitting a client who has acute pancreatitis. Which of the following provider prescriptions should the nurse anticipate? - Initiate a low-residue diet. - Pantoprazole 80 mg IV bolus twice daily - Ambulate twice daily. - Pancrelipase 500 units/kg PO three times daily with meals
Pantoprazole 80 mg IV bolus twice daily
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? - Perform a neurovascular assessment. - Explain the discharge instructions to the client and parents. - Provide reassurance to the client and parents. - Apply an ice pack to the casted leg.
Perform a neurovascular assessment.
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? - Replace the catheter every 3 days. - Check the catheter tubing for kinks or twisting. - Irrigate the catheter once each shift. - Clean the perineal area with an antiseptic solution daily.
Check the catheter tubing for kinks or twisting.
A nurse is caring for a client who is 1 day postop following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse's initial action? -Document the amount of drainage. - Obtain a culture of the drainage. -Check the drainage for glucose. - Notify the client's provider.
Check the drainage for glucose.
A nurse is caring for a client who is receiving cisplatin to treat bladder cancer. After several treatments, the client reports fatigue. Which of the following actions should the nurse take? - Check the results of the client's most recent CBC. - Assess the client for a hypersensitivity reaction. - Evaluate the client for hypercalcemia. - Examine the client for hepatomegaly.
Check the results of the clients most recent CBC
A nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? -Chvostek's sign -Babinski's sign -Brudzinski's sign -Kernig's sign
Chvostek's sign
A nurse is caring for a client who is 4 days post op following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand? -Buttoning her blouse -Eating her breakfast -Combing her hair -Brushing her teeth
Combing her hair
A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? SATA -Dyspnea -Bradycardia -Barrel chest -Clubbing of the fingers -Deep respirations
Dyspnea Barrel Chest Clubbing of the fingers
. A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? - Cleanse the perineum from back to front. - Obtain a prescription for an indwelling urinary catheter. - Encourage fluid intake at and between meals. - Offer the client the bedpan every 2 hr.
Encourage fluid intake at & between meals
A nurse is caring for a client who has COPD. The client tells the nurse " i can feel the congestion in my lungs, and i certainly cough a lot, but i can't seem to bring anything up." Which of the following actions should the nurse take to help the client with tenacious bronchial secretions? - Maintaining a semi-Fowler's position as often as possible - Administering oxygen via nasal cannula at 2 L/min - Helping the client select a low-salt diet - Encouraging the client to drink 2 to 3 L of water daily
Encouraging the client 2 to 3 L of water daily
A rehab nurse is caring for a client who had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? - Inform the client that privileges are related to participation in therapy. - Limit visiting hours until the client begins to participate in therapy. - Allow the client to control the timing and frequency of the therapy. - Establish a plan of care with the client that sets attainable goals.
Establish a plan of care with the client that sets attainable goals.
A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report - loss of central vision. - having a loss of peripheral vision. - seeing bright flashes of light and floaters. - having a decreased ability to perceive colors.
Having a decreased ability to perceive colors.
. A nurse is assessing a client who is admitted for elective surgery and has a history of addison's disease. Which of the following findings should the nurse expect? - Hyperpigmentation -Intention tremors -Hirsutism -Purple striations
Hyperpigmentation
A nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen? -"I will closely follow a high-purine diet." -"I will limit my fluid intake to 1 liter per day." -"I will take one aspirin every day." -"I will limit my alcohol intake."
I will limit my alcohol intake
. A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? - "I should consume most of the fluid during the evening." - "I will make a list of my favorite beverages." - "I will put beverages in large containers to give the appearance of drinking a lot." - "I will not add ice cream to the amount of fluid intake."
I will make a list of my favorite beverages
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the clients care? - Impaired tissue perfusion - Alteration in body image - Alteration in activity tolerance - Impaired skin integrity
Impaired tissue perfusion
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect? - Difficulty reading - Inability to recognize his family members - Right hemiparesis - Aphasia
Inability to recognize his family members
A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing the pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? -It decreases the client's level of anxiety. -It facilitates the client's deep breathing. -It enhances the client's ability to sleep. -It reduces the client's blood pressure.
It facilitates the client's deep breathing
A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort? -Lower the height of the solution container. -Encourage the client to bear down. -Allow the client to expel some fluid before continuing. -Stop the enema and document that the client did not tolerate the procedure.
Lower the height of the solution container.
A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? -Elevating her feet -Massaging her legs -Flexing her ankles -Ambulating soon after surgery
Massaging her legs
A nurse in a clinic is collecting a history from a client who reports that a member of his family just received a diagnosis of pulmonary tuberculosis -Sputum culture for acid-fast bacillus (AFB) -Nucleic acid amplification test (NAAT) -CT scan -Chest x-ray
Nucleic acid amplification test (NAAT)
A nurse is caring for a client with a trach. The clients partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the clients discharge? - Attending a class given about tracheostomy care - Verbalizing all steps in the procedure - Performing the procedure independently - Asking appropriate questions about suctioning
Performing the procedure independently
A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a sengstaken-blakemore tube to control the bleeding. Which of the following actions should the nurse take? -Ambulate the client four times per day. -Encourage the client to consume clear liquids. -Provide frequent oral and nares care. - Keep the client in a supine position.
Provide frequent oral and nares care.
A nurse is caring for a client who has a JP drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? -To prevent fluid from accumulating in the wound -To limit the amount of bleeding from the surgical site -To provide a means for medication administration -To eliminate the need for wound irrigations
To prevent fluid from accumulating in the wound