Exam 3 question bank

A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). 1. What condition does the nurse anticipate? 2. What laboratory tests does the nurse anticipate will be ordered?

1. acute pyelonephritis 2. urinalysis, blood culture and sensitivity, wbcs, c&s

Which parameters will the nurse monitor to ensure that a client's gas exchange response to oxygen therapy is adequate? Select all that apply. A. Level of consciousness B. Respiratory pattern C. Oxygen flow rate D. Pulse oximetry E. Respiratory rate F. Blood pressure

A, B, D, E A. Level of consciousness B. Respiratory pattern D. Pulse oximetry E. Respiratory rate

In what situations will the nurse consider oxygen therapy as possibly beneficial for a client? Select all that apply. A. Anemia B. Hypoxia C. Hypothermia D. Hypertension E. Pneumonia F. Venous insufficiency

A, B, E A. Anemia B. Hypoxia E. Pneumonia

A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include? (Select all that apply.) A. Avoid sitting in a wet bathing suit. B. Wipe the perineal area back to front following elimination. C. Empty the bladder when there is an urge to void. D. Wear synthetic fabric underwear. E. Take a shower daily.

A, C, E A. Avoid sitting in a wet bathing suit. C. Empty the bladder when there is an urge to void. E. Take a shower daily. A. CORRECT: The client should avoid sitting in a wet bathing suit, which can increase the risk for a UTI by colonization ot bacteria in a moist, warm environment. C. CORRECT: The client should empty the bladder when there is an urge to void rather than retain urine for an extended period of time, which increases the risk for a UTI. E. CORRECT: The client should take a shower daily to promote good body hygiene and decrease colonization of bacteria in the perineal area that can cause a UTI.

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Apply suction for 10 to 15 seconds.

A, D, E A. Apply suction while withdrawing the catheter. D. Use a new catheter for each suctioning attempt. E. Apply suction for 10 to 15 seconds. A. CORRECT: Apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue. D. CORRECT: Use a new suction catheter, unless an in-line suctioning system is in place, to prevent contamination with micro-organisms that can cause an infection. E. CORRECT: To prevent hypoxemia, apply suction for only 10 to 15 seconds and allow 2 to 3 min between passes for ventilation and oxygenation.

When providing care to a client who has undergone a nephrostomy for hydronephrosis, which observation alerts the nurse to a possible complication? Select all that apply. A. Urine output of 15 mL for the first hour and then diminishing B. Tenderness at the surgical site C. Pink-tinged urine draining from the nephrostomy D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 mm Hg that persists despite administration of pain medication

A, D, E, F A. Urine output of 15 mL for the first hour and then diminishing D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 mm Hg that persists despite administration of pain medication

What will the nurse teach about self-care management to a client with mild discomfort from a fibrocystic breast condition? Select all that apply. A. Use analgesics such as acetaminophen for discomfort. B. Avoid dietary caffeine and other stimulants. C. Wear a supportive bra, even when in bed. D. Limit salt intake before menses. E. Local ice or heat application may help control pain. F. Diuretics may help decrease premenstrual breast engorgement.

A,,B,C,D,E A. Use analgesics such as acetaminophen for discomfort. B. Avoid dietary caffeine and other stimulants. C. Wear a supportive bra, even when in bed. D. Limit salt intake before menses. E. Local ice or heat application may help control pain.

Which information is most important for the nurse to include when teaching a client and family about home care for acute pyelonephritis? Select all that apply. A. Role of nutrition and adequate fluid intake B. Need for a balance between rest and activity C. Signs and symptoms of disease recurrence D. Use of successful coping mechanisms E. Care of a permanent indwelling catheter F. Drug regimen (purpose, timing, frequency, duration, and possible side effects)

A,B,,C,D,F A. Role of nutrition and adequate fluid intake B. Need for a balance between rest and activity C. Signs and symptoms of disease recurrence D. Use of successful coping mechanisms F. Drug regimen (purpose, timing, frequency, duration, and possible side effects)

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A. Apply the oxygen source loosely if the SpOz decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.

A,B,C A. Apply the oxygen source loosely if the SpOz decreases during the procedure. B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer cannula surfaces in a circular motion from the stoma site outward. A. CORRECT: Provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. B. CORRECT: Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. CORRECT: Cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma site outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal.

A nurse is caring for a client who has cervical cancer and is scheduled for brachytherapy. Which of the following actions should the nurse take? (Select all that apply.) A. Permit visitors to stay with the client 30 min at a time. B. Warn pregnant individuals to visit the room only once daily. C. Wear a dosimeter when in the client's room. D. Place soiled dressings in a biohazard bag before discarding in the regular trash. E. Dispose soiled linens in the hamper outside the client's room.

A,B,C A. Permit visitors to stay with the client 30 min at a time. B. Warn pregnant individuals to visit the room only once daily. C. Wear a dosimeter when in the client's room. A. CORRECT: Visitors should remain for no more than 30 min at a time and maintain a distance of at least 6 ft. B. CORRECT: Pregnant individuals should not enter the room of a client receiving brachytherapy. C. CORRECT: Healthcare personnel should wear a dosimeter when there is potential exposure to radiation, such as in the radiology department or in the room of a client receiving brachytherapy.

Which actions reflect proper techniques for the nurse to use when performing deep suctioning on a client with a tracheostomy or endotracheal tube? Select all that apply. A. Preoxygenate the client for at least 30 seconds before suctioning. B. Instruct the client that he or she is going to be suctioned. C. Quickly insert the suction catheter until resistance is met. D. Suction the client for at least 30 seconds to ensure effective secretion removal. E. Repeat suctioning for four to five total suction passes. F. Apply intermittent suction while withdrawing the suction catheter.

A,B,C A. Preoxygenate the client for at least 30 seconds before suctioning. B. Instruct the client that he or she is going to be suctioned. C. Quickly insert the suction catheter until resistance is met.

A nurse is planning care for a client who has postrenal AKI due to metastatic cancer. The client has a blood creatinine of 5 mg/dL. Which of the following interventions should the nurse include in the plan? (Select all that apply.) A. Provide a high-protein diet. B. Assess the urine for blood. C. Monitor for intermittent anuria. D. Weight the client once per week. E. Provide NSAIDs for pain.

A,B,C A. Provide a high-protein diet. B. Assess the urine for blood. C. Monitor for intermittent anuria. A. CORRECT: Provide a high-protein diet due to the high rate of protein breakdown that occurs with acute kidney injury. B. CORRECT: Assess urine for blood, stones, and particles indicating an obstruction of the urinary structures that leave the kidney. C. CORRECT: Assess for intermittent anuria due to obstruction or damage to kidneys or urinary structures.

A nurse is planning postprocedure care for a client who received hemodialysis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Check BUN and blood creatinine. B. Administer medications the nurse withheld prior to dialysis. C. Observe for findings of hypovolemia. D. Assess the access site for bleeding. E. Evaluate blood pressure on the arm with AV access.

A,B,C,D A. Check BUN and blood creatinine. B. Administer medications the nurse withheld prior to dialysis. C. Observe for findings of hypovolemia. D. Assess the access site for bleeding. A. CORRECT: Check the BUN and blood creatinine to determine the presence and degree of uremia or waste products that remain following dialysis. B. CORRECT: Withhold medications the treatment can partially dialyze. After the treatment, the nurse should administer the medications. Antihypertensive medications might need to be withheld until the next day if the client is hypotensive. C. CORRECT: A client who is post-dialysis is at risk for hypovolemia due to a rapid decease in fluid volume. D. CORRECT: Assess the access site for bleeding because the client receives heparin during the procedure to prevent clotting of blood.

What will the nurse teach a client and family about prevention of kidney and genitourinary trauma? Select all that apply. A. Wear a seat belt. B. Practice safe walking habits. C. Use caution when riding bicycles and motorcycles. D. Wear appropriate protective clothing when participating in contact sports. E. Avoid all contact sports and high-risk activities if you have only one kidney. F. Penetrating trauma is responsible for most kidney injuries.

A,B,C,D,E A. Wear a seat belt. B. Practice safe walking habits. C. Use caution when riding bicycles and motorcycles. D. Wear appropriate protective clothing when participating in contact sports. E. Avoid all contact sports and high-risk activities if you have only one kidney.

Which priority instructions will the nurse teach the client and family to prevent harm from urinary tract infections (UTIs) after dis-charge? Select all that apply. A. Drink fluids liberally, as much as 2 to 3 liters daily if not contraindicated by health problems. B. Be sure to get enough sleep, rest, and nutrition daily to maintain immunologic health. C. Do not routinely delay urination because the flow of urine can help remove bacteria that may be colonizing the urethra or bladder. D. For both men and women, gently wash the perineal area before intercourse. E. For women, be sure to douche before and after sexual intercourse. F. If spermicides are used, consider changing to another method of contraception.

A,B,C,D,F A. Drink fluids liberally, as much as 2 to 3 liters daily if not contraindicated by health problems. B. Be sure to get enough sleep, rest, and nutrition daily to maintain immunologic health. C. Do not routinely delay urination because the flow of urine can help remove bacteria that may be colonizing the urethra or bladder. D. For both men and women, gently wash the perineal area before intercourse. F. If spermicides are used, consider changing to another method of contraception.

A nurse is planning care for a client who has malnutrition due to cancer. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Advise the client to keep a food diary. B. Encourage the client to brush teeth before and after meals. C. Assess the laboratory report of ferritin. D. Eat nutrient-dense foods last at meal time. E. Encourage the client to limit drinking fluids during meals.

A,B,C,E A. Advise the client to keep a food diary. B. Encourage the client to brush teeth before and after meals. C. Assess the laboratory report of ferritin. E. Encourage the client to limit drinking fluids during meals. A. CORRECT: The use of a food diary assists in monitoring changes in eating habits that occur in malnutrition due to cancer. B. CORRECT: Oral hygiene before and after meals promotes increased salivation and improves taste perception. C. CORRECT: Ferritin is an indicator of the protein intake of a client who has malnutrition due to cancer. E. CORRECT: Encourage the client to limit drinking fluids with meals because fluids can cause early satiety and decrease adequate intake of food, causing malnutrition, when the client has cancer. Some fluids are needed to treat dry mouth and thickened saliva.

A nurse is caring for a client who has type 2 diabetes mellitus and will have excretory urography. Prior to the procedure, which of the following actions should the nurse take? (Select all that apply.) A. Identify an allergy to seafood. B. Withhold metformin for 24 hr. C. Administer an enema. D. Obtain a blood coagulation profile. E. Assess for asthma.

A,B,C,E A. Identify an allergy to seafood. B. Withhold metformin for 24 hr. C. Administer an enema. E. Assess for asthma. A. CORRECT: Clients who have an allergy to seafood are at higher risk for an allergic reaction to the contrast media they will receive during the procedure. B. CORRECT: Clients who take metformin are at risk for lactic acidosis from the contrast media with iodine they will receive during the procedure. C. CORRECT: Clients should receive an enema to remove fecal contents, fluid, and gas from the colon for a more clear visualization. E. CORRECT: Clients who have asthma have a higher risk of an exacerbation as an allergic response to the contrast media they will receive during the procedure.

Which nonsurgical actions would the nurse include in the care of a middle-age female client with stress incontinence? Select all that apply. A. Suggest keeping a diary of urine leakage, activities, and foods eaten. B. Teach performance of pelvic floor (Kegel) exercise therapy. C. Encourage the client to take in adequate fluids, especially water. D. Instruct the client to consume a glass of cranberry juice every day. E. Refer to a registered dietitian nutritionist for diet or weight loss therapy. F. Prepare the client for a surgical sling or bladder suspension procedure.

A,B,C,E A. Suggest keeping a diary of urine leakage, activities, and foods eaten. B. Teach performance of pelvic floor (Kegel) exercise therapy. C. Encourage the client to take in adequate fluids, especially water. E. Refer to a registered dietitian nutritionist for diet or weight loss therapy.

A nurse is planning care for a client who has Stage 4 chronic kidney disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) А. Assess for jugular vein distention. B. Provide frequent mouth rinses. C. Auscultate for a pleural friction rub. D. Provide a high-sodium diet. E. Monitor for dysrhythmias.

A,B,C,E А. Assess for jugular vein distention. B. Provide frequent mouth rinses. C. Auscultate for a pleural friction rub. E. Monitor for dysrhythmias. A. CORRECT: Assess for jugular vein distention, which can indicate fluid overload and heart failure. B. CORRECT: Provide frequent mouth rinses due to uremic halitosis caused by urea waste in the blood. C. CORRECT: Auscultate for a pleural friction rub related to respiratory failure and pulmonary edema caused by acid base imbalances and fluid retention. E. CORRECT: Monitor for dysrhythmias related to increased blood potassium caused by Stage 4 chronic kidney disease.

Which client factors does the nurse consider a reason for implementation of a directly observed therapy DOT) for antimicrobial therapy for tuberculosis (TB)? Select all that apply. А. Client is homeless. B. Client is often confused. C. TB is multidrug resistant. D. Client has gained 11 lb (5 kg) in 8 weeks. E. The main prescribed drug is bedaquiline. F. Symptoms have decreased after 4 weeks of therapy.

A,B,C,E А. Client is homeless. B. Client is often confused. C. TB is multidrug resistant. E. The main prescribed drug is bedaquiline.

What factors will the nurse recognize as contributors to a client diagnosis of complicated urinary tract infection (UTI)? Select all that apply. A. Pregnancy B. Obstruction C. Diabetes D. Pulmonary infection E. Chronic kidney disease F. Decreased immunity

A,B,C,E,F A. Pregnancy B. Obstruction C. Diabetes E. Chronic kidney disease F. Decreased immunity

Which specific signs and symptoms does the nurse expect to see in an 80-year-old client admitted with bacterial pneumonia? Select all that apply. A. Confusion B. Decreased oxygen saturation C. Productive cough D. Weakness and fatigue E. Elevated white blood cell (WBC) count F. Fever

A,B,D A. Confusion B. Decreased oxygen saturation D. Weakness and fatigue

When the nurse takes a history from an older adult, which drugs will he or she recognize as possible contributing factors to urinary incon-tinence? Select all that apply. A. Diuretics B. Opioid analgesics C. Betas blockers D. Anticholinergic drugs E. Topical estrogen F. Tricyclic antidepressants

A,B,D A. Diuretics B. Opioid analgesics D. Anticholinergic drugs

Which drugs and side effects will the nurse plan to teach a client with active non-drug-resistant tuberculosis (TB) who is being discharged on first-line therapy? Select all that apply. А. Rifampin; contact lenses can become stained orange B. Isoniazid; report yellowing of the skin or darkened urine C. Pyrazinamide; maintain a fluid restriction of 1200 mL/day D. Ethambutol; report any changes in vision E. Amoxicillin; take this drug with food or milk

A,B,D А. Rifampin; contact lenses can become stained orange B. Isoniazid; report yellowing of the skin or darkened urine D. Ethambutol; report any changes in vision

A nurse is caring for several clients. Which of the following clients are at risk for developing pyelonephritis? (Select all that apply.) A. A client who is at 32 weeks of gestation B. A client who has kidney calculi C. A client who has a urine pH of 4.2 D. A client who has a neurogenic bladder E. A client who has diabetes mellitus

A,B,D,E A. A client who is at 32 weeks of gestation B. A client who has kidney calculi D. A client who has a neurogenic bladder E. A client who has diabetes mellitus A. CORRECT: A client who is at 32 weeks of gestation is at risk for developing pyelonephritis because of increased pressure on the urinary system during pregnancy causing reflux or retention of urine. B. CORRECT: A client who has kidney calculi is at risk for pyelonephritis because stones harbor bacteria. D. CORRECT: The client who has a neurogenic bladder can retain urine, promoting bacterial growth and causing pyelonephritis. E. CORRECT: The client who has diabetes mellitus is at risk of pyelonephritis because glucose that can be in the urine promotes bacterial growth.

Which are characteristics that the nurse expects to find in clients with a history of fibro-cystic changes (FCC) in the breast? Select all that apply. A. Breast pain B. Tender breast lumps C. Oval shape D. Breast swelling E. Symptom relief after menstruation F. Gynecomastia

A,B,D,E A. Breast pain B. Tender breast lumps D. Breast swelling E. Symptom relief after menstruation

A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). acute pyelonephritis For which diagnostic test does the nurse prepare the client? (Select all that apply.) A. CT scan B. KUB x-ray C. Thoracic MRI D. BUN and creatinine E. WBC with differential

A,B,D,E A. CT scan B. KUB x-ray D. BUN and creatinine E. WBC with differential

Which factors will the nurse question a male client about to assess risk for breast cancer? Select all that apply. A. Family history B. BRCA1 and/or BRCA2 mutation C. Respiratory disease D. Testicular disorders E. Obesity F. Hyperthyroidism

A,B,D,E A. Family history B. BRCA1 and/or BRCA2 mutation D. Testicular disorders E. Obesity

A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) A. Limit intake of food high in animal protein. B. Reduce sodium intake. C. Strain urine for 48 hr. D. Report burning with urination to the provider. E. Increase fluid intake to 3 L/day.

A,B,D,E A. Limit intake of food high in animal protein. B. Reduce sodium intake. D. Report burning with urination to the provider. E. Increase fluid intake to 3 L/day. A. CORRECT: The client should limit the intake of food high in animal protein, which contains calcium phosphate. B. CORRECT: The client should limit intake of sodium, which affects the precipitation of calcium phosphate in the urine. D. CORRECT: The client should report burning with urination to the provider because this can indicate a urinary tract infection. E. CORRECT: The client should increase fluid intake to 2 to 3 L/day. A decrease in fluid intake can cause dehydration, which increases the risk of calculi formation.

A nurse is planning care for a client who will undergo peritoneal dialysis. Which of the following actions should the nurse take? (Select all that apply.) A. Monitor blood glucose levels. B. Report cloudy dialysate return. C. Warm the dialysate in a microwave oven. D. Assess for shortness of breath. E. Check the access site dressing for wetness. F. Maintain medical asepsis when accessing the catheter insertion site.

A,B,D,E A. Monitor blood glucose levels. B. Report cloudy dialysate return. D. Assess for shortness of breath. E. Check the access site dressing for wetness. A. CORRECT: Monitor blood glucose levels because the dialysate solution contains glucose. B. CORRECT: Monitor for cloudy dialysate return, which indicates an infection. Clear, light-yellow solution is typical during the outflow process. D. CORRECT: Assess for shortness of breath, which can indicate inability to tolerate a large volume of dialysate. E. CORRECT: Check the access site dressing for wetness and look for kinking, pulling, clamping, or twisting of the tubing, which can increase the risk for exit-site infections.

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension

A,B,D,E A. Restlessness B. Tachypnea D. Confusion E. Hypertension A. CORRECT: Monitor for restlessness, which is an early manifestation of hypoxia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. B. CORRECT: Monitor for tachypnea, which is an early manifestation of hypoxia. D. CORRECT: Monitor for confusion, which is an early manifestation of hypoxia. E. CORRECT: Monitor for hypertension, which is an early manifestation of hypoxia.

A nurse is preparing to initiate hemodialysis for a client who has acute kidney injury. Which of the following actions should the nurse take? (Select all that apply.) A. Review the medications the client currently takes. B. Assess the AV fistula for a bruit. C. Calculate the client's hourly urine output. D. Measure the client's weight. E. Check blood electrolytes. F. Use the access site area for venipuncture.

A,B,D,E A. Review the medications the client currently takes. B. Assess the AV fistula for a bruit. D. Measure the client's weight. E. Check blood electrolytes. A. CORRECT: Reviewing the medications the client currently takes can help determine which medications to withhold until after dialysis. B. CORRECT: Assessing the AV fistula for a bruit determines the patency of the fistula for dialysis. D. CORRECT: Measuring the client's weight before dialysis is essential for comparing it with the client's weight after dialysis. E. CORRECT: Checking the blood electrolytes determines the need for dialysis.

In which situations will the nurse appropriately insert a urinary catheter into a client? Select all that apply. A. Acute urinary retention or bladder obstruction B. Accurate measurement of urine volume in critically ill clients C. To manage clients who are incontinent D. To assist in healing of open sacral wounds in incontinent clients E. To provide comfort at end of life F. Perioperatively for gynecological surgeries

A,B,D,E,F A. Acute urinary retention or bladder obstruction B. Accurate measurement of urine volume in critically ill clients D. To assist in healing of open sacral wounds in incontinent clients E. To provide comfort at end of life F. Perioperatively for gynecological surgeries

Which necessary equipment does the nurse ensure is kept at the bedside of a client with a newly created tracheostomy? Select all that apply. A. Oxygen B. Resuscitation bag C. Pair of wire cutters D. Oxygen tubing E. Suction equipment F. Tracheostomy tray with tube and obturator

A,B,D,E,F A. Oxygen B. Resuscitation bag D. Oxygen tubing E. Suction equipment F. Tracheostomy tray with tube and obturator

Which instructions must the nurse provide to an assistive personnel (AP) prior to feeding a client who is at risk for aspiration? Select all that apply. A. Position the client in the most upright position possible. B. Provide adequate time; do not "hurry" the client. C. Provide sips of water through a straw between bites of food to help with swallowing. D. Encourage the client to "tuck" his or her chin down and move the forehead forward while swallowing. E. If the client coughs, stop the feeding until he or she indicates that the airway has been cleared F. Allow the client to indicate when he or she is ready for the next bite.

A,B,D,E,F A. Position the client in the most upright position possible. B. Provide adequate time; do not "hurry" the client. D. Encourage the client to "tuck" his or her chin down and move the forehead forward while swallowing. E. If the client coughs, stop the feeding until he or she indicates that the airway has been cleared F. Allow the client to indicate when he or she is ready for the next bite.

Which clients will the nurse recognize to be at risk for developing pneumonia? Select all that apply. A. 72-year-old with chronic confusion B. 66-year-old with influenza C. 55-year-old with atrial fibrillation who is taking an oral anticoagulant D. 40-year-old being mechanically ventilated and is orally colonized with Gram-negative bacteria E. 35-year-old with hyperthyroid disease F. 28-year-old who is extremely malnourished

A,B,D,F A. 72-year-old with chronic confusion B. 66-year-old with influenza D. 40-year-old being mechanically ventilated and is orally colonized with Gram-negative bacteria F. 28-year-old who is extremely malnourished

Which symptoms will the nurse expect to find on assessment when a client with chronic glomerulonephritis (GN) develops uremia? Select all that apply. A. Ataxia B. Slurred speech C. Neck vein distention D. Asterixis E. Crackles in lung bases F. Itching

A,B,D,F A. Ataxia B. Slurred speech D. Asterixis F. Itching

Which assessment data would the nurse anticipate in a client with acute pyelonephritis? Select all that apply. A. Urinary frequency B. Dysuria C. Oliguria D. Heart rate 120 beats/min E. Uremia F. Costovertebral angle tenderness

A,B,D,F A. Urinary frequency B. Dysuria D. Heart rate 120 beats/min F. Costovertebral angle tenderness

Which symptoms will the nurse expect to find on assessment when a client with chronic glomerulonephritis develops uremia? Select all that apply. A. ataxia B. slurred speech C. neck vein distention D. asterixis E. crackles in the lung base F. itching

A,B,D,F A. ataxia B. slurred speech D. asterixis F. itching

Which self-care management techniques will the nurse teach a client with polycystic kidney disease (PKD) to prevent constipation? Select all that apply. A. Consume adequate fluid intake of 2 to 3 liters daily. B. Use stool softeners daily. C. Take NSAIDs for discomfort. D. Avoid aspirin-containing drugs. E. Maintain your fiber intake and exercise regularly. F. Increase your dietary protein intake with meals.

A,B,E A. Consume adequate fluid intake of 2 to 3 liters daily. B. Use stool softeners daily. E. Maintain your fiber intake and exercise regularly.

Which actions are most important for a nurse to take to prevent harm when caring for a client who is receiving oxygen therapy with a nasal cannula? Select all that apply. A. Making sure that the prongs on the nasal cannula are properly positioned in the nares B. Applying a water-soluble gel to the nares as needed C. Adjusting the flow rate between 1 and 8 L/min based on the client's report of dyspnea D. Removing the cannula during meals E. Checking the client's skin under the cannula and behind the ears F. Maintaining a flow rate below 20%

A,B,E A. Making sure that the prongs on the nasal cannula are properly positioned in the nares B. Applying a water-soluble gel to the nares as needed E. Checking the client's skin under the cannula and behind the ears

Which clients could benefit from the use of noninvasive positive-pressure ventilation (NPPV)? Select all that apply. A. 22-year-old with an acute asthma attack B. 36-year-old with sleep apnea C. 40-year old with acute pneumothorax D. 50-year-old with cardiopulmonary arrest E. 64-year-old with acute exacerbation of COPD F. 72-year-old with cardiogenic pulmonary

A,B,E,F A. 22-year-old with an acute asthma attack B. 36-year-old with sleep apnea E. 64-year-old with acute exacerbation of COPD F. 72-year-old with cardiogenic pulmonary

Anurse is monitoring a group of clients for increased risk for developing pneumonia. Which of the following clients should the nurse expect to be at risk? (Select all that apply.) A. Client who has dysphagia B. Client who has AIDS C. Client who was vaccinated for pneumococcus and influenza 6 months ago D. Client who is postoperative and has received local anesthesia E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravis

A,B,E,F A. Client who has dysphagia B. Client who has AIDS E. Client who has a closed head injury and is receiving mechanical ventilation F. Client who has myasthenia gravis A CORRECT The client who has difficulty swallowing is at increased risk for pneumonia due to aspiration. B. CORRECT: The client who has AIDS is immunocompromised, which increases the risk of opportunistic infections, such as pneumonia. E. CORRECT: Mechanical ventilation is invasive and places the client at risk for ventilator-associated pneumonia. F. CORRECT: A client who has myasthenia gravis has generalized weakresseases tan rave dificulty clearing airway secretions, which increases the risk of pneumonia.

With which interprofessional team members does the nurse expect to collaborate in preparing a client and family for home care with a permanent tracheostomy without oxygen therapy? Select all that apply. A. Discharge planner B. Pharmacologist C. Registered dietitian nutritionist D. Respiratory therapist E. Social worker F. Wound care specialist

A,C,D,E A. Discharge planner C. Registered dietitian nutritionist D. Respiratory therapist E. Social worker

Which information will the nurse include when teaching a client self-care measures after shock wave lithotripsy for kidney stones? Select all that apply. A. Finish the entire prescription of antibiotics to prevent infection. B. Pain in the region of the kidneys or bladder is to be expected. C. Balance regular exercise with adequate sleep and rest. D. Drink at the very least 3 liters of fluids every day. E. Your urine may appear bloody for a few days after the procedure. F. Watch for and immediately report any bruising to the urologist.

A,C,D,E A. Finish the entire prescription of antibiotics to prevent infection. C. Balance regular exercise with adequate sleep and rest. D. Drink at the very least 3 liters of fluids every day. E. Your urine may appear bloody for a few days after the procedure.

Which side effects of first-generation antihistamines to treat sinusitis does the nurse caution the family of an older client to observe for? Select all that apply. A. Insomnia B. Hypotension C. Confusion D. Dry mouth E. Constipation F. Increased urine output

A,C,D,E A. Insomnia C. Confusion D. Dry mouth E. Constipation

A nurse is providing information about tuberculosis to a group of clients at a local community center. Which of the following manifestations should the nurse include? (Select all that apply.) A. Persistent cough B. Weight gain C. Fatigue D. Night sweats E. Purulent sputum

A,C,D,E A. Persistent cough C. Fatigue D. Night sweats E. Purulent sputum A. CORRECT: A persistent cough is a manifestation of tuberculosis. C CORRECT: Fatigue is a manifestation of tuberculosis. D. CORRECT: Night sweats is a manifestation of tuberculosis. E. CORRECT: Purulent sputum is a manifestation of tuberculosis.

A nurse is planning care for a client who has chronic pyelonephritis. Which of the following actions should the nurse plan to take? (Select all that apply.) A. Provide a referral for nutrition counseling. B. Encourage daily fluid intake of 1 L. C. Palpate the costovertebral angle. D. Monitor urinary output. E. Administer antibiotics.

A,C,D,E A. Provide a referral for nutrition counseling. C. Palpate the costovertebral angle. D. Monitor urinary output. E. Administer antibiotics. A. CORRECT: The client requires adequate nutrition to promote healing. C. CORRECT: Gently palpate the costovertebral angle for flank tenderness, which can indicate inflammation and infection. D. CORRECT: Monitor urinary output to determine that 1 to 3 L of urine is excreted daily. E. CORRECT: Administer antibiotics to treat the bacteriuria and decrease progressive damage to the kidney.

Which client signs and symptoms cause the nurse to suspect the possibility of renovascular disease? Select all that apply. A. Sudden onset of hypertension B. Distended bladder on palpation C. Difficult to control hypertension D. Sustained hyperglycemia E. Elevated serum creatinine F. Decreased glomerular filtration rate

A,C,D,E,F A. Sudden onset of hypertension C. Difficult to control hypertension D. Sustained hyperglycemia E. Elevated serum creatinine F. Decreased glomerular filtration rate

Which questions will the nurse ask a client suspected of having polycystic kidney disease (PKD)? Select all that apply. A. "Do you have a family history of PKD or kidney disease?" B. "Have you ever had any problems with muscle aches or joint pains?" C. "Do you have any problems with headaches?" D. "Have you had any difficulty with constipation or abdominal discomfort?" E. "Do you have a history of any sexually transmitted infections?" F. "Have you noticed any changes in the color or frequency of urine?"

A,C,D,F A. "Do you have a family history of PKD or kidney disease?" C. "Do you have any problems with headaches?" D. "Have you had any difficulty with constipation or abdominal discomfort?" F. "Have you noticed any changes in the color or frequency of urine?"

Which nursing and collaborative actions are implemented by the nurse when caring for a client with nephrotic syndrome (NS)? Select all that apply. A. Administration of mild diuretics B. Fluid restrictions C. Frequent assessment of hydration status D. Administration of angiotensin-converting enzyme inhibitors E. Collection of urine sample for culture F. Assessment for periorbital swelling

A,C,D,F A. Administration of mild diuretics C. Frequent assessment of hydration status D. Administration of angiotensin-converting enzyme inhibitors F. Assessment for periorbital swelling

What recommendations does the nurse make to the client who has rhinosinusitis? Select all that apply. A. Get plenty of rest, at least 8-10 hours per day. B. Keep fluid intake between 1000 and 1200 mL/day. C. Use a humidifier to help relieve congestion. D. Use nasal saline irrigation to safely relieve symptoms. E. Try sleeping with the head of your bed flat for better drainage. F. Limit exposure to any allergic causes.

A,C,D,F A. Get plenty of rest, at least 8-10 hours per day. C. Use a humidifier to help relieve congestion. D. Use nasal saline irrigation to safely relieve symptoms. F. Limit exposure to any allergic causes.

For which symptoms or changes will the nurse instruct a client with polycystic kidney disease (PKD) to contact the health care provider immediately? Select all that apply. A. Presence of a foul urine odor B. Going more than 1 day between bowel movements C. Development of a headache that does not go away D. Getting up twice nightly to urinate E. Experiencing a sudden weight gain F. Consuming some small salty pretzels

A,C,E A. Presence of a foul urine odor C. Development of a headache that does not go away E. Experiencing a sudden weight gain

During a breast examination, the nurse practitioner palpates a small mass in the client's right breast. What are the most important items to include when documenting this finding? Select all that apply. A. "Face of the clock" location of the mass B. Amount of pressure required to detect the mass C. Size and shape of the mass D. Method used to examine the breast E. Whether the mass is fixed or moveable F. Skin changes around the mass such as dimpling

A,C,E,F A. "Face of the clock" location of the mass C. Size and shape of the mass E. Whether the mass is fixed or moveable F. Skin changes around the mass such as dimpling

For which conditions would the nurse prepare and teach a client about breast biopsy? Select all that apply. A. Fluid was not aspirated during fine needle aspiration. B. Hormonal replacement therapy is prescribed. C. Mammogram shows suspicious findings. D. Fluid buildup recurs after aspiration. E. Mass remains palpable after aspiration. F. Aspirated fluid reveals cancer cells.

A,C,E,F A. Fluid was not aspirated during fine needle aspiration. C. Mammogram shows suspicious findings. E. Mass remains palpable after aspiration. F. Aspirated fluid reveals cancer cells.

Which assessment findings for a community-dwelling client who reports "not feeling well" for about 2 months indicate to the nurse the possibility of active tuberculosis (TB)? Select all that apply. А. Fatigue B. Weight gain C. Night sweats D. Back soreness E. Persistent cough F. Low-grade fever G. Shortness of breath H. Blood-streaked sputum

A,C,E,F,G,H А. Fatigue C. Night sweats E. Persistent cough F. Low-grade fever G. Shortness of breath H. Blood-streaked sputum

Which activities are most important for the nurse to teach a client with a temporary tracheostomy to avoid until cleared by the surgeon? Select all that apply. A. Swimming B. Driving a car C. Riding a bicycle D. Paddleboarding E. Engaging in sexual intercourse F. Participating in airplane travel

A,D A. Swimming D. Paddleboarding

The nurse is caring for a client who just returned from an extended trip overseas. The client has severe headache, muscle aches, fever, fatigue, sore throat and cough with acute respiratory distress. Which nursing action is appropriate? Select all that apply. A. Ask the client about exposure to anyone who was ill. B. Use only gown and gloves when entering this client's room. C. Prepare to administer isoniazid when the first dose is available. D. Explain that visitors will not be allowed into the care unit. E. Obtain arterial blood gases and monitor oxygen status. F. Obtain sputum cultures for acid-fast bacilli.

A,D,E A. Ask the client about exposure to anyone who was ill. D. Explain that visitors will not be allowed into the care unit. E. Obtain arterial blood gases and monitor oxygen status.

The nurse has delegated care for a client with a radical left mastectomy for breast cancer to assistive personnel (AP). Which AP action requires nursing intervention? Select all that apply. A. Obtains blood pressure via left arm B. Reports client's pain level to the nurse C. Applies gait belt prior to walking with the client D. Records vital signs in the electronic health record E. Assists client to administer patient-controlled analgesia

A,E A. Obtains blood pressure via left arm E. Assists client to administer patient-controlled analgesia

Which actions help the nurse caring for a client with a pandemic influenza such as COVID-19 to prevent contracting the virus? Select all that apply. A. Wearing eye protection during suctioning B. Keeping the door of the client's room closed C. Changing the water in the oxygen nebulizer daily D. Checking results of the client's sputum cultures daily E. Washing hands after removing gowns, gloves, and masks F. Using a powered air-purifying respirator (PAPR) when in the client's room

A,E,F A. Wearing eye protection during suctioning E. Washing hands after removing gowns, gloves, and masks F. Using a powered air-purifying respirator (PAPR) when in the client's room

A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera

A,G A. Blurry vision G. Yellowing of the sclera

What priority question will the nurse be sure to ask a client at risk for acute pyelonephritis? A. "Have you recently been treated for a urinary tract infection?" B. "Are you taking birth control pills as contraception?" C. "Do your have a family history of stroke or myocardial infarction?" D. "Have you ever leaked urine when laughing, jogging, or coughing?"

A. "Have you recently been treated for a urinary tract infection?"

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? A. "I should wash my hands after blowing my nose to prevent spreading the virus." B. "I need to avoid drinking fluids if I develop symptoms." C. "I need a flu shot every 2 years because of the different flu strains." D. "I should cover my mouth with my hand when I sneeze."

A. "I should wash my hands after blowing my nose to prevent spreading the virus." A. CORRECT: Hand hygiene decreases the risk of the client spreading influenza viruses.

Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself" C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen?" D. "If my shortness of breath becomes worse or if I have chest pain I will contact my primary health care provider immediately?"

A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank."

What is the nurse's best response to a client who asks whether he can use a computer in the same room while using oxygen therapy? A. "Yes, as long as the cord is not frayed and has a three-pronged plug." B. "Yes, but only in battery mode to prevent the possibility of sparks." C. "No, overheating of the unit could cause the oxygen to explode." D. "No, only approved medical electronic equipment can be used during oxygen therapy."

A. "Yes, as long as the cord is not frayed and has a three-pronged plug."

What priority question will the nurse be sure to ask a client at risk for acute pyelonephritis? A. "have you recently been treated for a urinary tract infection?" B. "are you taking birth control as contraception?" C. "do you have a family history of stroke or myocardial infarction?" D, "have you ever leaked urine when laughing, jogging, or coughing?"

A. "have you recently been treated for a urinary tract infection?"

For which client would the nurse expect to teach intermittent catheterization? A. 35-year-old woman who has multiple sclerosis and incontinence B. 48-year-old man who is admitted for pneumonia and is on complete bed-rest C. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. 74-year-old man who has lung cancer with brain metastasis and has advanced dementia

A. 35-year-old woman who has multiple sclerosis and incontinence

For which client prescription for urinary incontinence would the nurse be sure to question the health care provider? A. 74-year-old male client with bilateral glaucoma prescribed oxybutynin B. Older female client prescribed a thin application of estrogen vaginal cream daily C. Female client prescribed mirabegron whose blood pressure is 132/80 mm Hg D. Middle-aged male client prescribed imipramine who experiences slight morning dizziness

A. 74-year-old male client with bilateral glaucoma prescribed oxybutynin

The nurse is caring for a male client 8 hours after a nephrectomy. Which assessment data point requires immediate nursing intervention? A. Abdominal distention B. Urine output 38 mL in the last hour C. Blood pressure 108/64 mm Hg D. Hemoglobin 14 g/dL

A. Abdominal distention

A nurse is planning care for a client who has a platelet count of 10,000/mm3. Which of the following interventions should the nurse include in the plan of care? A. Apply prolonged pressure to puncture site after blood sampling. B. Administer epoetin alfa as prescribed. C. Place the client in a private room. D. Have the client use an oral topical anesthetic before meals.

A. Apply prolonged pressure to puncture site after blood sampling. A. CORRECT: Implement bleeding precautions for the client who has thrombocytopenia.

What diagnostic test does the nurse expect the urologist to prescribe for a client with a urinary tract infection (UTI) who developed signs and symptoms of urosepsis (bacteremia)? A. Blood cultures B. Urine culture C. Culture of urinary meatus D. Repeat urinalysis

A. Blood cultures

Which outcome statement indicates to the nurse that the client's goal for pelvic floor (Kegel) exercises has been met? A. Client has no urinary leakage between voidings. B. Incontinence is still present, but frequency is decreased. C. Client is using fewer absorbent undergarments for protection. D. Reports of dysuria are no longer heard from the client.

A. Client has no urinary leakage between voidings.

Which assessment finding on a client with pneumonia who is receiving IV antibiotics and oxygen by nasal cannula indicates to the nurse that initial goals for this client have been met? A. Client is alert and oriented to person, place, and time. B. Blood pressure is within normal limits and client's baseline. C. Skin behind the ears demonstrates no redness or irritation. D. Urine output has been >30 mL/hr per foley catheter.

A. Client is alert and oriented to person, place, and time.

A nurse is planning care for a client who is scheduled for genetic testing for suspected cancer. Which of the following interventions should the nurse include in the plan of care? A. Determine the need for informed consent. B. Send testing results to the client's insurance agency. C. Verify the prescription for a tumor marker assay. D. Ensure the client is placed in a recovery position after testing.

A. Determine the need for informed consent.

Which additional assessment finding in a client who has a severe sore throat with pain that radiates behind the ear and difficulty swallowing supports the nurse's suspicion that the client may have a peritonsillar abscess? A. Deviated uvula B. Bad breath C. Coated tongue D. Beefy red mucous membranes

A. Deviated uvula

A client with diabetes has the following assessment changes after a percutaneous nephrolithotomy procedure. Which change requires immediate nursing intervention? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria) D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube after IV administration of a broad-spectrum antibiotic

A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula

A nurse in a clinic is talking with a client scheduled for a sentinel lymph node biopsy. Which of the following information should the nurse include? A. Dye is used during the procedure. B. The lymph nodes closest to the tumor are removed during the biopsy. C. A small amount of chemotherapy is used to test the lymph node response. D. A 2 mm plug of tissue is removed during the biopsy.

A. Dye is used during the procedure

When caring for a 28-year-old healthy client, how frequently does the nurse recommend a clinical breast examination (CBE)? A. Every 3 years B. At each annual physical C. Not until age 30, as the risks are low D. To begin at age 40 when risks increase

A. Every 3 years

Which condition is most likely when the nurse admits a 25-year-old female client, with a self-detected mass in the right breast that is oval-shaped, freely mobile, and rubbery? A. Fibroadenoma B. Ductal ectasia C. Macrocyst D. Papilloma

A. Fibroadenoma

What is the nurse's best first action when a client's heart rate changes from 78 beats/min to 48 beats/min during nasotracheal suctioning? A. Immediately stop suctioning. B. Gently pinch the client's cheek C. Administer oxygen by mask at 2 L/min D. Document the change as the only action

A. Immediately stop suctioning.

What problem will the nurse suspect when a client reports urgency, frequency, and bladder pain but the urinalysis shows a few white blood cells and red blood cells, but no bacteria and the urine culture results are negative? A. Interstitial cystitis B. Urethritis C. Kidney stones D. Incompletely treated bacterial cystitis

A. Interstitial cystitis

Which action will the nurse take to prevent harm from tracheomalacia in a client who has a newly created tracheostomy? A. Maintaining the tracheal cuff pressure between 14 and 20 mm Hg B. Wrapping gauze around the tube to prevent bleeding at the site C. Performing suctioning only when the client requests this action D. Changing the dressing whenever it becomes moist

A. Maintaining the tracheal cuff pressure between 14 and 20 mm Hg

Which postoperative action will the nurse take for a client who had a nephrostomy and a nephrostomy tube is now in place? A. Monitor the amount of drainage in the collection bag. B. Keep the client NPO for at least 6 to 8 hours. C. Irrigate the tube until the return drainage is clear. D. Instruct the client to sleep with the operative side down.

A. Monitor the amount of drainage in the collection bag.

What is the priority action the nurse will take for a client admitted with nephrotic syndrome (NS) who has proteinuria, hypertension, lipid-emia, and facial edema? A. Monitoring client's fluid volume and hydration status B. Consulting with registered dietician nutritionist about adequate intake C. Using clean and sterile techniques to prevent infections D. Teaching the client about and preparing for a renal biopsy

A. Monitoring client's fluid volume and hydration status

Which action does the nurse caring for a client receiving humidified oxygen take to prevent harm from potential infection? A. Never draining fluid from the water trap back into the nebulizer B. Administering the prescribed antibiotic for a current infection C. Always wearing gloves when changing the oxygen tubing D. Not allowing live or cut flowers into the client's room

A. Never draining fluid from the water trap back into the nebulizer

A nurse is caring for a client who, upon awakening, was disoriented to person, place, and time. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? A. Obtain baseline vital signs and oxygen saturation. B. Obtain a sputum culture. C. Obtain a complete history from the client. D. Provide a pneumococcal vaccine.

A. Obtain baseline vital signs and oxygen saturation. A. CORRECT: The first action the nurse should take using the nursing process is to assess the client in order to determine the next nursing intervention and provide safe and effective client care.

Which urinary characteristic most concerns the nurse when assessing a client whose lifestyle choices and occupational exposure indicate a high risk for bladder cancer? A. Painless hematuria B. Occasional incontinence C. Increased nocturia D. Frequent voidings

A. Painless hematuria

Which chest x-ray finding will the nurse expect to see for a client suspected to have pneumonia? A. Patchy areas of increased density B. "Ground-glass" appearance of the lung C. Mediastinal widening D. Large hyperinflated airways

A. Patchy areas of increased density

What results will the nurse expect from a 24-hour urine test for total protein when a client is diagnosed with glomerulonephritis (GN)? A. Protein excretion rate may be increased from 500 mg/24 hr to 3 g/24 hr. B. Protein excretion rate may be decreased from 500 mg/24 hr to 250 mg/24 hr. C. Protein excretion rate will be within normal limits for the client. D. Protein excretion rate will vary from normal to slightly increased.

A. Protein excretion rate may be increased from 500 mg/24 hr to 3 g/24 hr.

When the nurse reviews laboratory values for a client with chronic glomerulonephritis, and the serum phosphorus level is 5.3 mg/dl, which other change does the nurse expect to see? A. Serum calcium level is low normal or slightly below normal B. Serum potassium level below the normal range C. Elevated serum sodium levels related to dehydration D. Elevated chloride levels related to elevated sodium

A. Serum calcium level is low normal or slightly below normal

Which exercise will the nurse teach a client to perform on the first day after mastectomy surgery? A. Squeezing the affected hand around a soft, round object B. Hand wall climbing C. Shoulder blade squeezing D. Rope turning

A. Squeezing the affected hand around a soft, round object

Which essential nursing intervention will the nurse implement when a client returns from having shock wave lithotripsy? A. Strain the urine to monitor for the passage of stone fragments. B. Report bruising on the affected side immediately to the urologist. C. Apply a local anesthetic cream to the client's skin on the affected side. D. Continuously monitor the client's heart pattern for dysrhythmias.

A. Strain the urine to monitor for the passage of stone fragments.

What does the nurse suspect when assessment reveals a distended bladder and the client reports passing very small amounts of urine today despite a normal fluid intake and feeling the urge to urinate? A. Urethral stricture B. Polycystic kidney disease C. Hydroureter D. Hydronephrosis

A. Urethral stricture

Which urinary characteristic most concerns the nurse when assessing a client whose lifestyle choices and occupational exposure indicate a high risk for bladder cancer? A. painless hematuria B. occasional incontinence C. increased nocturia D. frequent voiding

A. painless hematuria

The nurse is caring for a client who has just been prescribed sildenafil for erectile dysfunction. Which teaching will the nurse provide? A. Take one hour before intercourse B. Be cautious when standing up quickly C. Drink grapefruit juice when taking drug D. Perform handwashing before giving injection

ANS: B Phosphodiesterase-5 inhibitors can lower blood pressure so the nurse will teach the client to use caution when standing up quickly. This drug, which comes in pill form, must be taken approximately 15 minutes before intercourse and should not be taken with grapefruit juice.

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. What factors place this client at risk for breast cancer? (List all that apply.)

Age, fam hx, first degree relative, nulliparity, smoking, alcohol consumption

What symptoms will the nurse expect a client who had a prophylactic oophorectomy to report? Select all that apply. A. Night sweats B. Mood changes C. Hot flashes D. Weight gain E. Difficulty sleeping F. Chills

All answers are correct

Which actions will the nurse implement to minimize catheter-associated urinary tract infections (CAUTI) on a client care unit? Select all that apply. A. Leaving urinary catheters in place only as long as needed B. Using sterile equipment in the acute care setting when inserting a urinary catheter C. Maintaining a closed system by ensuring that catheter tubing connections are sealed securely D. Emptying the bag regularly, using a separate, clean container for each client E. Ensuring that the drainage spigot does not come into contact with nonsterile surfaces F. Securing the catheter to the client's thigh (women) or lower abdomen (men)

All answers are correct

Which actions will the nurse implement to minimize catheter-associated urinary tract infections (CAUTI) on a client care unit? Select all that apply: • A. leaving urinary catheters in place only as long as needed • B. using sterile equipment in the acute care setting when inserting a urinary catheter • C. maintaining a closed system by ensuring that catheter tubing connections are sealed securely • D. emptying the bag regularly, using a separate, clean container for each client • E. ensuring that the drainage spigot does not come in contact with nonsterile surfaces • F. securing the catheter to the client's thigh (women) or lower abdomen (men)

All answers are correct

Which laboratory tests would the nurse expect the health care provider to order when a client has acute pyelonephritis? Select all that apply. А. Urine culture for specific infective organism to be treated B. Complete blood count with differential to monitor for increased WBCs C. Urinalysis for bacteria, leucocyte esterase, nitrate, and RBCs D. C-reactive protein and erythrocyte sedimentation rate (ESR) to determine immune response and inflammation E. Blood urea nitrogen (BUN) and serum creatinine levels to monitor for elevation F. Test to determine whether a woman is pregnant

All answers are correct

An older adult client with poor oral hygiene and undernourishment is admitted with a hip fracture after a fall. What is the priority nursing intervention? A. Initiate oral care every 4 hours. B. Implement aspiration precautions. C. Use swabs to moisten the mouth as needed. D. Request a consult with a registered dietitian nutritionist.

Answer: B Rationale: Older adults with poor oral hygiene are at high risk for mouth infections and aspiration pneumonia. Aspiration precautions should be immediately implemented, and all other interventions can then be accomplished

A 24-year old client reports one week of red, raised lesions at the base of tongue and on the inside of the mouth. What priority assessment question will the nurse ask? A. "Do you smoke cigarettes?" B. "Have you seen a dentist recently?" C. "What types of foods have you eaten lately?" D. "Do you have a history of human papillomavirus?"

Answer: D Rationale: It is now confirmed that in younger age groups, including those who have never used tobacco products, mouth lesions can be caused by human papillomavirus (HPV). HPV has been shown to be sexually transmitted between partners and is conclusively implicated in the increasing incidence of young, nonsmoking patients with oral cancer.

A 60-year-old client has undergone a CT scan and subsequent biopsy after being admitted to the hospital for difficulty swallowing. 1. While awaiting biopsy results, the client states, "What am I going to do if this turns out to be cancer?" What is the appropriate nursing response? A. "I would choose to get radiation." B. "You will have surgery to remove it." C. "The health care provider will go over the options with you." D. "You sound as if you are concerned about the biopsy results."

Answer: D Asking the client about concerns about the biopsy results addresses the client's feelings and provides an atmosphere where the client is invited to continue expressing concerns. Suggesting treatment options does not address the client's feelings and is not within the scope of the nurse's role. Deferring to the health care provider does not address the client's concerns.

For which client with pneumonia and hypoxemia will the nurse avoid the use of oxygen therapy? Select all that apply. A. 28-year-old with community-acquired pneumonia B. 38-year-old with fractured ribs C. 48-year-old with type 2 diabetes mellitus D. 58-year-old client with metastatic breast cancer E. 68-year-old with chronic obstructive pulmonary disease F. 78-year-old with acute confusion

Answer: None of the above

Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply. A. The client has a fever. B. Crackles and wheezes are heard on auscultation. C. The client requests that suctioning be performed. D. Suctioning was last performed more than 3 hours ago. E. The tracheostomy dressing has a moderate amount of serosanguineous drainage. F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.

B and C B. Crackles and wheezes are heard on auscultation. C. The client requests that suctioning be performed.

A nurse is reviewing the plan of care for a client who is receiving mechanical ventilation. Which of the following ventilator modes will increase the client's work of breathing? (Select all that apply.) A. Assist-control B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation E. Independent lung ventilation

B, C, D B. Synchronized intermittent mandatory ventilation C. Continuous positive airway pressure D. Pressure support ventilation B. CORRECT: Synchronized intermittent mandatory ventilation requires that the client generate force to take spontaneous breaths. C. CORRECT: Continuous positive airway pressure requires that the client generate force to take spontaneous breaths. D. CORRECT: Pressure support ventilation requires that the client generate force to take spontaneous breaths.

Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)

B, C, D, E B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years

Which changes in signs and symptoms in a client with bacterial pneumonia does the nurse report to the primary health care provider as indicators of possible empyema? Select all that apply. A. Increased production of thick yellow sputum B. Reduced chest wall motion on one side C. Decreased breath sounds D. Flat percussion E. Persistent fever F. Wheezing

B, C, D, E B. Reduced chest wall motion on one side C. Decreased breath sounds D. Flat percussion E. Persistent fever

Which adverse drug effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? (Select all that apply.) A. Insomnia B. Blurred vision C. Constipation D. Dry mouth E. Loss of sphincter control F. Increased sweating G. Worsening mental function

B, C, D, G B. Blurred vision C. Constipation D. Dry mouth G. Worsening mental function

Which clients will the nurse recognize as at higher risk for having active tuberculosis (TB) in North America? Select all that apply. A. 22-year-old college student sharing a room in a dormitory B. 28-year-old man with HIV-III (AIDS) C. 48-year-old homemaker who volunteers at a soup kitchen D. 55-year-old homeless man with alcoholism who stays weekly in a shelter E. 60-year-old migrant farm worker from Mexico F. 68-year-old man incarcerated for 20 years

B, D, E, F B. 28-year-old man with HIV-III (AIDS) D. 55-year-old homeless man with alcoholism who stays weekly in a shelter E. 60-year-old migrant farm worker from Mexico F. 68-year-old man incarcerated for 20 years

A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate calculus. To decrease the chance of recurrence, the nurse should instruct the client to avoid which of the following foods? (Select all that apply.) A. Red meat B. Black tea C. Cheese D. Whole grains E. Spinach

B, E B. Black tea E. Spinach B. CORRECT: A client who has renal calculi composed of calcium oxalate should avoid intake of black tea because it is a source of oxalate. E. CORRECT: A client who has renal calculi composed of calcium oxalate should avoid intake of spinach because it is a source of oxalate.

A home health nurse is teaching a client who has active tuberculosis and is following a medication regimen that includes a combination of isoniazid, rifampin, pyrazinamide, and ethambutol. Which of the following client statements indicate understanding? (Select all that apply.) A. "I can substitute one medication for another if I run out because they all fight infection." B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." D. "I am glad I don't have to have any more sputum specimens." E. "I don't need to worry where I go once I start taking my medications."

B,C B. "I will wash my hands each time I cough." C. "I will wear a mask when I am in a public area." B. CORRECT: The client should wash their hands each time they cough to prevent spreading the infection. C. CORRECT: The client should wear a mask while in public areas to prevent spreading the infection. The client has active TB, which is transmitted through the airborne route.

Which questions will the nurse ask to provide effective screening for urinary incontinence by asking clients to respond "always, "sometimes," or "never"? Select all that apply. A. Do you ever leak urine after drinking two cups of coffee? B. Do you ever leak urine or water when you don't want to? C. Do you ever leak urine or water when you cough, sneeze, laugh, or exercise? D. Do you ever leak urine or water on the way to the toilet? E. Do you ever use pads, tissue, or cloth in your underwear to catch urine? F. Do you ever talk about leaking urine with your health care provider?

B,C,D,E B. Do you ever leak urine or water when you don't want to? C. Do you ever leak urine or water when you cough, sneeze, laugh, or exercise? D. Do you ever leak urine or water on the way to the toilet? E. Do you ever use pads, tissue, or cloth in your underwear to catch urine?

Which nursing intervention is appropriate when caring for a female client who has undergone a mastectomy and will receive chemotherapy? Select all that apply. A. Encourage client to accept her new body image. B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastec-tomy. E. Involve partner in discussions about sexuality if client desires.

B,C,D,E B. Provide self-care resources to the primary caretaker. C. Teach client about birth control options that are available. D. Refer to support groups for people who have had mastec-tomy. E. Involve partner in discussions about sexuality if client desires.

A nurse is collecting information from a client in a provider's office. Which of the following findings should the nurse identify as an indication of possible cancer? (Select all that apply.) A. Temperature 102° F (38.9° C) for more than 48 hr B. Sore that does not heal C. Difficulty swallowing D. Unusual discharge E. Weight gain 4 lb (1.8 kg) in 2 weeks

B,C,D,E B. Sore that does not heal C. Difficulty swallowing D. Unusual discharge E. Weight gain 4 lb (1.8 kg) in 2 weeks

A nurse is planning care for a client who is undergoing chemotherapy and is on neutropenic precautions. Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Encourage a high-fiber diet. В. Eliminate standing water in the room. C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet.

B,C,D,E В. Eliminate standing water in the room. C. Have the client wear a mask when leaving the room. D. Have client-specific equipment remain in the room. E. Eliminate raw foods from the client's diet. B. CORRECT: Neutropenic precautions include the client not having contact with flowers and plants due to the presence of surface infectious agents in the water and soil. C. CORRECT: Neutropenic precautions include having the client wear a mask when leaving the room to reduce the incidence of infection. D. CORRECT: Neutropenic precautions include having equipment available that is only for use in caring for the client to reduce the incidence of infection. E. CORRECT: A client who has neutropenia should avoid consuming raw foods due to the presence of surface infectious agents on peeling and rind.

What will the nurse teach a client who had breast reconstruction about the Jackson-Pratt drain left in place? Select all that apply. A. The drain will be emptied every hour and the amount recorded. B. A drain is usually left in place 1 to 3 weeks after surgery. C. There should be less than 30 mL over 24 hours before the drain is removed. D. Contact the health care provider for excessive drainage. E. Record the color and amount of drainage when the drain is emptied. F. Drainage tubes collect any fluid that accumulates under the surgical area.

B,C,D,E,F B. A drain is usually left in place 1 to 3 weeks after surgery. C. There should be less than 30 mL over 24 hours before the drain is removed. D. Contact the health care provider for excessive drainage. E. Record the color and amount of drainage when the drain is emptied. F. Drainage tubes collect any fluid that accumulates under the surgical area.

Which information does the community health nurse include when preparing an information packet about a potential pandemic influenza outbreak? Select all that apply. A. In the event of an outbreak, do not eat any cooked or uncooked meat from exotic animals. B. Have on hand a minimum of 2 weeks' supply of food, water, and routine prescription drugs. C. Listen to public health announcements and early warning signs for disease outbreaks. D. Avoid traveling to areas where there has been a suspected outbreak of disease. E. Obtain a supply of antiviral drugs such as oseltamivir. F. In the event of an outbreak, avoid going to public areas such as churches or schools.

B,C,D,F B. Have on hand a minimum of 2 weeks' supply of food, water, and routine prescription drugs. C. Listen to public health announcements and early warning signs for disease outbreaks. D. Avoid traveling to areas where there has been a suspected outbreak of disease. F. In the event of an outbreak, avoid going to public areas such as churches or schools.

Which findings will the nurse assess when a client is experiencing problems with urinary elimination caused by acute pyelonephritis? Select all that apply. A. Hypertension B. Pain and burning with urination C. Client reports back, flank, or loin pain D. Urine is cloudy and has a foul odor E. Client produces large amounts of dilute urine F. Urine sample is dark or smoky colored

B,C,D,F B. Pain and burning with urination C. Client reports back, flank, or loin pain D. Urine is cloudy and has a foul odor F. Urine sample is dark or smoky colored

Which information will the nurse include when providing community education on prevention of seasonal influenza? Select all that apply. A. Adults older than 65 years should get the Prevnar-13 vaccination yearly. B. All adults younger than 49 years should receive a quadrivalent immunization annually. C. Sneeze into a disposable tissue or into your sleeve instead of your hand. D. Avoid large crowds during spring and summer to limit the chance for getting the flu. E. Wash your hands frequently and after blowing your nose, coughing, or sneezing. F. Call your provider for an antiviral prescription within 3 days of getting symptoms.

B,C,E B. All adults younger than 49 years should receive a quadrivalent immunization annually. C. Sneeze into a disposable tissue or into your sleeve instead of your hand. E. Wash your hands frequently and after blowing your nose, coughing, or sneezing.

Which clients diagnosed with urinary tract infection (UTI) may need longer antibiotic treat-ment? Select all that apply. A. Postmenopausal woman B. Diabetic woman C. Immunosuppressed male D. Female client prescribed birth control E. Pregnant woman F. Older male with complicated UTI

B,C,E,F B. Diabetic woman C. Immunosuppressed male E. Pregnant woman F. Older male with complicated UTI

Which client findings cause the nurse to suspect the possibility of chronic pyelonephritis? Select all that apply. A. Sudden onset of massive proteinuria B. Inability to conserve sodium C. Decreased urine-concentrating ability and nocturia D. Abscess formation E. Hypertension F. Hyperkalemia and acidosis

B,C,E,F B. Inability to conserve sodium C. Decreased urine-concentrating ability and nocturia E. Hypertension F. Hyperkalemia and acidosis

Which factors promote long-term adherence to the prescribed antihypertensive drug therapy for a client diagnosed with nephrosclerosis? Select all that apply. A. Monthly reminders B. Once-a-day dosing C. Written drug information D. Low cost E. Minimal side effects F. Eliminating diet restrictions

B,D,E B. Once-a-day dosing D. Low cost E. Minimal side effects

Which interventions will the nurse expect to implement for management of infection as the cause for glomerulonephritis (GN)? Select all that apply. A. Corticosteroids B. Antibiotics C. Cytotoxic drugs D. Personal hygiene E. Fluid restriction F. Handwashing

B,D,F B. Antibiotics D. Personal hygiene F. Handwashing

Which are the most common signs and symptoms of urinary tract infection that the nurse will recognize when assessing a client? Select all that apply. A. Nocturia B. Frequency C. Hematuria D. Urgency E. Suprapubic tenderness F. Dysuria

B,D,F B. Frequency D. Urgency F. Dysuria

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply.) A. Confusion В. Pale skin C. Bradycardia D. Hypotension E. Elevated blood pressure

B,E В. Pale skin E. Elevated blood pressure B. CORRECT: Pale skin is an early manifestation of hypoxemia. E. CORRECT: Elevated blood pressure is an early manifestation of hypoxemia.

Which additional client condition(s) or factor (s) will the nurse recognize as increasing the risk for ventilator-associated pneumonia (VAP)? Select all that apply. A. History of alcohol use and cigarette smoking B. Presence of feeding tube C. Unplanned weight loss D. IV therapy with normal saline E. Tooth loss and mouth sores F. Bacterial colonization of the airway

B,E,F B. Presence of feeding tube E. Tooth loss and mouth sores F. Bacterial colonization of the airway

Which action to prevent harm is most important for a nurse to include when teaching a client with tuberculosis (TB) about the prescribed first-line drug therapy? A. "Wear a mask for the first 8 weeks on therapy at home and when away from home." B. "Do not drink alcohol in any quantity while taking these drugs." C. "Avoid grapefruit and grapefruit juice while taking these drugs." D. "Restrict fluid intake to 2 quarts of liquid a day."

B. "Do not drink alcohol in any quantity while taking these drugs."

Which question will the nurse ask the client who has a urinary tract infection to assess the risk for pyelonephritis? A. "What drugs do you take for asthma?" B. "How long have you had diabetes?" C. "How much fluid do you drink daily?" D. "Do you take your antihypertensive drugs at night or in the morning?"

B. "How long have you had diabetes?"

What is the nurses best response when a client with renovascular disease asks why the endo-vascular procedure, stent placement, is preferable to surgery to correct his or her condition? A. "The procedure will make a bypass route for blood to enter your kidney and does not leave a scar." B. "Stent placement is less risky and requires less time for recovery than does renal artery bypass surgery?" C. "A synthetic blood vessel graft is inserted to redirect blood flow from the abdominal aorta into the renal artery. D. "An endovascular procedure is more cost-effective and does not need to be repeated."

B. "Stent placement is less risky and requires less time for recovery than does renal artery bypass surgery?"

A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."

B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season."

What does the nurse suggest when the client prescribed first-line therapy for tuberculosis develops nausea from the drugs? A. "Stop taking the drugs." B. "Try taking the drugs at bedtime." C. "Take the drugs on an empty stomach. D. "Take the drugs individually throughout the day."

B. "Try taking the drugs at bedtime."

A nurse is teaching a client who is scheduled for nuclear imaging for suspected cancer. Which of the following statements should the nurse give? A. "The presence of a liver enzyme will be identified." B. "You will be given an injection of a radioactive substance." C. "An endoscope will be inserted through your mouth." D. "The tumor will be aspirated."

B. "You will be given an injection of a radioactive substance."

A nurse is teaching a client who has tuberculosis. Which of the following statements should the nurse include? A. "You will need to continue to take the multimedication regimen for 4 months." B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." C. "You will need to remain hospitalized for treatment." D. "You will need to wear a mask at all times."

B. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication." B. CORRECT: The client who has tuberculosis needs to provide sputum samples every 2 to 4 weeks to monitor the effectiveness of the medication.

For which client is it appropriate for the nurse to teach intermittent self-catheterization? A. 18-year-old client with a severe head injury B. 25-year-old male client with paraplegia C. 48-year-old female client with stress incontinence D. 70-year-old client who wears absorbent briefs

B. 25-year-old male client with paraplegia

Which client does the nurse monitor carefully because of high risk for developing a complicated urinary tract infection (UTI)? A. 26-year-old male who is sexually active but consistently uses condoms B. 28-year-old male who has a neurogenic bladder due to a spinal cord injury C. 35-year-old woman who has had three full-term deliveries and one miscarriage D. 53-year-old woman who has some menstrual irregularities

B. 28-year-old male who has a neurogenic bladder due to a spinal cord injury

Which client will the nurse monitor carefully for highest risk of developing acute pyelonephritis? A. 32-year-old man with diabetes insipidus B. 34-year-old woman with diabetes mellitus in the second trimester of pregnancy C. 75-year-old man who drinks four beers each day D. 78-year-old woman prescribed diuretics for mild heart failure

B. 34-year-old woman with diabetes mellitus in the second trimester of pregnancy

When caring for four clients, which individual does the nurse identify as being at the highest risk for development of breast cancer? A. 33-year-old male with gynecomastia and obesity B. 45-year-old female whose mother has breast cancer C. 60-year-old male whose father died from colon cancer D. 72-year-old female who was treated for breast cancer 3 years ago

B. 45-year-old female whose mother has breast cancer

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.

B. Assist the client to Fowler's position. B. CORRECT: The priority action to be taken when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea (difficulty breathing). Fowler's position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the cause of the client's dyspnea can better assessed and determined.

When will the nurse expect a client with breast cancer to receive neoadjuvant therapy? A. After surgery to ensure that all cancer cells have been destroyed B. Before surgery to shrink the tumor and make it easier to remove C. With radiation therapy to treat any metastasis that may occur D. During surgery to make sure that all of the tumor cells are removed

B. Before surgery to shrink the tumor and make it easier to remove

With which client prescribed to receive oxygen therapy does the nurse suggest using a face tent rather than a nasal cannula? A. Client with severe sleep apnea B. Client with facial trauma C. Client who is confused D. An unconscious client

B. Client with facial trauma

A nurse is completing the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect? A. Bradycardia B. Diaphoresis C. Nocturia D. Bradypnea

B. Diaphoresis B. CORRECT: Diaphoresis is a manifestation associated with a client who has renal calculi.

What does the nurse suspect when a client reports identification of a hard breast mass with irregular borders, redness, swelling, nipple discharge, and enlarged axillary nodes? A. Intraductal papilloma B. Ductal ectasia C. Fibroadenoma D. Fibrocystic changes

B. Ductal ectasia

Which sign or symptom detected by the nurse practitioner during clinical breast examination of a client suggests advanced breast cancer? A. Thin, milky discharge from nipple B. Edematous thickening and pitting of breast skin called peau d'orange C. Oval-shaped, mobile, rubbery mass D. Replacement of normal cells with connective tissue and collagen

B. Edematous thickening and pitting of breast skin called peau d'orange

Which priority action does the nurse perform to prevent harm for a client receiving oxygen therapy through a nonrebreather mask? A. Preventing the reservoir bag from inflating to more than one-half full B. Ensuring that valves and flaps are patent, functional, and not stuck C. Switching to partial rebreather mask for more precise FiOr D. Ensuring that the flow rate does not exceed 6 L/min

B. Ensuring that valves and flaps are patent, functional, and not stuck

Which finding will the nurse associate with an obstruction in the urinary system specifically associated with hydronephrosis? A. Chills and fever B. Flank asymmetry C. Urge incontinence D. Bladder distention

B. Flank asymmetry

Which assessment findings will the nurse expect to see documented when a client is first admitted with renal cell carcinoma? A. Gross hematuria, hypertension, diabetes, and oliguria B. Flank pain, blood in the urine, palpable renal mass, and renal bruit C. Nocturia and urinary retention with difficulty initiating the urine stream D. Dysuria, polyuria, dehydration, and palpable kidney mass

B. Flank pain, blood in the urine, palpable renal mass, and renal bruit

A nurse is reviewing client laboratory data. Which. of the following findings is expected for a client who has Stage 4 chronic kidney disease? A. Blood urea nitrogen (BUN) 15 mg/dL B. Glomerular filtration rate (GFR) 20 mL/min C. Blood creatinine 1.1 mg/dL D. Blood potassium 5.0 mEq/L

B. Glomerular filtration rate (GFR) 20 mL/min B. CORRECT: The GFR is severely decreased to approximately 20 mL/min, which is indicative of stage 4 chronic kidney disease.

What action by the assisted living facility nurse is most appropriate to prevent influenza spread when a resident client tests positive for influenza A? A. Prepare to administer antibiotics. B. Have the resident eat meals in his or her room. C. Provide oseltamivir to the staff. D. Arrange a follow-up chest x-ray in 2 weeks.

B. Have the resident eat meals in his or her room.

A nurse is monitoring a client who had a kidney biopsy for postoperative complications. Which of the following complications should the nurse identify as causing the greatest risk to the client? A. Infection B. Hemorrhage C. Hematuria D. Pain

B. Hemorrhage B. CORRECT: The greatest risk to the client following a kidney biopsy is hemorrhage due to a lack of clotting at the puncture site. Report this finding to the provider immediately.

What is the priority action for the nurse to take to prevent harm when caring for a client who is receiving oxygen at 5 L/min by nasal cannula? A. Switch to a mask delivery system. B. Humidify the oxygen with sterile water. C. Add extension tubing for client mobility. D. Check to ensure the delivery equipment is plugged into a grounded outlet.

B. Humidify the oxygen with sterile water.

The nurse is reviewing the client's laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action? A. White blood cells in the urine B. INR of 2.1 C. Hematocrit 44% D. Creatinine 0.8 mg/dL

B. INR of 2.1

A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her 02 flow rate by 2 L and reassess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.

B. Increase her 02 flow rate by 2 L and reassess in 5 minutes.

What is the nurse's priority concern for an older client with urinary incontinence, who is alert and oriented, but refuses to call for help and has fallen while trying to get to the bathroom alone? A. Managing incontinence B. Initiating fall precautions C. Managing noncompliance D. Accurately measuring urinary output

B. Initiating fall precautions

What advantage does the nurse discuss with a client who is prescribed trastuzumab for treatment of breast cancer? A. The drug will shrink the tumor. B. It is less likely to harm normal cells. C. Nausea and vomiting are rare side effects. D. Cardiac side effects are not a concern.

B. It is less likely to harm normal cells.

What early sign would the nurse expect when a client is suspected of autosomal dominant polycystic kidney disease (ADPKD)? A. Headache B. Nocturia C. Pruritus D. Facial edema

B. Nocturia

Which laboratory result for a client with pneumonia will the cause the nurse to collaborate quickly with the primary health care provider? A. White blood cell (WBC) count of 14,526/mm B. Pao2 68 mm Hg C. Paco2 48 mm Hg D. Fasting blood glucose 146 mg/dI

B. Pao2 68 mm Hg

Which therapy does the nurse expect after a client's nephrectomy to prevent an adrenal complication? A. Administration of a potassium supplement B. Prescription for steroid supplement C. Addition of extra calcium to diet D. Estrogen supplements for postmenopausal women

B. Prescription for steroid supplement

What is the most appropriate action for the nurse to take to prevent accidental decannula-tion of client's tracheostomy tube? A. Obtaining an order for continuous upper extremity restraints B. Securing the tube in place using twill ties or commercial fasteners C. Allowing at least 2 inches of space between the ties and the client's neck D. Instructing the client to hold the tube in place with a tissue while coughing

B. Securing the tube in place using twill ties or commercial fasteners

Which action will the nurse avoid to prevent harm for a client with overflow incontinence? A. The Crede method to help initiating the emptying of the bladder B. The Valsalva maneuver when a client has heart disease C. Double voiding using a second attempt to empty the bladder D. Splinting to compress the bladder and move it into a better position

B. The Valsalva maneuver when a client has heart disease

Which assessment finding in a client who recently had a right mastectomy 2 days ago will the home health nurse report to the health care provider? A. Temperature of 99°F B. Tingling sensation in the right arm C. Impaired range of motion in the right arm D. Drainage of 20 mL collected over 24 hours

B. Tingling sensation in the right arm

What is the reason that the nurse performing tracheal suctioning on a client applies continuous suction only during catheter withdrawal? A. To promote adequate oxygenation during the procedure B. To prevent dropping of secretions into the trachea C. To assist the client in effective coughing efforts D. To ensure the catheter does not go beyond the carina

B. To prevent dropping of secretions into the trachea

What is the nurse's best interpretation when a client is admitted with flank pain, and the urine report indicates turbidity, foul odor, rust color, presence of white and red blood cells as well as bacteria, and microscopic crystals? A. Staghorn calculus with infection B. Urolithiasis and infection C. Pyuria and cystitis D. Dysuria and urinary retention

B. Urolithiasis and infection

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? A. Nonrebreather mask B. Venturi mask C. Nasal cannula D. Simple face mask

B. Venturi mask B. CORRECT: A venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered.

Which action does the nurse teach a client to prevent harm after breast augmentation surgery? A. Begin exercising by twisting at the waist the day after surgery. B. Walk every few hours to prevent venous thromboembolism (VTE). C. Wait a week or more after surgery before resumption of smoking. D. Have someone stay with you during the first 6 hours after discharge.

B. Walk every few hours to prevent venous thromboembolism (VTE).

Which actions will the nurse delegate to the assistive personnel (AP) for appropriate care of a client with acute glomerulonephritis? A. Teaching how to collect a 24-hour urine specimen B. Weighing the client every morning with the same scale C. Assessing for changes in the urine sample D. Evaluating the client's ability to safely get to the bathroom

B. Weighing the client every morning with the same scale

Which question is most important to ask a client who may have an endemic respiratory infection with fever, cough, headache, muscle aches, chest pain, and night sweats, and tests negative to the common forms of influenza? Select all that apply. A. Do you have any known allergies? B. What medications do you take daily? C. Do you have a chronic illness of any kind? D. Where have you traveled in the past 2 to 4 weeks? E. Have you ever been ill with these symptoms before? F. What type of heating system do you have in your home?

B. What medications do you take daily? C. Do you have a chronic illness of any kind? D. Where have you traveled in the past 2 to 4 weeks?

Which factors does the home health nurse identify as safety hazards in the home of a client requiring home oxygen therapy? Select all that apply. A. Three-pronged outlets in every room B. Bottle of wine in the kitchen area C. Candles on the mantelpiece D. Pack of cigarettes on the coffee table E. Electric heater with a frayed cord in the bathroom F. Computer with a three-pronged plug

C, D, E C. Candles on the mantelpiece D. Pack of cigarettes on the coffee table E. Electric heater with a frayed cord in the bathroom

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations.

C, D, E C. Check the position of the cannula frequently. D. Report any nausea or difficulty breathing. E. Post "No Smoking" signs in prominent locations. C. CORRECT: Teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary. D. CORRECT: Teach the client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nausea, and vomiting. The client should report any of these promptly. E. CORRECT: Teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.

Which client assessment findings alert the nurse to the possibility of uncomplicated community-acquired pneumonia (CAP)? Select all that apply. A. Abdominal pain B. Back pain C. Chest discomfort D. Dyspnea E. Increased sputum production F. Fever

C, D, E, F C. Chest discomfort D. Dyspnea E. Increased sputum production F. Fever

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. What information will the nurse include when teaching this client about health promotion? (Select all that apply.) A. Mammograms are not effective in diagnosing breast cancer. B. An MRI of the breasts should be completed every year. C. Ask your provider to perform a clinical breast examination (CBE). D. Notify your provider if you notice changes in your breasts. E. Breast self-examination (BSE) is the best way to detect breast cancer early.

C,D C. Ask your provider to perform a clinical breast examination (CBE). D. Notify your provider if you notice changes in your breasts.

A nurse is assessing a client who has prerenal AKI. Which of the following findings should the nurse expect? (Select all that apply.) A. Reduced BUN B. Elevated cardiac enzymes C. Reduced urine output D. Elevated blood creatinine E. Elevated blood calcium

C,D C. Reduced urine output D. Elevated blood creatinine C. CORRECT: A manifestation of prerenal AKI is reduced urine output. D. CORRECT: A manifestation of prerenal AKI is elevated blood creatinine.

Which statements about oxygen therapy are true? Select all that apply. A. When oxygen therapy is successful, hypercarbia is cured. B. Oxygen therapy must be monitored to prevent explosions. C. The oxygen provided during oxygen therapy is considered a drug. D. Nurses must know the purposes and expected outcomes for each client prescribed oxygen therapy. E. Because oxygen is a normal component of atmospheric air, its use as therapy is completely safe. F. When oxygen therapy increases the clients oxygen saturation to 99%, hypoxia and hypoxemia are cured.

C,D C. The oxygen provided during oxygen therapy is considered a drug. D. Nurses must know the purposes and expected outcomes for each client prescribed oxygen therapy.

The nurse is caring for an 80-year-old female client with recurrent cystitis. Which teaching will the nurse include in the plan of care? Select all that apply. A. Drink citrus juices daily. B. Douche regularly; a minimum of two times weekly. C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as pre-scribed. F. Instruct her to empty her bladder immediately before and after having intercourse.

C,D,E,F C. Encourage fluid intake of 2-3 L of fluid throughout the day. D. Instruct her to always wipe the perineum from front to back after each toilet use. E. Reinforce that she should complete the entire course of antibiotics as pre-scribed. F. Instruct her to empty her bladder immediately before and after having intercourse.

With which clients who have tracheostomies will the nurse remain extra vigilant for possible tracheal tissue injury? Select all that apply. A. 26-year-old who is 6 months pregnant B. 30-year-old who also has seasonal asthma C. 42-year-old taking corticosteroids daily for a chronic inflammatory condition D. 50-year-old on hormone replacement therapy for menopause E. 61-year-old with chronic alcoholism and malnutrition F. 78-year-old who also has early-stage prostate cancer

C,E,F C. 42-year-old taking corticosteroids daily for a chronic inflammatory condition E. 61-year-old with chronic alcoholism and malnutrition F. 78-year-old who also has early-stage prostate cancer

A 28-year-old female client states, "I don't know why I get cystitis every year. I don't drink much at work so that I can avoid using the public toilet." Which teaching by the nurse is most likely to reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.

C,E,F,G C. Suggest that she drink at least 2 to 3 L of fluid throughout the day. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before intercourse.

With which clients does the nurse anticipate probable placement of a temporary tracheos-tomy? Select all that apply. A. 28-year-old who became quadriplegic from a C-2 spinal transection B. 36-year-old with permanent brain damage after a traumatic brain injury C. 45-year-old with facial and oral cavity burns D. 56-year-old with stage IV lung cancer E. 69-year-old unable to wean from a ventilator F. 72-year-old with an acute airway obstruction caused by epiglottitis

C,F C. 45-year-old with facial and oral cavity burns F. 72-year-old with an acute airway obstruction caused by epiglottitis

What is the nurse's best response when the family of a client who has been receiving first-line therapy for tuberculosis (TB) for 8 weeks and has shown clinical improvement asks if the client is still infectious? A. "He or she will remain infectious until the entire treatment period is completed." B. "The ability to spread the infection remains as long as his or her skin test remains positive." C. "Although he or she is no longer infectious, treatment may need to continue for at least 18 more weeks." D. "His or her sputum will likely always remain infectious although treatment is not needed after the cough has resolved."

C. "Although he or she is no longer infectious, treatment may need to continue for at least 18 more weeks."

Which home care instructions will the nurse provide the client who receives intravesical instillation of bacille Calmette-Guerin. At the outpatient clinic to prevent recurrence of superficial bladder cancer? A. "Your urine will be radioactive for 24 hours so avoid contact with children and pregnant women." B. "Drink a lot of extra fluid to flush your bladder but otherwise there are no special instructions." C. "For 24 hours others should not share your toilet and then you should clean it with 10% bleach before anyone else uses it." D. "Flush the toilet twice after every voiding and remind all family members to practice safe hand hygiene."

C. "For 24 hours others should not share your toilet and then you should clean it with 10% bleach before anyone else uses it."

What question does the nurse ask a client, who reported a breast mass 6 months ago, related to possible metastases of breast cancer? A. "Have you had any exposure to radiation or toxic chemicals?" B. "Has your mother or sister ever been diagnosed with breast cancer?" C. "Have you noticed any joint or bone pain or other changes in your body?" D. "Have you developed a cough, shortness of breath, or difficulty sleeping?"

C. "Have you noticed any joint or bone pain or other changes in your body?"

Which statement by a client to the nurse indicates that treatment for urge incontinence has been successful? A. "I have been using bladder compression and it works." B. "I lose a little urine when I sneeze, but I wear a thin pad." C. "I had a little trouble at first, but now I go to the toilet every 3 hours." D. "Im doing the exercises, but I think that surgery is my best choice."

C. "I had a little trouble at first, but now I go to the toilet every 3 hours."

A nurse is teaching a client about screening prevention for cancer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will need to have a mammogram every 2 years beginning at age 45." В. "I should have a colonoscopy every 15 years beginning at age 60." C. "I will need to have an annual breast examination every year after 40." D. "I should have a fecal occult test done every 3 years."

C. "I will need to have an annual breast examination every year after 40." C. CORRECT: Instruct the client that after the age of 40, they should have annual clinic breast exams.

What is the nurse's best response when a client with kidney cancer, who had a nephrectomy, asks if the remaining kidney can take over kidney function immediately? A. "Your remaining kidney isn't able to provide adequate function, so other therapies will be necessary?" B. "That's a good question. We'll ask your health care provider about it during next rounds." C. "The kidney you have left will provide adequate function, but it may take a few days or weeks." D. "It varies from person to person, but you can expect normal kidney function to return the same day?"

C. "The kidney you have left will provide adequate function, but it may take a few days or weeks."

A nurse is caring for a client who is undergoing chemotherapy and reports severe nausea. Which of the following statements should the nurse make? A. "Your nausea will lessen with each course of chemotherapy." B. "Hot food is better tolerated due to the aroma." C. "Try eating several small meals throughout the day." D. "Increase your intake of red meat as tolerated."

C. "Try eating several small meals throughout the day." C. CORRECT: Several small meals a day are usually better tolerated by the client who has nausea.

A nurse is caring for a client who has a new diagnosis of tuberculosis and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the client related to ethambutol? A. "Your urine can turn a dark orange." B. "Watch for a change in the sclera of your eyes." C. "Watch for any changes in vision." D. "Take vitamin B6 daily."

C. "Watch for any changes in vision." C. CORRECT: The client who is receiving ethambutol will need to watch for visual changes due to optic neuritis, which can result from taking this medication.

What is the nurse's best response when a 65-year-old client with no health problems states that he had a flu shot last year and asks if it is necessary to have it again this year? A. "No, because once you get a flu shot, it lasts for several years and is effective against many different viruses." B. "Yes, because the immunity against the virus wears off, increasing your chances of getting the flu?" C. "Yes, because the vaccine guards against a few specific viruses and reduces your chances of acquiring flu and is only effective for 1 year." D. "No, flu shots are only for high-risk clients and you are not considered to be at high risk."

C. "Yes, because the vaccine guards against a few specific viruses and reduces your chances of acquiring flu and is only effective for 1 year."

A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."

C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting.

What is the best explanation a nurse will provide to a client whose skin test result for tuberculosis (TB) is positive? A. "There is active disease, but you are not yet infectious to others." B. "There is active disease, and you need to start drug therapy immediately." C. "You have been infected, but this does not mean active disease is present." D. "A repeat skin test is necessary because the test could give a false-positive result."

C. "You have been infected, but this does not mean active disease is present."

A nurse is preparing to administer a new prescription for isoniazid (INH) to a light-skinned client who has tuberculosis. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication? A. "You might notice yellowing of your skin." B. "You might experience pain in your joints." C. "You might notice tingling of your hands." D. "You might experience a loss of appetite."

C. "You might notice tingling of your hands." C. CORRECT: Tingling of the hands can be an adverse effect of isoniazid.

Which male client does the nurse understand has the greatest risk of developing gynecomastia? A. 25-year-old injured in a touch football game B. 38-year-old with stable angina C. 49-year-old prescribed spironolactone D. 61-year-old with hypothyroidism

C. 49-year-old prescribed spironolactone

A 68-year-old male client is seeing the primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A 5 pack-year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

C. A 30-year occupation as a long-distance truck driver

Which circumstance is cause for the nurse's greatest concern when several clients in the long-term facility have developed urinary tract infections (UTIs)? A. Residents are not drinking enough fluids with meals and snacks. B. Assistive personnel (AP) are not assisting with toileting in a timely manner. C. A large percentage of residents have indwelling urinary catheters. D. Many residents have dementia and functional incontinence.

C. A large percentage of residents have indwelling urinary catheters.

A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings is the priority for the nurse to report to the provider? A. Flank pain that radiates to the lower abdomen B. Client report of nausea C. Absent urine output for 1 hr D. Blood WBC count 15,000/mm

C. Absent urine output for 1 hr C. CORRECT: The greatest risk to this client is damage to the kidney resulting from obstruction of urine flow by the renal calculus. Therefore, the priority finding to report to the provider is anuria.

A nurse is caring for a client who develops disequilibrium syndrome after receiving hemodialysis. Which of the following actions should the nurse take? A. Administer an opioid medication. B. Monitor for hypertension. C. Assess level of consciousness. D. Increase the dialysis exchange rate.

C. Assess level of consciousness. C. CORRECT: Assess the client's level of consciousness. A change in urea levels can cause increased intracranial pressure. Subsequently, the client's level of consciousness decreases.

What is the nurse's next action after assessing a client with glomerulonephritis (GN) who reports mild shortness of breath and finding crackles in all lung fields, distended neck veins? A. Obtaining a urine sample to check for proteinuria B. Checking for costovertebral angle tenderness or flank pain C. Assessing carefully for additional signs of fluid overload D. Alerting the health care provider about the respiratory symptoms

C. Assessing carefully for additional signs of fluid overload

What priority teaching will the nurse provide to a client after mastectomy surgery? A. Begin exercises 3 to 4 days after the surgery. B. A regular diet can be started the first day after surgery. C. Check the surgical site for signs of infection or bleeding. D. Start ambulating the day after surgery.

C. Check the surgical site for signs of infection or bleeding.

The Spo2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8 L/min C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen delivery system is adequately humidified

C. Check the tubing for kinks, leaks, or obstructions

Which advice will the nurse provide for a client who is prescribed tamoxifen to decrease the chance of breast cancer recurrence, with regard to the side effects of the drug? A. Ginger ale with the drug will decrease the nausea. B. Have a handrail installed around the bathtub to prevent falls. C. Check your weight and report weight gain to the health care provider. D. Use a soft-bristled toothbrush to prevent bleeding.

C. Check your weight and report weight gain to the health care provider.

For which activity does the nurse teach the client who is receiving oxygen by a transtracheal oxygen (TTO) delivery system to switch to a nasal cannula oxygen delivery system? A. Eating a meal B. Sleeping at night C. Cleaning the catheter D. Performing mouth

C. Cleaning the catheter

What does the nurse identify as an expected outcome when planning care for a client with genital herpes being treated with antiviral drugs? A. Eradication of the infection B. No chance of transmitting the virus to a partner C. Decrease in the severity and frequency of recurrent outbreaks D. Prevention of viral shedding even when the patient is asymptomatic

C. Decrease in the severity and frequency of recurrent outbreaks

Which precaution is most important for the nurse to take to prevent harm when caring for a client who is breathing on his own and has a fenestrated tracheostomy tube with a cuff? A. Keeping the cuff inflated to prevent secretions from entering the lung B. Providing mouth care with sterile solutions at least every 4 to 6 hours C. Deflating the cuff before capping the tube with the decannulation cap D. Ensuring that a manual resuscitation bag accompanies the client whenever he or she is out of the room

C. Deflating the cuff before capping the tube with the decannulation cap

What information will the nurse explain to the family of a client who has been prescribed to receive transtracheal oxygen (TTO) therapy? Select all that apply. A. Cures sleep apnea B. Prevents nitrogen toxicity C. Delivers oxygen directly into the lungs D. Less likely to cause pressure injury to the skin E. Used with mechanical ventilation F. Provides high humidity with oxygen delivery

C. Delivers oxygen directly into the lungs D. Less likely to cause pressure injury to the skin

Which intracollaborative therapy does the nurse expect the health care provider to prescribe for a postmenopausal client diagnosed with noninfectious urethritis? A. Antibiotic therapy B. Frequent sitz baths C. Estrogen vaginal cream D. Culture of drainage

C. Estrogen vaginal cream

A nurse administered captopril to a client during a renal scan. Which of the following actions should the nurse take? A. Assess for hypertension. B. Limit the client's fluid intake. C. Monitor for orthostatic hypotension. D. Encourage early ambulation.

C. Monitor for orthostatic hypotension. C. CORRECT: Monitor for orthostatic hypotension because this is an adverse effect of captopril. This results in a change in blood flow to the kidneys after the initial dose.

Which health problem does the nurse suspect when a client with decreased kidney function has increased proteinuria, decreased serum al-bumin, lipids in blood and urine, increased aPTT and INR, facial edema, and hypertension? A. Glomerulonephritis B. Pyelonephritis C. Nephrotic syndrome D. Chronic kidney failure

C. Nephrotic syndrome

In addition to routine assessment, what specific assessment will the nurse perform on a client with very large breasts? A. Careful examination of the size and shape of nipples B. Ask if client has considered breast reduction mammoplasty C. Observe for fungal infection underneath the breasts D. Assess for pain in the bones and joints

C. Observe for fungal infection underneath the breasts

A nurse is reviewing the results of a client's urinalysis. The findings indicate the urine is positive for leukocyte esterase and nitrites. Which of the following actions should the nurse take? A. Repeat the test early the next morning. B. Start a 24-hr urine collection for creatinine clearance. C. Obtain a clean-catch urine specimen for culture and sensitivity. D. Insert an indwelling catheter urinary catheter to collect a urine specimen.

C. Obtain a clean-catch urine specimen for culture and sensitivity. C. CORRECT: Obtain a clean-catch urine specimen for culture and sensitivity. This test will identify which antibiotic will be most effective for treating the client's urinary tract infection.

A nurse is caring for a client who is receiving chemotherapy and has mucositis. Which of the following actions should the nurse take? A. Use a glycerin-soaked swab to clean the client's teeth. В. Encourage increased intake of citrus fruit juices. C. Obtain a culture of the lesions. D. Provide an alcohol-based mouthwash for oral hygiene.

C. Obtain a culture of the lesions. C. CORRECT: Obtain a culture of the oral lesions to identify pathogens and determine appropriate treatment.

How will the nurse determine whether a postoperative client has subcutaneous emphysema following the creation of a tracheostomy? A. Checking the volume of the pilot balloon B. Listening for airflow through the tube C. Palpating for air under the skin D. Assessing oxygen saturation

C. Palpating for air under the skin

Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion

C. Performing oral suctioning before suctioning the artificial airway

The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated

C. Pneumonia may be present

A nurse is planning care for a client who has prerenal acute kidney injury (AKI) following abdominal aortic aneurysm repair. Urinary output is 60 mL in the past 2 hr, and blood pressure is 92/58 mm Hg. The nurse should expect which of the following interventions? A. Prepare the client for a CT scan with contrast dye. B. Plan to administer nitroprusside. C. Prepare to administer a fluid challenge. D. Plan to position the client in Trendelenburg.

C. Prepare to administer a fluid challenge. C. CORRECT: Plan to administer a fluid challenge for hypovolemia, which is indicated by the client's low urinary output and blood pressure.

In the event of a new pandemic influenza out-break, such as COVID-19, what is the nurse's primary role? A. Immediately report new cases to the Centers for Disease Control and Prevention (CDC). B. Administer oxygen, standard antibiotics, and supportive therapies to clients. C. Prevent the spread of infection to other employees and clients. D. Ensure all unit staff have annual influenza vaccination.

C. Prevent the spread of infection to other employees and clients.

Which is the nurses best action for an ambulatory obese older client with incontinence and dementia? A. Teach the client about strategies for weight reduction. B. Assist the client to apply estrogen cream. C. Provide the client assistance with toileting every 2 hours. D. Perform intermittent catheterization on the client.

C. Provide the client assistance with toileting every 2 hours.

For which minimal risk diagnostic test will the nurse prepare the client with polycystic kidney disease to have as initial screening? A. Kidney-ureter-bladder (KUB) x-rays B. Computed tomography with angiography C. Renal ultrasonography D. Renal needle biopsy

C. Renal ultrasonography

Which circumstance does the nurse recognize as creating the greatest risk of recurrent uroli-thiasis when a client is admitted for an orthopedic procedure? A. Providing milk to the client with every meal tray or snack B. Insertion of an indwelling urinary catheter for the procedure C. Restricting foods and fluids for extended periods of time D. Administering an opioid narcotic drug for the severe pain

C. Restricting foods and fluids for extended periods of time

A 22-year-old sexually active male reports a low-grade fever and headache, and a rash on his hands. What condition does the nurse anticipate? A. HIV B. HPV C. Syphilis D. Gonorrhea

C. Syphilis

Which priority action will the nurse take to help prevent the complication of pneumonia for a client who is postoperative from extensive abdominal surgery? A. Monitoring chest x-rays and WBC counts for early signs of infection B. Monitoring lung sounds every shift and encouraging fluids C. Teaching coughing, deep-breathing exercises, and use of incentive spirometry D. Encouraging hand hygiene among all caregivers, clients, and visitors

C. Teaching coughing, deep-breathing exercises, and use of incentive spirometry

Which condition best indicates to the nurse that a client's fluid intake is sufficient to manage acute pyelonephritis? A. Client estimates an intake of 1.5 liters of water per day. B. Client reports no burning or pain with urination. C. Urine output is clear yellow and dilute. D. Antibiotic treatment was completed exactly as prescribed.

C. Urine output is clear yellow and dilute.

Which action will the nurse take to prevent infection when a 95-year-old nursing home resident has a productive cough, fever, chills, and a history of night sweats but the client's Mantoux test for tuberculosis (TB) is negative? A. Use Standard Precautions alone because the client does not have TB. B. Use Airborne Precautions because the client is at high risk for TB. C. Use Airborne Precautions until a chest x-ray shows the client not to have active TB. D. Use Standard Precautions alone because the client is taking penicillin therapy for another respiratory infection.

C. Use Airborne Precautions until a chest x-ray shows the client not to have active TB.

Which factor will the nurse recognize as increasing a client's risk for developing community-acquired pneumonia (CAP)? A. Obtaining an influenza vaccination in November rather than September B. Having received a pneumococcal vaccination C. Using tobacco and alcohol often and regularly D. Living alone and preparing own meals

C. Using tobacco and alcohol often and regularly

For which minimal risk diagnostic test will the nurse prepare the client with polycystic kidney disease to have as initial screening? A. kidney-ureter-bladder (KUB) x-rays B. computed tomography with angiography C. renal ultrasonography D. renal needle biopsy

C. renal ultrasonography

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8° C (100° F), respirations 30/min, blood pressure 130/76, heart rate 100/min, and Sa02 91% on room air. Prioritize the following nursing interventions. A. Administer antibiotics. B. Administer oxygen therapy. C. Perform a sputum culture. D. Instruct the client to obtain a yearly influenza vaccination.

Correct order: B,C,A,D B. The client's respiratory and heart rates are elevated, and her oxygen saturation is 91% on room air. Using the ABC priority framework, providing oxygen is the first intervention. C. Obtaining a sputum culture is the second nursing intervention. It should be done prior to administering oral medications to obtain an accurate specimen. A. Administration of antibiotics is the third action the nurse should take. The sputum culture should be obtained prior to antibiotic administration. D. The last action the nurse should take is to instruct the client to receive yearly influenza vaccinations, to reduce the risk of acquiring influenza that can lead to pneumonia.

For which serious complications of the infection will the nurse caring for a client who has seasonal influenza continuously monitor? Select all that apply. A. Chronic obstructive pulmonary disease (COPD) B. Fever C. Hypertension D. Pneumonia E. Renal failure F. Sepsis

D, F D. Pneumonia F. Sepsis

Which statements about oxygen and oxygen therapy are true? Select all that A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. B. Clients must provide informed consent to receive oxygen therapy. C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In nonemergency situations, a health care provider's prescription is needed for oxygen therapy. E. Oxygen can explode when handled improperly. F. Oxygen is a beneficial element but can harm lung tissue. G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.

D,F,H D. In nonemergency situations, a health care provider's prescription is needed for oxygen therapy. F. Oxygen is a beneficial element but can harm lung tissue. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.

A nurse is teaching a client who is scheduled for a shave biopsy for suspected cancer. Which of the following client statements indicates understanding of the procedure? A. "A test of my bone marrow will be performed." B. "A lymph node will be removed." C. "A needle will be inserted into the mass." D. "A small skin sample will be obtained."

D. "A small skin sample will be obtained."

A 40-year-old client is admitted to the ED with fever, chills, and severe right flank pain. Her heart rate is 114/min and respiratory rate is 30/min. She reports recently being treated for a urinary tract infection. Assessment reveals tenderness of the right costovertebral angle (CVA). acute pyelonephritis Two days later during the nursing assessment, the client expresses embarrassment. She reports not taking the full treatment of antibiotics prescribed for the UTI she had recently. What is the appropriate nursing response? A. "The next time you will know to do better." В. "Why didn't you take all of your medication?" C. "Superbugs can develop when antibiotics aren't finished." D. "Can you tell me more about why you didn't take all of your antibiotics?"

D. "Can you tell me more about why you didn't take all of your antibiotics?"

What priority question will the nurse ask when taking a history of a client with BPH? A. "Do you have high blood pressure?" B. "Have you had a recent urinary tract infection?" C. "Do you have a family history of kidney disease?" D. "Do you have difficulty starting and continuing urination?"

D. "Do you have difficulty starting and continuing urination?"

A nurse is teaching a client who is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which of the following statements by the client indicates understanding of the teaching? A. "I will be fully awake during the procedure." B. "Lithotripsy will reduce my chances of having stones in the future." C. "I will report any bruising that occurs to my doctor." D. D. "Straining my urine following the procedure is important."

D. "Straining my urine following the procedure is important." D. CORRECT: A client is instructed to strain urine following lithotripsy to verify that the calculi have passed.

A nurse is teaching a client who will have an x-ray of the kidneys, ureters, and bladder. Which of the following statements should the nurse include in the teaching? A. "You will receive contrast dye during the procedure." B. "An enema is necessary before the procedure." C. "You will need to lie in a prone position during the procedure." D. "The procedure determines whether you have a kidney stone."

D. "The procedure determines whether you have a kidney stone." D. CORRECT: Explain to the client that a KUB can identify renal calculi, strictures, calcium deposits, and obstructions of the urinary system.

When a client with glomerulonephritis has a urine output over the past 24 hours of 1050 ml, how much fluid will the nurse allow the client during the next 24-hour period? A. 1050 to 1150 mL B. 1250 to 1350 mL C. 1450 to 1550 mL D. 1550 to 1650 mL

D. 1550 to 1650 mL

Which client would the nurse expect is at highest risk for development of bladder cancer? A. 25-year-old woman who has experienced three episodes of bacterial cystitis over the past year B. 27-year-old man with type 1 diabetes who is nonadherent with his therapeutic regimen C. 60-year-old woman with malnutrition secondary to chronic alcoholism and self-neglect D. 64-year-old man who smokes two packs of cigarettes a day and works in a chemical factory

D. 64-year-old man who smokes two packs of cigarettes a day and works in a chemical factory

For which client does the nurse recommend vaccination with the influenza "super vaccine"? A. 19-year-old living in a college dormitory B. 36-year-old who has type 1 diabetes mellitus C. 50-year-old who just underwent aortic valve replacement D. 75-year old community-dwelling client after hip replacement surgery

D. 75-year old community-dwelling client after hip replacement surgery

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. A 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. A 48-year-old man who has established paraplegia and is admitted for pneumonia C. A 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

D. A 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice

Which condition does the nurse suspect when noting that a client who is receiving 40% oxygen therapy now has new onset of crackles and decreased breath sounds on auscultation? A. Alveolar drying B. Arterial hypoxemia C. Chronic hypercarbia D. Absorptive atelectasis

D. Absorptive atelectasis

A nurse is caring for a client who has a urinary tract infection (UTI). Which of the following is the priority intervention by the nurse? A. Offer a warm sitz bath. B. Recommend drinking cranberry juice. C. Encourage increased fluids. D. Administer an antibiotic.

D. Administer an antibiotic. D. CORRECT: The greatest risk to the client is injury to the renal system and sepsis from the UTI. The priority intervention is to administer antibiotics.

A client is diagnosed with renal colic. What would the nurse do first? A. Prepare the client for lithotripsy. B. Encourage oral intake of fluids. C. Strain the urine and send for urinalysis. D. Administer opioids as prescribed.

D. Administer opioids as prescribed.

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take? A. Apply a vest restraint if self-extubation is attempted B. Monitor ventilator settings every 8 hr. C. Document tube placement in centimeters at the angle of jaw. D. Assess breath sounds every 4 hr.

D. Assess breath sounds every 4 hr. D. CORRECT: The nurse should assess the breath sounds of a client receiving mechanical ventilation every 4 hr.

The nurse is caring for a client who has had a transurethral resection of the prostate (TURP). Which assessment finding requires immediate nursing intervention? A. Temperature 99.9 °F B. Pain of 6 on 0-10 scale C. Report of bladder spasms D. Bleeding from the surgical site

D. Bleeding from the surgical site

What normal findings will the nurse expect when assessing the breasts of an older woman? A. Gentle palpation may cause discomfort or mild pain. B. Nipples are retracted and there may be a discharge. C. Tissue is difficult to palpate because of fat deposits. D. Breasts are atrophied, flattened, and elongated.

D. Breasts are atrophied, flattened, and elongated.

What advice will the nurse give to a postmeno-pausal client about when to perform breast self-examination (BSE)? A. Perform breast self-examination on the 15th day of each month. B. The last day of the month is the best day for breast self-examination. C. After menopause, breast self-examination will not detect a mass. D. Choose any day of the month but follow a consistent schedule.

D. Choose any day of the month but follow a consistent schedule.

Which report or manifestation indicates to the nurse that a client's treatment for renal colic has been successful? A. Urine is pink tinged. B. Urine output is 50 mL per hour. C. Bladder scan shows no residual urine. D. Client reports that pain is relieved.

D. Client reports that pain is relieved.

Which manifestations in a client receiving oxygen therapy at 60% for more than 24 hours alerts the nurse to the possibility of oxygen toxicity? A. Oxygen saturation greater than 100% B. Decreased rate and depth of respiration C. Wheezing on inhalation and exhalation D. Discomfort or pain under the sternum

D. Discomfort or pain under the sternum

What priority finding will the nurse assess for when inspecting the hands, face, and eyelids of a client with possible acute glomerulonephritis (GN)? A. Redness B. Rash C. Dryness D. Edema

D. Edema

What teaching about the affected arm will the nurse provide for a client who had a partial mastectomy (lumpectomy)? A. Do not start any arm or hand exercises until the drains are removed from the incision. B. Do push-ups and arm circles on a routine basis for a full recovery. C. Avoid using the affected arm for having blood pressure measured, receiving injections, or having blood drawn for 2 weeks after surgery. D. Elevate the head of the bed at least 30 degrees, with the affected arm elevated on a pillow while awake.

D. Elevate the head of the bed at least 30 degrees, with the affected arm elevated on a pillow while awake.

The nurse is caring for a client with a long history of osteoarthritis. Which risk factor will the nurse teach that may contribute to development of gastroesophageal reflux disease (GERD)? A. Weight of 150 pounds B. Walks 15 minutes once daily C. Chooses foods high in calcium D. Frequently takes NSAIDs for pain

D. Frequently takes NSAIDs for pain

A nurse is teaching a client who has chronic kidney disease and is to begin hemodialysis. Which of the following information should the nurse include in the teaching? A. Hemodialysis restores kidney function. B. Hemodialysis replaces hormonal function of the renal system. C. Hemodialysis allows an unrestricted diet. D. Hemodialysis returns a balance to blood electrolytes.

D. Hemodialysis returns a balance to blood electrolytes. D. CORRECT: Explain to the client that hemodialysis restores electrolyte balance by removing excess sodium, potassium, fluids, and waste products, and also restores acid-base balance.

Which assessment finding for a client who received the subcutaneous Mantoux skin test 72 hours ago will the nurse interpret as a positive test result for tuberculosis (TB)? A. Test area is red, warm, and blistered. B. A flat, erythematous skin rash is present at the test site. C. Induration/hardened area measures 5 mm or greater. D. Induration/hardened area measures 10 mm or greater.

D. Induration/hardened area measures 10 mm or greater.

What is the nurse's best action when an anx-ious, upset client has just been diagnosed with breast cancer and informed that surgery is likely the best treatment option? A. Provide education about treatment options. B. Assist with making independent decisions. C. Provide reassurance about long-term outcomes. D. Listen and allow open discussion about feelings.

D. Listen and allow open discussion about feelings.

Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? A. Providing meticulous oral care every 8 hours B. Deflating the cuff for 15 minutes every 2 hours C. Feeding the client liquids rather than solid foods D. Maintaining cuff inflation pressure less than 25 cm H20

D. Maintaining cuff inflation pressure less than 25 cm H20

Pathologic examination of the removed breast lump tissue reveals malignancy. The client undergoes a modified radical mastectomy with lymph node dissection, which will be followed by radiation and chemotherapy. What immediate postoperative intervention will the nurse implement? A. Check vital signs every four hours. B.Position the client supine to facilitate drainage. C. Instruct assistive personnel (AP) to avoid taking blood pressure (BP) in the client's right arm. D. Measure the Jackson-Pratt tube drainage and assess color and odor.

D. Measure the Jackson-Pratt tube drainage and assess color and odor.

What is the nurse's priority concern when caring for clients with hydronephrosis or hydroureter? A. Dilute urine B. Dehydration C. Pain with urination D. Obstruction

D. Obstruction

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? A. Percussion of posterior lobes of lungs B. Auscultation of the trachea C. Inspection of the conjunctiva D. Palpation of the orbital areas

D. Palpation of the orbital areas D. CORRECT: A client who has sinusitis will report tenderness when the orbital, frontal, and facial areas are palpated.

What priority information will the nurse teach a client and family about self-catheterization for the long-term problem of incomplete bladder emptying? A. Use sterile technique especially if the catheterization will be done by a family member. B. Use a large-lumen catheter with good lubrication for rapid emptying of the bladder. C. Catheterize yourself after you are incontinent or when your bladder feels distended D. Perform careful handwashing and cleaning of the catheter to prevent risk for infection.

D. Perform careful handwashing and cleaning of the catheter to prevent risk for infection.

What is the priority nursing concern when a client is admitted with a history of kidney stones and presents with severe flank pain, nausea and vomiting, pallor, and diaphoresis? A. Possible hemorrhage B. Urinary elimination blockage C. Impaired tissue perfusion D. Severe pain

D. Severe pain

The nurse is assessing a female client with genital warts. What assessment finding does the nurse anticipate? A. Chancre B. No symptoms C. Abdominal pain D. Small flesh-colored growths

D. Small flesh-colored growths

What type of incontinence does the nurse recognize when a 45-year-old female client reports the loss of small amounts of urine during coughing, sneezing, jogging, or lifting? A. Urge incontinence B. Overflow incontinence C. Functional incontinence D. Stress incontinence

D. Stress incontinence

For which symptom does the nurse teach the client who is going home with a peritonsillar abscess to go to the emergency department im-mediately? A. Persistent cough B. Sore throat C. Nausea and vomiting D. Stridor or excessive drooling

D. Stridor or excessive drooling

Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/min. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.

D. The reservoir bag is not inflated during inhalation.

Which complication of a tracheostomy does the nurse suspect in a client who has difficulty breathing, noisy respirations, difficulty inserting a suction catheter, and thick, dry secretions? A. Accidental decannulation B. Aspiration pneumonia C. Pneumothorax D. Tube obstruction

D. Tube obstruction

What type of incontinence does the nurse recognize when a 45-year-old female client reports the loss of small amounts of urine during coughing, sneezing, jogging, or lifting? • A. urge incontinence • B. overflow incontinence • C. functional incontinence • D. stress incontinence

D. stress incontinence

The nurse is taking a history for a 66-year-old female client whose sister has breast cancer. She is married and has never been pregnant. She smokes, but states she has "cut down a lot lately" and reports consuming "a couple" of glasses of wine daily. Six months later, the client returns because she has noticed a lump in her left breast. Upon examination, a small mass is palpated. A diagnostic mammogram is ordered and confirms the presence of a 2 x 3 cm mass. The client is scheduled for a surgical excisional biopsy. What should the client be taught about this procedure?

It is the only definitive way to dx breast cancer, removes the mass itself to evaluate for cancer

What is the nurse's best advice to a client with urge incontinence regarding fluid intake? А. Drink 120 mL every hour or 240 ml every 2 hours and limit fluid intake after dinner. B. Drink at least 2000 mL of water every day unless you have a heart problem. C. Drinking water is especially good for bladder health so drink as much as you can. D. Drink fluid freely in the morning hours but limit fluid intake after going to bed.

А. Drink 120 mL every hour or 240 ml every 2 hours and limit fluid intake after dinner.

Which action associated with a habit training bladder program for an older client who is alert but mildly confused will the nurse delegate to the assistive personnel (AP)? А. Remind the client when it is time to use the bathroom and assist him or her on a regular schedule. B. Help the client record all incidents of incontinence that occur in a bladder diary. C. Change the client's incontinence pad or containment briefs every 4 hours. D. Gradually encourage the client's independence and increase the intervals between voidings.

А. Remind the client when it is time to use the bathroom and assist him or her on a regular schedule.

When assessing a client with acute glomerulonephritis, which question will the nurse ask to determine if the client is following best practices to slow progression of kidney damage? A. "Do you avoid contact sports while you are taking cyclo-sporine?" В. "How are you evaluating the amount of daily fluid you drink?" C. "Have you contacted anyone from our dialysis support services?" D. "Have you increased your protein intake to promote healing of the damaged nephrons?"

В. "How are you evaluating the amount of daily fluid you drink?"

A nurse is caring for a client who is receiving mechanical ventilation and is on pressure support ventilation (PSV) mode. Which of the following statements by the nurse indicates an understanding of PSV? А. "It keeps the alveoli open and prevents atelectasis." В. "It allows preset pressure delivered during spontaneous ventilation." C. "It guarantees minimal minute ventilator." D. "It delivers a preset ventilatory rate and tidal volume to the client."

В. "It allows preset pressure delivered during spontaneous ventilation." CORRECT: PSV allows preset pressure delivered during spontaneous ventilation to decrease the work of breathing.

A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? A. Positive for hyaline casts В. Positive for leukocyte esterase C. Positive for ketones D. Positive for crystals

В. Positive for leukocyte esterase B. CORRECT: A positive leukocyte esterase indicates a urinary tract infection.

What is the nurse's best first action when a client who is 4 days postoperative with a tracheostomy suddenly sneezes during tracheostomy care and the tube falls out onto the bed linens? A. Ventilate the client with 100% oxygen and notify the Rapid Response Team. В. Quickly and gently replace the tube with a clean cannula kept at the bedside. C. Clean and rinse the tube with sterile solution and gently replace it. D. Apply oxygen with a facemask and prepare the client for surgery.

В. Quickly and gently replace the tube with a clean cannula kept at the bedside.