final exam

100. A nurse has taught a client about dietary changes that can reduce the chances of developing cancer, what statement by the client indicates the nurse needs to provide additional teaching?

"I'm so glad I don't have to give up my juicy steaks"

98. A nurse is assessing clients for fluid and electrolyte imbalances, which client will the nurse assess first for potential hyponatremia?

A 34 year old who is NPO and is receiving rapid iv D5W infusions.

68. The nurse is performing a physical examination on a client. Which assessment finding leads the nurse to check the client's abdomen for the presence of a acquired umbilical hernia

A BMI of 41.9

37. Two days after an accident in which a client sustained multiple injuries, including fractures, the client becomes confused and dyspneic and has a fever for 103.4. The nurses assess that client has developed

A fat embolism

82. While assessing an older adult client admitted 2 days ago with a fractured hip, the nurse notes that the client is confused, tachypneic, and restless. Which is the nurse's first action?

Administer oxygen via nasal cannula

73. A nurse learns that which of the following is the single biggest risk factor developing cancer?

Advancing age

The nurse is assessing a group of clients for their risk of kidney disease, which racial/ethnic group is at the greatest risk as they age

African americans

39. Which action by the nurses shows an understanding for the principle of self determination?

Allow a post op client to decide to take meds with fruit juice rather than water

31. A nurse is assessing clients on a medical surgical unit. which adult client does the nurse identify as being feverish for insensible water loss?

An anxious client who has tachypnea

77. The nurse is providing health education to a client with chronic venous stasis ulcers. What priority instruction does the nurse include

Apply anti embolism stockings before getting out of bed in the morning

41. A nurse is changing a dressing over a client's abdominal surgical incision which action by the nurse is most important?

Apply dressings using aseptic or sterile technique

46. CLient had surgical repair of a fractured ankle under local anesthesia and is being transferred from the post anesthesia care unit (PACU) to the surscial floor. Once admitted, what is the nurse's priority action?

Assess a full set of vital signs

A client who has sustained a crush injury to the right lower leg reports numbness and tingling of the affected extremity, the skin of the right leg appears pla. Which is the nurses first intervention

Assess pedal pulses

62. A client has bluish tinge to the palms,soles, and conjunctiva. Based on these assessment data, what does the nurse do next

Assess pulse oximetry

A nurse is caring for an older client who exhibits dehydration induced confusion. Which intervention by the nurse is best?

Assess the client

The nurse is caring for a client who has started on a tpn 2 days previously. The client reports blurred vision, dry mouth, and frequent urination. What is the nurse's priority?

Assess the client's blood sugar.

86. A nurse assesses a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first?

Assess the client's respiratory rate, rhythm, and depth

A client has returned to the nursing unit after esophagogastroduodenoscopy (EGD). Which action by the nurse takes priority?

Assess the clients gag reflex

94. One horse after admission to the postanesthesia care unit(PACU), the postoperative client has become very restless. What is the nurse's first action?

Assess the o2 sat

50. A client is receiving chemotherapy through peripheral IV Line. What action by the nurse is most important?

Assessing the iv site and blood return every hour

60. A clinic nurse is working with an older client. What action is most important for preventing infections in this client?

Assessing vaccination records for booster shot needs

95. A NURSE TEACHES A CLIENT WHO IS BEING DISCHARGED HOME WITH A PERIPHERALLY INSERTED CENTRAL CATHETER (PICC). WHICH STATEMENT WILL THE NURSE INCLUDE IN THE CLIENT'S TEACHING?

Avoid carrying your grandchild with the arm that has the central catheter.

A client with pneumonia and dementia is admitted with an indwelling catheter in place. During interprofessional rounds the following day, which question would the nurse ask?

Can we remove the catheter

96. After delegating care to assistive personnel for a client who is prescribed habit training to manage incontinence, a nurse evaluates the AP/s understanding. Which action indicates that the AP needs additional teaching?

Changing the clients incontinence brief when wet (toilet training)

97. The nurse is assessing for skin changes in an african-american client admitted with peripheral arterial disease. What does the nurse monitor for?

Cyanosis of the nail beds

52. The nurse working with oncology clients understands that which age related change increases the older client's susceptibility to infection during chemotherapy

Decreased immune function

In the emergent care of a client with a pelvic fracture, the nurse must be especially alert for indications of the complication of

Deep vein thrombosis

83. The nurse is caring for a client who has just returned from abdominal surgery. When auscultating the client's abdomen, the nurse does not hear any bowel sounds which is the nurse's best action?

Document the finding

93.the nurse is caring for a client who just completed an upper GI radiographic series with oral barium contrast. Which instructions does the nurse provide to the client?

Drink plenty of fluids over the next few days

51. The nurse is teaching self care measures for a client who has hemorrhoids. Which nurse intervention f does the nurse include in the plan of care for the client

Encourage the client to dab with moist wipes instead of wiping with toilet paper.

90. A nurse reviews the urinalysis results of a client and notes a urine osmolarity of 1200 mOsm/kg. Which action would the nurse take?

Encourage the client to drink more fluids

27. The nurse is caring for a client who has just had a cva line inserted. What action will the nurse take next?

Ensure an x-ray is taken to confirm placement

40. The nurse is caring for a client who has been brought to the emergency department with upper GI bleeding, the cline is commuting copious amounts of bright red blood. Which is the nurse's priority action?

Ensure the client has a patent airway

56. The nurse is caring for a client who is beran and has developed B12 deficiency. Which foods does the nurse encourage the client to include in the diet?

Fortified cereals and tofu

A client is admitted to the ed with a complete fracture of the left radius. The nurse understands that with this type of fracture the bone is

Fractured through the entire bone

A nurse is learning the difference between normal and benign tumor cells. What info does this include?

Growing in the wrong place or time is typical of benign tumors

A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty which action by the nurse is appropriate

Have adequate help to transfer the patient

65. A client has been taking naproxen for several months, which assessment question is important for the nurse to ask?

Have you had any stomach pain or indigestion?

61. Preoperative assessment data that should be reported to the duration include

Having a sore throat (pre existing infection)

36. The nurse is reviewing recent laboratory values for a client who is being treated for malnutrition. Which laboratory finding indicated that the client is not receiving adequate iron supplementation?

Hematocrit 31%

34. After teaching a client with early polycystic kidney disease about nutritional therapy the nurse assesses the client's understanding. Which state made by the client indicates a correct understanding of the teaching?

I must increase my intake of dietary fiber and fluids.

88. Which statement indicates that the client understands the management of his or her sliding hiatal hernia?

I will remain upright for several hours after each meal

79. After teaching a client who is being treated for dehydration, a nurse assesses the client;s understand. Which statement indicates that the client correctly understood the teaching?

I will weigh myself each morning before i eat or drink

85. The nurse is teaching a client who is prescribed acetaminophen for control of osteoarthritic joint pain. What statement by the client indicates a need for further teaching?

I won't take more than 5000 mg of this drug each day

After teaching a client with hypertension secondary to renal disease the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching

If i have increased urination at night i need to drink less fluid during the day

A nurse cares for a client with a urine specific gravity of 1.040. What action does the nurse take?

Increase the client's fluid intake

The nurse assesses a client who has just been brought to the oacu. In the or, the clients bp was 136/80; it is now 110/80. Rine output was 40 ml/hr which action by the nurse is best?

Increase the iv of 0.9 ns as ordered to 100 ml/hr

The nurse is caring for a patient with pud. The client vomits a large amount of undigested food after breakfast. Which intervention does the nurse prepare to provide the client?

Insert ng tube to low intermittent suction

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?

Instruct the client to call for help to get out of bed

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?

It is normal to be fatigued for even months afterward.

84. A NURSE REVIEWS a client's laboratory results. Which results from the clients urinalysis would the nurse recognize as abnormal

Ketone bodies present

66. A nurse cares for a postmenopausa client who had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How would the nurse respond?

Low estrogen levels

The nurse is caring for an older client with salmonella food poisoning. Which is the priority action if the nurse?

Maintain iv fluids

49. A client asks the nurse if eating only preservative and dye free foods will decrease cancer risk. What response by the nurse is best?

Maybe; preservatives, dyes, and preparation methods may be risk factors.

An older client expresses concern about developing "new age spots". Which instruction is most important for the nurse to provide to the client?

Monitor sports for color change

71. The nurse understands that which type of immunity is the longest acting?

Natural active

67. A nurse is assessing a client with glioblastoma. What assessment is most important.

Neurological examination

76. The nurse is caring for a female client who is 5 ft. 7 inches tall and weighs 115 pounds the client asks the nurse if she needs to lose weight, which response by the nurse is best

No, in fact your bmi suggests you are already underweight

63. After a total knee arthroplasty, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the skin of both legs is pale pink, warm, and dry, nut the client is unable to dorsiflex or plantar flexion the foot

Notify the surgeon or anesthesia provider immediately

44. The nurse is with a client at risk for venous thromboembolism (WTE) on low molecular weight heparin WHat instrication does the nurse provide to this client?

Notify your hcp if your stools arrear tarry

81. Which action demonstrates that the nurse understands the purpose of the rapid response team?

Notifying the physician of the clients change in BP from 140 to 88 mm Hg systolic

74. The nurse is preparing to administer tube feedings through a client's new salem sump nasogastric tube. The nurse is unable to withdraw any fluid from the tube before stating the feeding which is the priority action

Obtain orders for a chest x-ray to confirm the placement before starting the feeding

48. The health care provider is prescribing medication to treat a clients severe fastroesophafeal refulx disease (GEARD). Which medication does the nurse anticipate teaching the client about?

Omeprazole (prilosec)

78. The nurse assesses a client who is possible landing associated with this type of cancer would the nurse expect

Painless hematuria

87. On assessing a client's lower extremities, the nurse notices that one leg is pale and cooler to the tough. Which assessment does the nurse perform next?

Palpate the clients pedal pulses bilaterally

80. The nurse is preparing to perform an abdominal assessment on a client with suspected cholecystitis,, in what sequence does the nurse palpate the client's abdomen?

Palpate the upper quadrants last

45. A client has been transferred to the post anesthesia care unit, which action does the receiving nurse perform?

Participate in a hand-off report

The nurse is caring for an older adult client with multiple fractures. How does the nurse manage pain in this client?

Pca pump with morphine

69. A nurse reviews the analysis of a client and notes the presence of glucose, what action would the nurse take

Perform a finger stick blood glucose assessment

54. A nurse assesses a client with polycystic kidney disease. Which assessment finding would alert the nurse to immediately contact the primary health care provider?

Periorbital edema

72. Which client does the nurse assess carefully for the development of gastroesophageal reflux disease?

Postoperative client who has a ng tube

59. The preoperative assessment insing that the nurse would report to the surgeon for properatue treatment is

Potassium level of 3.0 mEq/L

57. The edges of a clients appendectomy incisions are approximated, and no drainage is notd. The nurse documents on the client's wound record that the incision appears to be healing by

Primary intention

70. A nurse asks the staff development nurse what "apoptosis" means what response best

Programmed cell death

43. The nurse learns that the most important function of inflammation and immunity is which purpose?

Providing maximum protection against infection

Client has a leg wound is in stage 2 of inflammatory response, for what sign or symptom does the nurse assess?

Purulent drainage

55. A nurse is caring for a client who is receiving an epidural infusion for apina management, which assessment finding requires immediate intervention from the nurse.

Report of a headache and a stiff neck

A nurse is caring for a client admitted for non-hodgkin's lymphoma and chemotherapy. The client reports nausea, flank pain, and muscle cramps. What action by the nust is most important?

Request an order for serum electrolytes and uric acid

A client has a chronic non healing ulcer on the lower leg. The nurse thinks the client could benefit from negative pressure wound therapy. The most appropriate action by the nurse would be to

Request the physician to consult the wound care nurse.

The nurse is planning care for an older adult client who has very thin skin on the back of the hands and arms. What is the client's priority problem?

Risk for injury

58. The nurse conducts a physical assessment for a client with abdominal pain. Which finding leads the nurse to suspect appendicitis?

Severe steady RLQ pain

33. A nurse assesses a client who has a radial artery catheter, which assessment will the nurse complete first?

Skin color and capillary refill

During the pre operative interview, the client;s statement that would alert the nurse to an increased risk during surgery is

Take a couple of aspirin everyday for my headaches

The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed.

Take my medication until heartburn is gone

35. A nurse cares for a client who has pyelonephritis. The client states, : I am embarrassed to talk about my symptoms." how would the nurse respond?

Take your time. It is ok to use words that are familiar to you.

32. A nurse world with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

Teaching measures to prevent scalp injury

99. The methodology likely to be most effective in meeting a clients teaching/learning needs preoperatively is

Teaching the client and family

A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

The clients lle is cool to the touch.

An obese client gas reflux and asks how being overweight could cause this condition which response by the nurse is best

The weight adds extra pressure, which helps push the stomach contents up

38. A client has long term rheumatoid arthritis that especially affects the gans. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is appropriate?

Try a paraffin wax dip 20 minutes before you quilt.

89. Which statement about carcinogenesis is accurate?

Tumor cells need to develop their own blood supply

75. The nurse conducts a physical assessment for a client with severe right lower quadrant abdominal pain. The nurse notes that the abd,em os rigid and the client's temperature is 101.1 which laboratory value does the nurse bring to the attention of the health care procedure.

WBC count 22,000/mm3 (normal 10,000)

47. The older client's adult child questions the nurse as to why the client is at higher risk for infection when the client's white cell count is within the normal range. What response by the nurse is best?

]Wbcs are less active in older people so they are not as efficient.

64. A nurse is teaching clients newly diagnosed with osteoarthritis about drugs used to treat disease. For which drug does the nurse plan health teaching

acetaminophen

92. The nurse is admitting a client who has acute glomerulonephritis caused by beta streptococcus, what drug therapy would the nurse expect to be prescribed to this client

antibiotics

91. The nurse is caring for a client who has chronic pyelonephritis. What assessment findings would the nurse expect?

hypertension

53. The nurse notes a bulge in a client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings?

reducible inguinal hernia

42. On removing a dressing from a client on the third postoperative day the nurse notes thing, pink-colored drainage and documents this as

serosanguineous