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Final Exam (Minus Test 1 Content)

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the nurse is caring for a postoperative parathyroidectomy patient. which would require the nurse's immediate attention? a. incisional pain b. laryngeal stridor c. difficulty voiding d. abdominal cramps

2 laryngeal stridor is is a high pitched sound hear on inspiration and expiration caused by compression of the trachea

A nurse is preparing to administer metoprolol 200 mg PO daily. The amount is available is 100 mg/tablet. How many tablets should the nurse administer?

2 tab

Which type of abuse is described as the failure to meet the basic needs of children by those persons responsible for their health and well-being? 1)Physical abuse 2)Physical neglect 3)Emotional abuse and neglect 4)Nonassaultive abuse

2) physical neglect

The best way to treat violent families is to offer families: 1)A crisis intervention program. 2)A multidisciplinary approach to treatment. 3)A safe haven from the abuser. 4)Legal counseling and court assistance.

2)A multidisciplinary approach to treatment.

the nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from DKA regarding measures to prevent a reoccurrence. which instruction is important for the nurse to emphasize? a. eat 6 small meals a day b. test the urine ketone level c. monitor blood glucose levels frequently d. receive appropriate followup healthcare

3 home glucose monitoring should be emphasized 4-5 times a day

Which form of abuse is least reported to authorities? 1)Elder abuse 2)Sexual abuse 3)Child sexual abuse 4)Child maltreatment

3)Child sexual abuse

Infants less than 1 year of age who present with apnea, seizures, lethargy, respiratory difficulty, coma, or death should be suspected of: 1) Maltreatment. 2)Physical abuse. 3)Shaken baby syndrome. 4)Child neglect.

3)Shaken baby syndrome.

a client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia. which statement by the client indicates a correct understanding of humulin N insulin and exercise? a. "i should not exercise after lunch" b. "i should not exercise after breakfast" c. "i should not exercise in the late evening" d. "i should not exercise in the late afternoon"

4 clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks at 12-14 hours. therefore late afternoon exercise would occur during the peak time of insulin

A nurse is preparing to administer lactated ringer's (LR) IV 100 ml over 15 minutes. The nurse should set the IV infusion pump to deliver how many mL/hr?

400 mL/hr

A nurse is preparing to administer 0.9% NaCl 250 mL IV to infuse over 30 min. the drop factor of the manual tubing is 10 gtt/min. the nurse should adjust the manual IV infusion to deliver how many gtt/min?

83 gtt/min

A nurse asks a patient when her pain started. This is an example of what type of question? a. Closed ended b. Affective c. Open ended d. Focused

A nurse is assisting with the plan of care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse recommend? a. Reinforcing new ways to use new behaviors b. Practicing new problem-solving skills c. Developing goals d. Establishing boundaries

Which organ in the body regulates fluid and electrolyte balance? A. Kidney B. Liver C. Heart D. Adrenal cortex

The three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill, and which other element? A. Accountability B. Attitude C. Education D. Value

Verbal communication includes: A. body language. B. spoken words. C. intonation. D. gesture.

A child weighs 52 lbs. The child has a fever and the doctor orders Tylenol. The safe dose range of this medication is 10-15 mg/kg every 6 hours. What is the maximum safe dose this child can have per day?* A. 148 mg/day B. 289 mg/day C. 1,418 mg/day D. 785 mg/day

A nurse observes smoke coming out from under the door of the staff's lounge. Which of the following actions is the nurse's priority? a. Extinguish the fire b. Activate the fire alarm c. Move the clients who are nearby d. Close all open doors on the unit

Which of the following patients is burned more easily than a person in good health? A. Patient with pneumonia B. Patient with hypothyroidism C. Patient with diabetes D. Patient with morbid obesity

Which of the following statements by a nursing student demonstrates an understanding of collaboration? A. "Collaboration is a new way of interacting with physicians." B. "Collaboration means that the care team can make all of the decisions for the patient." C. "Collaboration with patients has been used by nurses throughout the history of nursing." D. "Collaboration is an outdated concept that has been replaced by managed care."

A nurse is observing a client's IV infusion site. Which of the following findings should the nurse identify as an indications of phlebitis? (Select all that apply) A. Pallor B. Dampness C. Erythma D. Coolness E. Pain

C, E

a patient known to he positive for HIV is admitted with oral thrush, recurrent vaginal yeast infections, and skin infections. what do these signs indicate? a. opportunistic infection b. antimicrobial resistance c. resistant strain of HIV d. sentinel infection

Candidiasis is a common opportunistic infection (OI) in the HIV-positive patient. Antimicrobial resistance can be determined only via microbiologic culture accompanied by the antibiogram (test that shows drug sensitivities). Resistant strains of HIV are mutations of the virus that do not respond well to chemotherapy. Sentinel infections are seen in AIDS-defining infections and where the candidiasis is currently located is not indicative of this type of infection.

A nurse uses the ISBAR R format for an end-of-shift report. ISBAR-R is an abbreviation for: A. Introduction, situation, background, analysis recommendation, and readback. B. Introduction, situation, background, assessment, review, and readback. C. Introduction, situation, background, analysis, report, and readback. D. Introduction, situation, background, assessment, recommendation, and readback.

the obligation to do or cause no harm to another

Nonmaleficence

a nurse is collecting data from a client who has a history of asthma. which of the following factors should the nurse identify as a risk factor for asthma? a. gender b. environmental allergies c. alcohol use d. race

b environmental allergies are a risk factor

the priority nursing intervention when administering dilantin (phenytoin) to a patient diagnosed with epilepsy is: a. recording of the BP b. providing detailed oral hygiene c. encouraging bed rest d. administering the drug with milk

b A side effect of Dilantin use is gum hyperplasia; therefore, detailed oral hygiene and gum massage are imperative interventions to decrease the risk of this side effect.

the major component necessary for metabolism of carbohydrates is (are): a. pancreatic enzymes b. insulin secreted by the pancreas c. bile secreted by the liver d. mucous secreted from the duodenum

b Insulin is needed for the metabolism of carbohydrate.

which action is appropriate for the care of a person who is on mechanical ventilation? a. instruct the respiratory therapist to check the ventilator settings and alarms b. auscultate the lungs bilaterally to ensure both lungs are being ventilated c. disconnect the alarms before suctioning or before turning the patient d. perform endotracheal suctioning every 15 minutes, using sterile technique

b The nurse is primarily responsible for the daily ongoing assessment of the respiratory status of the patient and verifying that ventilation is occurring correctly. (1) The respiratory therapist (RT) will check the settings and alarms, but the actions of the RT do not replace good nursing assessment. Disconnecting alarms and excessive suctioning are inappropriate actions.

a post cardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL. the nurse understands that the client has a total urine output of 25 mL. the nurse understands that the client is at risk for? a. hypovolemia b. acute kidney injury c. glomerulonephritis d. urinary tract infection

b a person who underwent cardiac surgery is at risk for kidney injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy

the nurse is evaluating the pin sites of a client in skeletal traction. the nurse would be least concerned with which finding? a. inflammation b. serous drainage c. pain at pin site d. purulent drainage

b a small amount of serous drainage is expected at pin insertion site. signs of infection like inflammation, purulent drainage, and pain at the pin site are not expected findings and should be reported

a nurse is caring for a client who has a new prescription for adalimumab for rheumatoid arthritis. based on the route of administration of the medication which of the following should the nurse plan to monitor? a. the vein for thrombophlebitis during IV administration b. the subq site for redness following injection c. the oral mucosa for ulceration after oral administration d. the skin irritation after removing a transdermal patch

b adalimumab is given subcutaneously so redness of the site needs to be monitored

a nurse is reinforcing teaching with a client on the purpose of taking albuterol. which of the following client statements indicates an understanding of the teaching? a. "this medication can decrease my immune response" b. "i take this medicine to stop an asthma attack" c. "i need to take this medication with food" d. "this medication has a slow onset to treat my symptoms"

b albuterol is a short acting beta2 antagonist that is used to abort an ongoing asthma attack or to prevent exercise-induced bronchospasms

a nurse in a providers office is reviewing laboratory results for a client who has secondary hypothyroidism. which of the following findings should the nurse expect? a. elevated serum T4 b. decreased serum T3 c. elevated serum thyroid-stimulating hormone d. decreased serum cholesterol

b decreased serum T3 is expected with hypothyroidism

the role of the LPN/LVN in the patient admission procedure differs from that of the RN and might include: select all that apply a. writing nursing diagnoses for the patients care plan b. obtain an ordered urine specimen c. takes the patients history d. assist the physical data collection data e. orients the patient to the unit

b, c, d, e The LPN's role in this situation would be to obtain an ordered urine specimen, to take the patient's history, to assist with physical data collection, and to orient the patient to the unit.

a nurse is reviewing manifestations of hyperthyroidism with a client. which of the following findings should the nurse include? (select all that apply) a. anorexia b. heat intolerance c. constipation d. palpitations e. weight loss f. bradycardia

b, d, e hyperthyroidism increases metabolism, which causes heat intolerance, palpitations, and weight loss

a nurse is collecting data on a client who has pulmonary embolism. which of the following manifestations should the nurse expect to find? select all that apply a. bradypnea b. pleural friction rub c. hypertension d. petechiae e. tachycardia

b, d, e the nurse should expect pleural friction rub, petechiae, and tachycardia

the duty to do good to others and maintain a balance between benefits and harms. paternalism is an undesirable outcome, in which the HCP decides what is best for the client and encourages the client to act against his or her own choices

beneficence

the nurse is doing a 48 hour postpartum check on a client with mild gestational hypertension (GH). which data indicates that the GH is a concern? a. urinary output has increased b. there is no evidence of proteinuria c. the client complains of blurred vision and headache d. the BP reading has returned to the prenatal baseline

c a, b, d are all signs that gestational hypertension is not present. c is a sign of the worsening of the GH and is a concern the needs to be reported

a community health nurse is assessing a client who reports numbness of the hands and feet for the past two weeks. this finding is associated with which of the following nutritional deficiencies? a. folic acid b. potassium c. vitamin b12 d. iron

c numbness in the hands and feet are manifestations of a vitamin b12 deficiency

the nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. which instruction should be included in the plan of care? a. soak the feet in hot water b. avoid using soap on the feet c. apply a moisturizing lotion to dry feet, but not between the toes d. always have a podiatrist cut your toenails, never cut them yourself

c the client should use a moisturizing lotion of the feet just not between the toes

a nurse is reinforcing teaching about screening for cancer. which of the following statements by the client indicates understanding? a. i will need to have a mammogram every 2 years beginning at age 45 b. i should have a colonoscopy every 15 years beginning at age 60 c. i will need to have a pap test every 5 years beginning at age 30 d. i should have a fecal occult test done every 3 years

c the nurse should instruct the client to have a pap every 5 years beginning at age 30. the american cancer society suggest that women have annual mammograms starting at age 40. the client should have colonoscopys at age 50 and every 10 years. the client should have a fecal occult test performed every year

a nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. which of the following information should the nurse include? a. stools will be dark red b. take with a glass of milk if GI distress occurs c. foods high in vitamin c will promote absorption d. take for 14 days

c vitamin c enhances the absorption of iron. stools will be dark green to black, milk binds with iron and decreases its absorption, and iron therapy takes 4-6 weeks for the hbg and hct to return to normal level

a nurse is caring for a patient who has type 1 DM. the nurse should identify which of the following findings are manifestations of DKA? (select all that apply) a. blood glucose of 58 mg/dL b. weight gain c. dehydration d. mental confusion e. fruity breath

c, d, e clients who have DKA experience osmotic diuresis, mental confusion because of electrolyte shift, and fruity breath because of the body's attempt to eliminate ketones

a nurse is caring for a client who is 12 hours postoperative following a thyroidectomy. which of the following findings indicate that the client is experiencing thyroid crisis? (select all that apply) a. bradycardia b. hypothermia c. dyspnea d. abdominal pain e. mental confusion

c, d, e excessive thyroid hormone causes dyspnea, GI troubles like vomiting and diarrhea, and confusion

a nurse is teaching self monitoring of blood glucose (SMBG) to a client who has diabetes mellitus. which of the following instructions should the nurse include? (select all that apply) a. perform SMBG once daily at bedtime b. wipe the hand with an alcohol swab c. hold the hand in a dependent position prior to the puncture d. place the puncturing device perpendicular to the site e. prick the outer edge of the fingertip for the blood sample

c, d, e hold hand in dependent position to get blood flowing, client should hold the lancet perpendicular to ensure that it is getting the right depth, and the client should use the outer edge for blood sampling

Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? a. Administration of oxygen by nasal cannula at 15 L/min b. Intravenous infusion of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin

d The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.

Which nursing action is most appropriate for monitoring a patient with a casted lower extremity for infection? a. Assess vital signs every hour while the patient is awake. b. Remove the cast weekly to check the wound for signs of infection. c. Remove the cast bi-weekly to check the wound for signs of infection. d. Assess temperature trends and sniff around the cast for signs of foul odor.

d The most appropriate nursing action for monitoring a patient with a casted lower extremity for signs of infection is to assess for signs of infection every shift: assess wound for redness, swelling, and tenderness; administer prophylactic antibiotics as ordered; assess temperature trends and trend of white blood count values for signs of infection; assess patient for subjective signs of malaise; and sniff around the cast for signs of foul odor indicating infection. The cast should never be removed bi-weekly or weekly unless the physician orders it to be removed. Assessing vital signs is important but is not required on an hourly basis.

a nurse is caring for a patient who has asthma. which lung sound would the nurse expect to hear when auscultating the lungs? a. fine crackles b. stridor c. pleural friction rub d. wheezes

d Wheezing is commonly heard in asthma due to the narrowing of airways. Fine crackles can be heard in patients who have atelectasis, fibrosis, pneumonia, or early congestive heart failure. Stridor can be heard when there is partial obstruction of the upper air passages. Pleural friction rub occurs when irritated visceral and parietal pleura rub against each other.

a nurse is reinforcing discharge teaching for a client who experienced a pneumothorax. which of the following statements should the nurse use when teaching the client? a. "notify your provider if you experience weakness" b. "you should be able to return to work in one week" c. "you need to wear a mask when in crowded areas" d. "notify your provider if you experience a productive cough"

d a productive cough may indicate that there is a need for respiratory treatment

a nurse is caring for a client who has acute otitis media. which of the following is the priority action for the nurse to take? a. provide emotional support to the family b. instruct the family on care of the child c. encourage the child to socialize with other toddlers d. administer analgesics

d according to maslows hierachy of needs you meet the toddlers physiological needs first. providing emotional support is necessary, instructing the family on how to care for the child is important, and encouraging the child to socialize is important, but those are not the priority

a mother with HIV brings her 10 month old infant to the clinic for a checkup. a hcp has documented that the client is asymptomatic for HIV infection. after the checkup the mother tells the nurse that she is so pleased that the infant will not get HIV. which response by the nurse is appropriate? a. i am also so pleased that everything has turned out fine b. since symptoms has not developed it is unlikely that the infant will develop HIV infection c. everything looks great but be sure that that you return with your infant next month for the scheduled visit d. most children infected with HIV develop symptoms within the first 9 months of life and some become symptomatic at some point before the age of three

d most children who are infected with HIV develop symptoms within the first 9 months of life. the remainder of these infected children become symptomatic sometime before the age of 3 years. children with their immature immune systems have a shorter incubation period than adults. options 1, 2, 3 are incorrect

a nurse is caring for a child who has AIDS. which of the following isolation precautions should the nurse implement? a. contact b. airborne c. droplet d. standard

d standard isolation precautions prevent transmission of diseases that spread through blood or bodily fluids. contact, airborne, and droplet precautions are only needed for someone with a disease that can spread easily

a client is having a lumbar puncture performed. the nurse should place the client in which position for the procedure? a. supine, in semi-fowlers b. prone, in slight trendelenburg c. prone, with a pillow under the abdomen d. side lying, with legs pulled up and chin to the chest

d this position opens up the spaces between the vertebrae.

the nurse is one of several people who witness a vehicle hit a pedestrian at a fairly slow speed on a small street. the individual is dazed and tries to get up, and the leg appears to be fractured. the nurse should plan to perform which action? a. try to manually reduce the fracture b. assist the person to get up and walk to the sidewalk c. leave the person for a few minutes to call an ambulance d. stay with the person and encourage the person to remain still

d with a suspected fracture the client is not moved unless it is dangerous in that spot. the nurse should remain with the client and have someone else call an ambulance. a fracture is not reduced at a scene. before moving the client, the site of fracture is immobilized to prevent further injury

a nurse is assisting a provider with the removal of a chest tube. which of the following actions should the nurse instruct the client to do? a. lie on his left side b. use the incentive spirometer c. cough at regular intervals d. perform the valsava maneuver

d. the nurse should instruct the client to take a deep breath, exhale and bear down

the duty to do what one has promised

fidelity

the equitable distribution of potential benefits and tasks determining the order in which clients should be provided care

justice

the obligation to tell the truth

veracity

which home care instructions should the nurse plan to reinforce to the mother of a child with AIDS? select all that apply a. frequent hand washing is important b. the child should avoid exposures to other illnesses c. the childs immunization schedule will need revision d. kissing the child on the mouth will not transmit the disease e. clean body fluid spills with bleach solution f. fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention

1, 2, 5 AIDS is a disorder that is caused by HIV and is characterized by a generalized dysfunction of the immune system. both cellular and humoral immunity are compromised. the horizontal transmission of HIV occurs through intimate sexual contact or parenteral exposure to blood of bodily fluid that contain blood. vertical (parenteral) transmission occurs an HIV infected pregnant woman passes the infection to her infant. home care instructions include the following: frequent hand washing, monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level and oral lesions and notify the hcp if these occur.

which sign or symptom observed in a sleeping 2 year old child immediately after a tonsillectomy necessitates reporting to follow up care? a. a pulse of 110/min b. BP of 96/64 c. nausea d. frequent swallowing

4 Frequent swallowing while the child is sleeping is an early sign of bleeding after a tonsillectomy.

during a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. the nurse determines that the teaching has been effective when the client makes which statement? a. "a can eat more sweets now because i need more calories" b. "i need more fat in my diet so that the baby can gain enough weight" c. "i need to eat a high protein, low carb diet now to control my blood glucose" d. "i need to increase the fiber in my diet to control my blood glucose and prevent constipation"

4 an increase in calories is needed, but an increase of sugar can cause hyperglycemia

A nurse is preparing to administer dextrose 5% in lactated ringer's (D5LR) 1000 mL to infuse over 6 hours. The drop factor of the manual IV tubing it 15 gtt/mL. the nurse should adjust the manual IV infusion to deliver how many gtt/min?

42 gtt/min

Doctor orders Zithromax for a child that weighs 82 lbs. The safe dose range for this medication is 10-12 mg/kg/day. What is the maximum safe daily dose for this child?* A. 447.3 mg/day B. 984 mg/dose C. 347 mg/dose D. 586.8 mg/dose

Doctor orders an IV drip of Dopamine for a child that weighs 78 lbs. The safe dosage range for this medication is 5-20 mcg/kg/min. What is the safe dosage range for this child?* A. 177.3-709.1 mcg/min B. 289.6-652.3 mcg/min C. 152.4-189.5 mcg/min D. 250-350 mcg/min

Interrelated concepts regarding patient attributes and preferences that a nurse would consider when addressing patient education include which concept? a. Adherence b. Health promotion c. Quality d. Technology

One of the most common accidents among patients is: A. falls. B. hip fracture. C. subdural hematoma. D. hand trauma.

When communicating with a hearing-impaired patient, a nurse should: A. stand or sit 3 feet from the patient. B. Shout at the patient. C. speak directly into the patient's ear. D. speak in a low pitch.

When planning the evaluation of a teaching activity that has the goal of educating a patient and family about the long-term effects of diabetes, it would be most appropriate for the nurse to include which opportunity for the patient? a. Ask questions. b. Inject insulin. c. Meet exercise goals. d. Prepare a menu.

Which of the following is a true statement about communication? a. Verbal, nonverbal, and affective communication must be congruent for the communication to be honest b. Common expressions are not appropriate for patients c. Medical jargon is usually helpful when communicating with patients d. Cultural characteristics do not influence communication

Which of the following statements is not true regarding communication with older adults? a. Detailed information is best given early in the day b. Visual information is more permanent than the auditory information c. Most older adults hear lower pitched sounds more clearly d. Communication is more difficult with older adults

Ethical principles for professional nursing practice in a clinical setting are guided by the principles of conduct that are written as the: A American Nurses Association's (ANA's) Code of Ethics B Nurse Practice Act (NPA) written by state legislation C Standards of care from experts in the practice field D Good Samaritan laws for civil guidelines

A (This set of ethical principles provides the professional guidelines established by the ANA to maintain the highest standards for ideal conduct in practice. As a profession, the ANA wanted to establish rules and then incorporate guidelines for accountability and responsibility of each nurse within the practice setting.)

A nurse on an acute care unit is caring for a client following a total hip arthroplasty. The client is confused, moving his leg into positions that could dislocate the new hip joint, and he repeatedly attempts to get out of bed. After determining that restraint application is indicated, which of the following actions should the nurse take? (Select all that apply) a. Secure the restraint to the frame of the bed b. Get a prescription for restraints from the provider c. Have a family member sign the consent for restraints d. Use a square knot to secure the restraints to the bed e. Ensure that only one finger can be inserted between the restraint and the client

A, B, C

A charge nurse is providing information about fat emulsion added to total parenteral nutrition (TPN) to a group of nurses. Which of the following statements by the charge nurse are appropriate? (Select all that apply) a. "Concentration of lipid emulsion can be up to 30%." b. "Adding lipid emulsion gives the solution a milky appearance." c. "Check for allergies to soybean oil." d. "Lipid emulsion prevents essential fatty acid deficiency." e. "Lipids provide calories by increasing the osmolality of the PN solution."

A, B, C, D

A home health nurse is assessing the safety of a client's home. The nurse should identify which of the following factors as increasing the client's risk for falls? (Select all that apply) a. History of a previous fall b. Reduced vision c. Impaired memory d. Takes rosuvastatin e. Uses a night light f. Kyphosis

A, B, C, F

A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the the nurse manager include? (Select all that apply) a. Request assistance when repositioning a client b. Avoid twisting your spine or bending at the waist c. Keep your knees slightly lower that your hips when sitting for long periods of time d. Use smooth movements when lifting and moving clients e. Take a break from repetitive movements every 2 hours to 3 hours to flex stretch your joints and muscles

A, B, D

Which factors affecting a patient's environment must be controlled? Select all that apply. A. Temperature B. Ventilation C. Decor D. Odor

A, B, D

Which of the following are blood cells? Select all that apply. A. Thrombocytes B. Leukocytes C. Eosinocytes D. Erythrocytes

A, B, D

a nurse is collecting data from a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (Select all that apply) a. Decreased skin turgor b. Concentrated urine c. Bradycardia d. Low-grade fever e. Tachypnea

A, B, D, E

A Nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply:) a. Restlessness b.Tachypnea c.Bradycardia d.confusion e.pallor

A, B, D, E (these are all early manifestations of hypoxemia) Bradycardia is a LATE manifestation.

A nurse mentor is explaining the benefits of collaborative practice to a nurse new to a facility. Which of the following research-based benefits is the nurse likely to identify as positive outcomes of collaboration? Select all that apply. A. Decreased length of stay for patients B. Decreased staff resignations C. Decreased use of pain medications D. Increased reimbursement from insurance carriers E. Increased patient follow-up appointments after discharge F. Increased job satisfaction of the staff

A, B, E

The nurse is having a therapeutic conversation with a patient who is newly diagnosed with hypertension. Which communication techniques will most likely prove effective for this newly diagnosed patient? Select all that apply. A. The nurse presents a laminated poster to the patient that depicts pictures of foods that would be on the low sodium diet. B. The nurse and patient engage in a humorous conversation about the top ten "what not to eat when you are being treated for hypertension". C. The nurse gives the patient a sheet full of information and asks the patient to read the information and let the nurse know if they have any questions. D. The nurse states the risk factors and statistics of patients who do not take their medications as prescribed. E. The nurse helps the patient identify weight loss goals that are reasonable. F. The nurse waits until the patient has been awake for a few hours before beginning the teaching plan.

A, B, E, F

A nurse is reviewing the laboratory results for a client who has an elevated temperature. The nurse should recognize which of the following finding as a manifestation? (Select all that apply) a. Hct 55% b. Serum osmolarity of 260 mOsm/kg c. Urine specific gravity 1.035 d. Serum creatinine 0.6 mg/dL

A, C, D

A nurse caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take is an allergic transfusion reaction is suspected? (Select all that apply) a. Stop the transfusion b. Monitor for hypertension c. Maintain an IV infusion with 0.9% NaCl d. Position the client in an upright position with the feet lower than the heart e. Administer diphenhydramine

A, C, E

The nurse is caring for a patient with pitting edema to the lower extremities. Which intervention(s) for pitting edema are the nurse likely to include in the nursing care plan of this patient? (select all that apply) Select all that apply. A. Daily weight B. High-calorie diet C. Intake and output record D. Skin care and mouth care E. Edema assessment using an edema scale every shift

A, C, E

Which of the following actions should the nurse take when using the communication technique of active listening? (Select all that apply) A Use open posture B Write down what the client says to avoid forgetting details C Establish and maintain eye contact D Nod in agreement with the client throughout the conversation E Respond positively when giving feedback

A, C, E

A nurse is collecting data from a client who has a serum sodium level of 5.4 mEq/L. which of the following manifestations should the nurse expect? (Select all that apply) a. ECG changes b. Constipation c. Polyuria d. Hypotension e. Tachycardia

A, D

A physician has reprimanded you at the patient's bedside. You feel an instant flash of anger, but you say nothing. When the physician leaves the room, you follow quickly to catch up before he moves on to another room. What might you say? (Select all that apply) a. "Dr. Jones, I wish to speak with you privately b. "How dare you shame me in front of a patient?" c. "Please explain what you wanted me to know." d. "In the future, talk to me privately, not at the bedside." e. "I am going to report you to my nursing supervisor."

A, D

A nurse on the IV team is conducting an in-service education program about the complications of IV therapy. Which of the following statements by an attendee indicates an understanding of the manifestations of infiltration? (Select all that apply) a. "The temperature around the IV site is cooler" b. "The rate of the infusion increases" c. "The skin at the IV site is red" d. "The IV dressing is damp" e. "The tissue around the venipuncture site is swollen"

A, D, E

A nurse is collecting data from a client who has pancreatitis. The clients ABG's indicate metabolic acidosis. Which of the following findings should the nurse expect? (Select all that apply) a. Tachycardia b. Hypertension c. Bounding pulses d. Insomnia e. Dysrhythmias f. Tachypnea

A, E, F

The nurse is reinforcing teaching concerning the use of a cromolyn sodium inhaler for a 10 year old with asthma. Which would be an accurate concept to emphasize? 1. You should use the inhaler whenever you have difficulty breathing. 2.You should use the inhaler between meals. 3. You should use the inhaler regularly every day even if you are symptom free. 4.You can discontinue using the inhaler when you are feeling stronger.

Answer-3. You should use the inhaler regularly every day even if you are symptom free. Cromolyn sodium (Intal) is a nonsteroidal, anti-inflammatory medication that is inhaled using a Spinhaler. It is used as a prophylactic, or preventive, medication. Daily doses are prescribed to ensure an adequate blood level.

Which is a priority nursing diagnosis in a child admitted with acute asthma? 1. Risk for Infection 2. Imbalanced Nutrition 3. Ineffective Breathing pattern 4. Disturbed body image

Answer: 3-Ineffective Breathing Pattern In acute asthma, the patient coughs, wheezes, and has difficulty breathing. Shortness of breath accompanied by restricted breath sounds and rising respiratory rate may indicate imminent respiratory failure and should be reported promptly to the health care provider. In acute asthma, an ineffective breathing pattern would be a priority diagnosis with nursing actions aimed at increasing oxygenation and decreasing respiratory distress.

An infant is admitted with a diagnosis of respiratory syncytial virus infection (RSV). The type of transmission-based isolation precaution the nurse would set up would be: (Select all that apply): 1. Standard Precautions 2.droplet precautions 3. contact precautions 4. airborne infection isolation precautions.

Answers: 2 and 3 RSV is spread by direct contact with respiratory secretions. Contact isolation precautions are used to prevent fomite spread. RSV can be spread when droplets containing the virus are sneezed or coughed into the air by an infected person. Such droplets can linger briefly in the air, and if someone inhales the particles or the particles contact his or her nose, mouth, or eye, he or she can become infected; therefore droplet precautions are implemented as well.

A 48-year-old woman who is being given information about what to expect post surgically smiles and nods while the nurse is speaking with her. Given the characteristics of communication by women, which action would be particularly important by the nurse? Which of the following statements is true about male and female communication differences? a. Assume the patient agrees with the information b. Ask the patient to tell what she understood from the nurse c. Assume that the patient has under stood the information d. Ask the patient if she has any questions about what has been said

A charge nurse is teaching a group of nurses about medication compatibility with TPN. Which of the following statements should the nurse make? a. "Use the Y-port on the TPN IV tubing to administer antibiotics." b. "Regular insulin may be added to the TPN solution." c. "Administer heparin through a port of the TPN tubing." d. "Administer vitamin K IV bolus via Y-port on the TPN tubing."

A nurse in an outpatient clinic is reinforcing discharge instructions with a client who has a new prescription for erythropoietin. Which of the following statements should the nurse make? a. "You will need an erythrocyte sedimentation rate test weekly" b. "You should have your hemoglobin level checked twice per week" c. "Your oxygen saturation levels should be monitored" d. "Your folic acid production will increase"

A nurse is caring for a client who is receiving enteral tube feedings due to dysphasia. Which of the following bed positions should the nurse use for safe care of this client? a. Supine b. Semi-fowler's c. Semi-prone d. Trendelenburg

A nurse is caring for a client who states, "I have to check with my wife and see if she thinks I am ready to go home." The nurse replies, "How do you feel about going home today?" Which clarifying technique is the nurse using to enhance communication with the client? a. Pacing b. Reflecting c. Paraphrasing d. Restating

A nurse is caring for a school aged child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take? a. Touch the child's arm b. Sit at eye level with the child c. Stand facing the child d. Stand with a relaxed posture

A nurse is collecting data from a client who has anemia. Which of the following integumentary findings should the nurse expect? a. Absent turgor b. Spoon-shaped nails c. Shiny, hairless legs d. Yellow mucous membranes

A nurse is communicating with an aphasic patient. The nurse should: A. use open-ended questions. B. ask one question at a time. C. speak to the patient as if the patient has no new learning ability. D. not assume the patient can understand what is heard.

A nurse is demonstrating how to insert an IV catheter. Which of the following statements by a nurse viewing the demonstration indicates understanding of the procedure? a. "I will thread the needle all the way into the vein until the hub rests against the insertion site after I see a flashback of blood b. "I will insert the needle into the client's skin at an angle of 10-30 degrees with the bevel up" c. "I will apply pressure approximately 1.2 inches below the insertion site prior to removing the needle" d. "I will choose a vein in the antecubital fossa for IV insertion due to its size and easily accessible location"

A nurse is explaining why collaboration is valued to a new nurse during her orientation to the unit. Which of the following outcomes is a key patient care outcome that occurs when collaboration is correctly used? A. Governmental accrediting agencies give more favorable reviews to the agency. B. There are fewer errors that occur in patient care. C. Agencies can offer higher salaries due to the cross-training of staff. D. Ongoing education is not needed, because other specialties contribute to care decisions.

A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior? a. The client asks the nurse whether the will go out to dinner with him. b. The client accuses the nurse to telling him what to do just like his ex-girlfriend c. The client reminds the nurse of a friend who died from a substance overdose d. The client becomes angry and threatens to harm himself

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? a. Administer antihypertensive on schedule b. Check the client's weight each morning c. Notify the provider of a urine output greater than 30 mL/hr d. Encourage independent ambulation four times a day

A student nurse comes to clinical with his uniform slightly dirty and unshaven. His patient asks him if he is wide enough awake to provide safe care. Clothing and physical appearance are part of which communication method? a. Two way b. Nonverbal c. Affective d. One way

Doctor orders Zofran 2 mg for a child that weighs 13.6 kg. The safe dosage range of this drug is 0.15 mg/kg. Is this a safe dose?* A. No, this is not a safe dose. A safe dose would be 1.02 mg/dose. B. Yes, this is a safe dose. C. No, this is not a safe dose. A safe dose would be 0.5 mg/dose.

Given the following blood gas, which state is the patient currently experiencing: pH 7.47, PaO2 84, PCO2 34, and HCO3 21? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

In an agency with a culture of safety, when an error or patient safety issue is identified, the individual who reports the problem knows which information? A. Is disciplined according to established protocols. B. Must communicate the problem to the patient. C. Near misses in health care are used to improve care. D. Shares details to locate the individual at fault

The health care provider has prescribed an isotonic IV solution administration for a patient. The nursing student correctly identifies which solutions as being isotonic? A. Sterile distilled water, 5% dextrose in water B. 0.9% normal saline, lactated Ringer's solution C. 5% dextrose in 0.45% normal saline, Ringer's solution D. 10% dextrose in water, 5% dextrose in 0.9% normal saline

The nurse caring for a patient with metabolic acidosis would expect the patient to exhibit which symptom? A. Flushing B. Lethargy C. Hyperactivity D. Shallow, slow respirations

The nurse is assessing a patient who has diabetic ketoacidosis. Her assessment reveals tachycardia, lethargy, and hyperventilation. Treatment for the ketoacidosis has been initiated. What should the nurse do about the hyperventilation? a. Request an order for pain medication and oxygen at 6 L/min. b. Lubricate the patient's lips and allow continued hyperventilation. c. Have the patient breathe into a paper bag to stop hyperventilating. d. Contact the physician immediately regarding this complication.

What should a patient with home oxygen be instructed to avoid when oxygen is in use? A. Eating B. Smoking C. Driving D. Working

Which is an appropriate response to the patient when you pick up affectively and nonverbally on the patients anger? a. Leave the room and report your observations to the team leader immediately b. Lighten up the situation by sharing some funny email jokes with the patient c. Provide observations of nonverbal behavior and encourage the patient to talk about their feelings d. Continue what you came in to do silently and leave as soon as you are done

Which of the following communication terms can be applied to this statement: How messages are received and interpreted would include personal states such as mood disturbance, environmental stimuli related to the setting of the communication, and contextual variables? A. Therapeutic communication B. Metacommunication C. Vigor communication D. Internal noise

_________ refers to mood or emotion. a. Nonverbal b. Affect c. Verbal

A nurse educator is reviewing proper body mechanics during employee orientation. Which of the following statements should the nurse identify as an indication that an attendee understands the teaching? (Select all that apply) a. "My line of gravity should fall outside my base of support" b. "The lower my center of gravity, the more stability I have" c. "To broaden my base of support, I should spread my feet apart" d. "When I lift an object, I should hold it as close to my body as possible" e. "When pulling an object, I should move my front foot forward"

B, C, D

A nurse is caring for a client receiving dextrose 5% in 0.9% NaCl IV at 120 mL/hr. which of the following statements by the client should alert the nurse to suspect a fluid overload? (Select all that apply) a. "I feel lightheaded" b. "I feel as though my heart is racing" c. "I feel a little short of breath" d. "The nurse technician told me that my BP was 150 over 90" e. "I think my ankles are swollen"

B, C, D

Which of the following concepts would a nurse think has the strongest link to safety? Select all that apply. A. Cognition B. Communication C. Quality D. Regulation E. Teamwork

B, C, D, E

A home health nurse is discussing the dangers of food poisoning with a client. Which of the following information should the nurse include in her counseling? (Select all that apply) a. Most food poisonings are caused by a virus b. Immunocompromised individuals are at risk for complications from food poisoning c. Clients who are at high risk should eat or drink only pasteurized dairy products d. Healthy individuals usually recover from the illness in a few weeks e. Handling raw and fresh food separately can prevent food poisoning

B, C, E

A nurse is providing discharge instructions to a client who has a prescription for oxygen use at home. Which of the following information should the nurse include about home oxygen therapy? (Select all that apply) a. Family members who smoke must be at least 10 feet from the client when oxygen is in use b. Nail polish should not be used near a patient receiving oxygen c. A "no smoking" sign should be placed on the front door d. A fire extinguisher should be readily available in the home

B, C, E

The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? Select all that apply. a. Extracellular fluid volume (ECV) excess b. Extracellular fluid volume (ECV) deficit c. Hypokalemia d. Hyperkalemia e. Hypocalcemia f. Hypercalcemia

B, C, E

The patient has been prescribed a non-potassium-sparing diuretic. Which food(s) should the nurse suggest the patient include in his diet? (select all that apply) Select all that apply. A. Eggs B. Bananas C. Tomatoes D. Aged cheese E. Baked potato with skin

B, C, E

The nurse should ask which of the following questions to detect the risk factors for metabolic acidosis? Select all that apply. a. Have you been vomiting today? b. When did your kidneys stop working? c. How long have you had diarrhea? d. Are you still feeling short of breath? e. What type of antacid did you take? f. Which weight loss diet are you using?

B, C, F

A nurse is caring for a client who has a NG tube with low intermittent suctioning. The nurse should monitor the client for the following electrolyte imbalances? (Select all that apply) a. Hypercalcemia b. Hyponatremia c. Hyperphosphatemia d. Hypomagnesemia e. Hyperkalemia

B, D

A nurse is collecting data from a client who has hypercalcemia as a result of long term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply) a. Hyperreflexia b. Confusion c. Positive chvostek's sign d. Bone pain e. Nausea and vomiting

B, D, E

Which of the following are important in resolving conflict situations? (Select all that apply) a. Avoid conflict at any cost b. See conflict as an opportunity to learn c. Ensure that the other parties know what they did wrong d. Use "I" statements e. Think before reacting

B, D, E

A nurse is caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurses use of interpersonal communication? a. The nurse discusses the clients weight loss during a health care team meeting b. The nurse examines her own personal feeling about clients who has anorexia nervosa c. The nurse asks the client about her body image perception d. The nurse assists in presenting an educational session about anorexia nervosa to a large group of adolescents

A nurse is caring for a client who has confusion and lethargy. The client was unresponsive at home, with an empty bottle of aspirin lying next to her bed. Vital signs are BP 104/72 mmHg, HR 116/min, and regular, and respiratory rate is 42/min. which of the following ABG results should the nurse expect? a. pH 7.68; PaCO2 38 mmHg; HCO3 28 mEq/L b. pH 7.48; PaCO2 28 mmHg; HCO3 23 mEq/L c. pH 7.16; PaCO2 38mmHg; HCO3 18 mEq/L d. pH 7.58; PaCO238 mmHg; HCO3 29 mEq/L

A nurse is orienting a new client to a mental health unit. When explaining the unit's community meetings, which of the following which of the following statements should the nurse make? a. "You and a group of other clients will meet to discuss your treatment plans." b. "Community meetings have a specific agenda that is established by staff." c. "You and the other clients will meet with staff to discuss common problems." d. "Community meetings are an excellent opportunity to explore your personal mental health issues."

A nurse is preparing to administer lipid emulsion and notes a layer of fat floating in the IV solution bag. Which of the following actions should the nurse take? a. Shake the bag the mix the fat b. Turn the bag upside down one time c. Return the bag to the pharmacy d. Administer the bag of solution

A nurse is reinforcing preoperative teaching with a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse make? a. "You should make an appointment to donate blood 8 weeks prior to the surgery" b. "If you need an autologous transfusion, the blood your brother donates can be used" c. "you can donate blood each week if your hemoglobin is stable" d. "Any unused blood that is donated can be used for other clients"

A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include? a. stools will be dark red b. take with a glass of milk if GI distress occurs c. foods high in vitamin C will promote absorption d. Take for 14 days

A nurse is talking with a client who is at risk for suicide following the death of his partner. Which of the following statements should the nurse make? a. "I feel very sorry for the loneliness you must be experiencing." b. "Suicide is not the appropriate way to cope with loss." c. "Losing someone close to you must be very upsetting." d. "I know how difficult it is to lose a loved one."

A patient's lab results indicate a potassium level of 5.6 mEq/L. Which of the following conditions would the nurse expect to see a potassium value at this level? a. Diarrhea b. Cushing's c. Massive third-degree burn d. Prolonged laxative use

Doctor order Cefazolin 350 mg IV every 4 hours. The child weighs 31 lbs. The safe dosage range for this medication is 25-75 mg/kg/day. Is this a safe dose for this patient?* A. Yes, this is a safe dose. B. No, this is not a safe dose. A safe dose would be 60-100 mg/dose. C. No, this is not a safe dose. A safe dose would be 58.7-176.1 mg/dose.

Hyponatremia may be caused by: A. increased secretion of aldosterone. B. stroke. C. congestive heart failure (CHF). D. dehydration.

The communication process is circular to ensure a. The patient receives feedback on a daily basis b. Verbal, nonverbal, and affective communication is used c. That feedback is received from the receiver, potentially prompting the sender to send a new message d. That all the team members are aware of the patients needs

The student nurse reviews the records of a patient with pneumonia and finds that the patient has a blood pH of 7.46. The student is correct in determining that this pH is considered __. A. slightly acidic B. grossly acidic C. slightly alkaline D. grossly alkaline

When a patient receives a hypotonic solution intravenously (IV), what happens to the patient's cells? A. There is a net loss of water across the cell membrane. B. There is no change in the cells because there is no fluid shift. C. The cells begin to swell as water enters the intracellular compartment. D. The cells begin to shrink as water is pulled from the intracellular compartment.

Which acronym is used to describe the process that should occur in response to a fire? A. PACE B. AREA C. RACE D. RACK

Which fluid output measurement is the most concerning for a nurse? A. 720 mL of urine in a 24-hour period B. 600 mL of urine in a 10-hour period C. 100 mL of urine in a 5-hour period D. 60 mL of urine in a 2-hour period

Which of the following behaviors by a nurse indicates the effective use of collaboration with other professionals? A. Strongly defends own professional role B. Avoids conflict C. Negotiates with others D. Aggressively presents a personal view of a situation

Which transport mechanism involves cellular energy? A. Diffusion B. Osmosis C. Active transport D. Filtration

a nurse is inspecting a client's IV catheter insertion site and notes a hematoma. which of the following actions should the nurse take? (select all that apply) a. stop the infusion b. apply alcohol to the insertion site c. apply warm compresses to the insertion site d. elevate the clients arm e. obtain a specimen for culture at the insertion site

C, D

A nurse is monitoring a client who began receiving a unit of packed RBC's 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion? (Select all that apply) a. Temperature change from 37C (98.6 F) pretransfusion to 37.2C (99.0 F) b. BP 178/90 mmHg c. HR change from 88/min pretransfusion to 120/min d. Client reports of itching e. Flushed appearance

C, E

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assign to the room closest to the nurse's station? a. A middle adult who is postoperative following a laparoscopic cholecystectomy b. A middle adult who requires telemetry for a possible myocardial infarction c. A young adult who is postoperative following an open reduction internal fixation of the ankle d. An older adult who is postoperative following a below the knee amputation

A home health nurse is discussing the dangers of carbon monoxide poisons with a client. Which of the following information should the nurse include in her counseling? a. Carbon monoxide has a distinct odor b. Water heaters should be inspected every 5 years c. The lungs are damaged from the carbon monoxide inhalation d. Carbon monoxide binds with the hemoglobin in the body

A newly licensed nurse is assisting the charge nurse with the administration of a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates understanding of the procedure? a. Ensures the insertion of an 18 gauge IV catheter in the client b. Verifies blood compatibility and expiration date of the blood with another PN c. Ensures the administration of dextrose 5% in 0.9% NaCl IV with the transfusion d. Obtains vital signs every 15 minutes throughout the procedure

A nurse educator is conducting a parenting class for new parents of infants. Which of the following statements made by participants indicated understanding of the instructions? a. "I will set my water heater to 130 F." b. "Once my baby can sit up he should be safe in the bathtub." c. "I will place my baby on his stomach to sleep." d. "Once my infant starts to push up, I will remove the mobile from over the crib."

A nurse in an acute mental health facility is communicating with a client. The client states, "I can't sleep. I stay up all night." The nurse responds, "You are having difficulty sleeping?" which of the following therapeutic communication techniques is the nurse demonstrating? A. Offering general leads B. Summarizing C. Focusing D. Restating

A nurse is caring for a client who is sitting in a chair and asks to return to the bed. Which of the following actions is the nurse's priority at this time? a. Obtain a walker for the client to use to transfer back to the bed b. Call for additional staff to assist with the transfer c. Use a transfer belt and assist the client back into bed d. Determine the client's ability to help with the transfer

A nurse is caring for an older adult client in a long-term care facility who is dehydrated. Which of the following actions should the nurse take? a. Initiate fluid restriction to limit the client's intake b. Observe for indications of peripheral edema c. Encourage the client to promote oxygenation by ambulating d. Monitor for orthostatic hypotension

A nurse is caring for the parents of a child who has demonstrated recent changes in behavior and mood. When the mother of the child asks the nurse for reassurance about her son's condition, which of the following responses should the nurse make? a. "I think your son is getting better. What have you noticed?" b. "I'm sure everything will be okay. It just takes time to heal." c. "I'm not sure what's wrong. Have you asked the doctor about your concerns?" d. "I understand you're concerned. Let's discuss what concerns you specifically."

A nurse is checking the ABG results for a client who has vomited repeatedly for the past 24 hours. Which of the following acid-base imbalances should the nurse expect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

A nurse working in a free clinic has recognized that health promotion for teenagers who are pregnant is needed. The nurse works to develop a team of health care experts in several disciplines from across the region to work toward improving the nutrition of pregnant teenagers. This is an example of what type of collaboration? A. Nurse-patient collaboration B. Nurse-nurse collaboration C. Intraprofessional collaboration D. Interorganizational collaboration

A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? a. "I should drink a lot of tap water today." b. "I need to take more calcium tablets today." c. "I should avoid fruits with potassium in them." d. "I need to drink liquids with some sodium in them."

A patient has end-stage chronic obstructive pulmonary disease (COPD). Which acid-base imbalance would be predictable in a patient with COPD? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Respiratory acidosis

A patient may protect oneself from radiation by: A. wearing a device to deflect the radiation. B. taking special medication to decrease exposure. C. limiting exposure to family/friends who have had radiation. D. decreasing the amount of time near a source.

A patient reports that his chest hurts. The nurse asks where exactly it hurts. This is an example of what type of active listening behavior? a. Summarizing b. Reflection c. Restating d. Clarification

A student nurse receives an order for diazepam to be given intravenously. Diazepam tablets are available. The student nurse crushes a tablet and mixes it with sterile water for injection. The instructor notes that the solution is cloudy and asks to see the medication vial. When the student produces the vial of sterile water for injection and the instructor stops the medication from being given, what type of error is prevented? A. Communication error B. Diagnostic error C. Preventive error D. Treatment error

Active listening includes: A. three senses, which are sight, hearing, and touch. B. closed body posture. C. only verbal messages. D. focused energy.

An 82-year-old patient is admitted to the unit with a temperature of 100.2° F, urine specific gravity (SG) of 1.032, and dry tongue. The nurse should recognize which to be the most critical aspect of the plan of care? A. A diuretic B. An antibiotic C. An antipyretic D. IV solution

During new employee orientation, a nurse is explaining how to prevent IV infections. Which of the following statements by an orientee indicates understanding of the preventative strategies? a. "I will leave the IV catheter in place after the client completes the course of the IV antibiotics" b. "as long as I am working with the same client, I can use the same IV catheter for my second insertion attempt" c. "If my client needs to use the restroom, it would be safer to discontinue the IV infusion as long as I clean the injection port thoroughly with an antiseptic swab" d. "I will replace any IV catheter when I suspect contamination during insertion"

The nurse is assessing a patient who was admitted for dehydration. Which assessment finding is an indication that the dehydration is resolving? A. Loose skin B. Sunken eyes C. 1200 mL urine output D. Moist mucous membranes

The thirst mechanism is located in the: A.adrenal gland. B. cerebral cortex. C. pituitary gland. D. hypothalamus.

To address administrative concerns about the effectiveness of staff nurses related to patient education, what is the nurse manager's first action? a. Assign one nurse to teach patients. b. Organize patient teaching resources. c. Post a teaching outline in the lounge. d. Survey nurses about patient teaching.

To understand what type of fluid a patient needs, the LPN/LVN should understand that the term semipermeable membrane indicates that: A. the membrane is only a temporary structure. B. only electrically charged particles may pass through the membrane. C. the membrane does not allow for the passage of anything but water. D. the membrane allows some particles to pass through and prohibits the passage of others.

What is the primary reason for basic male/female differences in communication? a. Socialization b. Environment c. Acculturation d. Biology

When a patient tells the nurse about plans to do research about the patient's diagnosis and potential treatment on the Internet, what is the nurse's most appropriate initial response? a. Discount the reliability of the Internet. b. Evaluate the patient's computer competency. c. Provide a list of recommended sources. d. Teach about evaluation of Internet resources

When should a nurse make a bed with the patient in the bed? A. Patient leaving for a procedure B. Patient with visitors C. Patient with an amputation D. Patient on bed rest

Which is a true cultural statement? A. Touch is common in Japanese culture. B. Jamaicans expect direct eye contact with any interaction. C. African Americans believe maintaining silence in a conversation means "no." D. Native Americans may use long pauses in conversation.

Which may cause hyperkalemia? A. Blood transfusion B. Diaphoresis C. Diarrhea D. Renal failure

Which patient is at highest risk for dehydration? A. Infant who has a high fever B. Teenager who has intentionally limited fluid intake to avoid weight gain C. Young patient with diarrhea D. Elderly patient with fever and persistent nausea and vomiting (N&V)

Which technique is used when a nurse asks a patient, "Tell me how your night was?" A. Clarifying B. Offering of self C. Summarizing D. General lead

a nurse is collecting data from a client who is receiving IV therapy and reports pain in his arm, chills, and "not feeling well." The nurse notes warmth, edema, induration, and red streaking on the clients arm close to the IV insertion site. Which of the following actions should the nurse plan to take first?

A nurse is assisting in conducting a class in therapeutic communication to a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication? a. Personal space b. Posture c. Eye contact d. Intonation

D (tone of ones voice)

a nurse is caring for a child who just experienced a generalized seizure. which of the following is the priority action for the nurse to take? a. maintain the child in a side lying position b. check to see if the child bit his tongue c. reorient the child to the environment d. document the time and characteristics if the childs seizures

a the greatest risk right now is aspiration, so keeping the child side laying is the priority

you observe an older adult patient with pneumonia for early signs of hypoxia. you know that the first signs of hypoxia are: select all that apply a. increasing irritability or restlessness b. increased respiratory rate c. cyanosis of the nailbeds of the fingers d. retraction of the muscles in breathing e. cyanosis around the lips

a, b Early signs of hypoxia include tachypnea, restlessness, irritability, and confusion. Cyanosis and muscle retraction are late signs of hypoxia.

a nurse is teaching a community program on nutritional guidelines for cancer prevention. which of the following instructions should the nurse include? select all that apply a. eat foods high in vitamin a b. add cruciferous vegetables c. increase intake of red meats d. use saturated cooking oil e. consume refined grains

a, b consuming foods high in vitamin a such as apricots, carrots, and leafy green vegetables reduces the risk of cancer, and consuming cruciferous vegetables such as broccoli and cabbage, reduces the risk of cancer. increasing consumption of red meat increases the risk of cancer. using polyunsaturated and monounsaturated fats reduces the risk of cancer. consuming whole grains reduces the risk of colon cancer

the classic signs of increased ICP include which of the following? select all that apply a. rising systolic BP b. widening pulse pressure c. bradycardia d. positive babinski sign

a, b, c These are the classic signs of increased intracranial pressure (Cushing Triad). (D) Babinski sign indicates CNS damage.

a nurse is planning care to create dietary guidelines for a client who has type 2 DM. which of the following information should the nurse include in the dietary plan? (select all that apply) a. weight management b. lipid profile c. cultural needs d. sleep patterns e. personal preferences

a, b, c, e weight management, lipid profile, cultural needs, and preferences should be included in the teaching session

a nurse is assisting in planning care for a client who has myxedema coma. which of the following actions should the nurse include? (select all that apply) a. monitor daily weights b. observe for evidence of urinary tract infection c. record I&O d. initiate aspiration precautions e. provide warmth using a heating pad

a, b, c,d monitor weight for effective therapy, any infection can precipitate myxedema coma, I&O record can be an indication of effective therapy, and the nurse should initiate aspiration precautions

a nurse is preparing to receive a client from the PACU who is postoperative from a thyroidectomy. the nurse should ensure that which of the following equipment is available? (select all that apply) a. suction equipment b. humidified oxygen c. flashlight d. tracheostomy tray e. chest tube tray

a, b, d the client could need oral or trach suctioning, supplemental oxygen, and experience airway obstruction, which is why you need a tracheostomy tray at the bedside

a nurse is assisting with the admission data collection of a patient who has pulmonary edema. which of the following manifestations are expected findings? select all that apply a. tachypnea b. persistent cough c. increased urinary output d. thick yellow sputum e. orthopnea

a, b, e tachypnea, cough with pink, frothy sputum, and orthopnea are all manifestations of pulmonary edema

a nurse is assisting with health screenings at a health fair. the nurse should identify that which of the following clients are at risk for osteoporosis? (select all that apply) a. 40 year old client who takes prednisone for asthma attacks b. 30 year old client who jogs 3 miles a day c. 45 year old client who takes phenytoin for seizures d. 65 year old client who has a sedentary lifestyle e. 70 year old client who has smoked for 50 years

a, c, d, e prednisone affects calcium absorption, phenytoin affects the absorption of calcium, a sedentary lifestyle puts the person at risk for osteoporosis because of non-weight bearing, smoking increases the risk because it decreases osteogenesis

during a routine checkup, the HCP tells a patient with diabetes that the test results reveal albuminuria. which long term complication is specific to this test result? a. metabolic syndrome b. neuropathy c. retinopathy d. peripheral vascular disease

b Albuminuria indicates that protein is passing into the urine because the filtering mechanism of the kidney has sustained damage from filtering blood with elevated glucose. The other complications are likely to be simultaneously occurring over time because of the damage to blood vessels and other organs.

a 35 year old woman reports episodes if emotional extremes with uncontrollable crying and depression followed by intense physical activity and euphoria. she complains of drying of the eyes and difficulty swallowing. her symptoms confirm a nursing problem of altered coping. what is the cause of this diagnosis? a. parathyroid hormone deficiency b. excessive thyroid hormone secretion c. deficient estrogen production d. growth hormone deficiency

b Patient has symptoms of hyperthyroidism. Parathyroid hormone is primarily involved with calcium regulation. Estrogen is associated with the female reproductive organs; changes in estrogen levels could contribute to mood but not the other symptoms. Growth hormone is responsible for tissue growth.

a nurse in an outpatient clinic is reinforcing teaching to a client who has a new prescription for erythropoietin. which of the following statements should the nurse make? a. you will need an erythrocyte sedimentation rate (ESR) test weekly b. you should have your hemoglobin level checked twice per week c. your oxygen saturation levels should be monitored d. your folic acid production will increase

b hbg and hct are monitored to see the effectiveness of the erythropoietin. ESR test detects inflammation, the bp needs to be monitored not the oxygen levels, and this medication increases rbcs

a nurse is talking with a client who reports constipation. when the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. macaroni and cheese b. fresh fruit and whole toast c. bread pudding and yogurt d. roast chicken and white rice

b high fiber diet promotes bowel elimination, fruits and veggies with whole grain carbs provide the highest amount of fiber

a nurse is reviewing information about capsaicin cream with a client who reports continuous knee pain from osteoarthritis. which of the following information should the nurse reinforce? a. continuous pain relief is provided b. inspect for skin irritation and cuts prior to application c. cover the area with tight bandages after application d. apply the medication every 2 hours during the day

b if there are cuts in the skin the hot peppers in the cream will cause burning in the areas of skin breakdown. capsaicin cream is a temporary pain relief, covering the skin with a bandage after application could lead to skin irritation, and you can only apply capsaicin cream up to 4 times a day

a nurse is caring for a client who has MS. which of the following findings should the nurse expect? a. fluctuations in BP b. loss of cognitive function c. ineffective cough d. drooping eyelids

b loss of cognitive function is a manifestation of MS. the other options are manifestations to amyotrophic lateral sclerosis

a nurse is conducting chart reviews of multiple clients at a mental health facility. which of the following events should the nurse identify as an example of a maturational crisis? a. rape b. marriage c. physical illness d. job loss

b marriage is a naturally occurring event in life that occurs in the lifetime. rape is an adventitious crisis. severe physical illness and loss of a job are situational crisis.

a nurse is reinforcing teaching with a client who is to have nuclear imaging for suspected cancer. which of the following statements should the nurse make? a. the test will identify the presence of liver enzymes b. you will be given an injection of a radioactive substance during the test c. insertion of an endoscope through your mouth will occur during the test d. aspiration of the tumor will be part of the imaging test

b nuclear imaging requires the administration of an oral or IV radioactive tracer to detect cancerous tissue. liver enzyme test, endoscopy, and needle biopsy are not nuclear imaging.

a client is admitted into the ED and a diagnosis of myxedema coma is made. which action should the nurse prepare to carry out initially? a. warm the client b. maintain a patient airway c. monitor IV fluids d. administer thyroid hormone

b the initial action should be to maintain airway

while obtaining sputum for culture and sensitivity, the nurse notes that the specimen is thick, tenacious, and "ropey." this finding is most likely to be present in which disorder? a. pneumococcal pneumonia b. pulmonary edema c. chronic bronchitis d. tuberculosis

a nurse is reinforcing discharge instructions with a female client who has a prescription for phenytoin. which of the following information should the nurse include? a. consider taking oral contraceptives when on this medication b. watch for receding gums when taking medication c. take the medication at the same time everyday d. provide a urine specimen to determine therapeutic levels of the medication

c the client should take phenytoin at the same time everyday to enhance effectiveness

a nurse is caring for a client who has been sitting in a chair for 1 hour. which of the following complications is the greatest risk for the patient? a. decreased subcutaneous fat b. muscle atrophy c. pressure ulcer d. fecal impaction

c the greatest risk for this client is injury from skin breakdown due to unrelieved pressure over a bony prominence for prolonged time sitting in a chair.

a nurse is assisting with the care of a client who is admitted to the ED with a BP of 266/147 mmHg. the client reports a headache and double vision. the client reports running out of diltiazem 3 days ago, and inability to purchase for more. which of the following actions should the nurse take? a. administer acetaminophen for headache b. reinforce teaching regarding the importance of not abruptly stopping an antihypertensive c. obtain IV access and ask the charge nurse to administer an IV hypertensive d. call social services for a referral for financial assistance in obtaining prescribed medication

c the main concern is getting the BP down so administering a BP lowering agent immediately. IV acts faster than oral medications

A health care issue often becomes an ethical dilemma because: A A clients legal rights coexist with a health professionals obligation B Decisions must be made quickly, often under stressful conditions C Decisions must be made based on value systems D The choices involved do not appear to be clearly right or wrong

a patient who works as a personal trainer is diagnosed with insulin dependent diabetes. what should the nurse teach regarding to self administration of regular insulin? a. if you have a strenuous workout, skip your insulin for the day b. inject insulin before moderate exercise c. exercise during the insulin peak of action d. use the abdomen as an injection site

d The abdomen is a good site for insulin injection as absorption is steady, rapid, and not affected by exercise. Do not encourage the patient to skip insulin doses. Diabetics must learn to balance their nutrition, exercise, and insulin doses. Instruct the patient to eat a light snack before exercising. Depending on the type of insulin and the onset of action, injecting the insulin before exercise may cause a hypoglycemic reaction. Exercising during the peak of insulin will increase the chances of hypoglycemia.

d this position opens up the spaces between the vertebrae.

the provider explains the treatment options to a hispanic woman diagnosed with occlusion of multiple coronary vessels. before signing an informed consent, the patient is most likely to defer her health care decision to her: a. oldest adult son b. oldest adult daughter c. brother-in-law d. husband

d A Hispanic female traditionally within the culture will seek and follow her husband's wishes. Other relatives will not be involved in the decision, although male relatives may be consulted. This question requires applying knowledge of cultures learned in the Fundamentals of Nursing course and applying that knowledge to issues with the cardiac system.

a nurse feels that there may be a need to administer ordered medication to an older adult for anxiety. which strategy would help the nurse make this clinical decision? a. listen to verbalization of apprehension b. be sensitive to somatic complaints c. initiate therapeutic communication d. observe for escalation of agitation

d Escalation of agitation is a sign that medication is necessary. Listening to verbalization of apprehension in itself will not help make this clinical decision. Listening to somatic complaints may temporarily give the patient a sense of gratification, but the long-term goal for patients with somatic complaints may be better served by setting limits. The nurse would use listening and therapeutic communication as the first-line intervention to try and help the patient gain self-control without medication; the nurse then observes to see if these measures are working.

which patient statement indicates a need for further teaching regarding the prevention of seizures? a. i need to avoid situations that could potentially trigger a seizure b. alcohol can lower the seizure threshhold c. i must avoid becoming overly fatigued and should pace activities d. i am less likely to have seizures during menstruation

d Menstruation is a time when a seizure is more likely in women. Avoiding seizure triggers is appropriate. Alcohol does lower the seizure threshold. Work and leisure activities should allow for plenty of rest so that the patient does not become unduly fatigued, which can lead to a seizure.

the nurse is assigned care for a client who has a chest tube. the nurse is told to monitor the client for crepitus (subcutaneous emphysema). which method should be used to monitor the client for crepitus? a. asking about pain b. checking the respirations hourly c. checking the BP every 2 hours d. palpating for the leakage of air into the subcutaneous tissues

d crepitus is caused by air entering the subcutaneous tissues

the client with a cervical spine injury has crutchfield tongs applied in the ED. the nurse should perform which essential action when caring for this client? a. providing a standard bedframe b. removing the weights to reposition the client c. removing the weights if the client is uncomfortable d. comparing the amount of prescribed weights with the amount is use

d crutchfield tongs are applied after drilling holes in the clients skull under local anesthesia, weights are added to the tongs to align the cervical spine

a nurse is preparing to perform a peripheral vision test on a child. which of the following actions should the nurse take? a. place the child 10 feet away from a snellen chart b. show a set of cards to a child at a time c. cover the childs eyes while performing the test on the other eye d. have the child focus on an object while performing the test

when performing a peripheral vision test on a child use an object like a pencil and bring it into the childs peripheral vision. a child goes 10 feet away from a snellen chart. only give one card at a time when doing the color test. the nurse only covers a childs eye when doing a cover test

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect to find which of the following? (Select all that apply) a. Distended neck veins b. Hyperthermia c. Tachycardia d. Syncope e. Decreased skin turgor

C, D, E

respect for an individuals right to self-determination

autonomy

A nurse is preparing to administer acetaminophen 320 mg PO every 4 hr PRN for pain. The amount available is liquid 160 mg/5 mL. How many mL should the nurse administer per dose?

10 mL

A nurse is preparing to administer dextrose 5% in water (D5W) 1000 mL IV to infuse over 10 hours. The nurse should set the IV infusion pump to deliver how many mL/hr?

100 mL/hr

A nurse is observing a newly licensed nurse and an assistive personnel pull a client up in bed using a draw sheet. Which of the following actions by the newly licensed nurse indicated understanding of this technique? a. The nurse stands with her feet together b. The nurse uses his body weight to counter the clients weight c. The nurses feet are facing inward, toward the center of the bed d. The nurse uses the muscles in his back to lift the client off the bed using the draw sheet

A nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? A. "I will place the client on his side." B. "I will go to the nurse's station for assistance." C. "I will administer his medication." D. "I will prepare to insert an airway."

A nurse is completing discharge instructions to a client who has COPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing? a. Lie on her back with her head and shoulders on a pillow b. Lie flat on her stomach with her head to one side c. Sit on the side of her bed and rest her arms on top of her bedside table d. Lie on her side with her weight on her hip and shoulder with her arm flexed in front of her

A nurse tells a patient "Don't worry, everything will be fine." This is an example of what type of blocked communication? A. Inattentive listening B. Changing the subject C. Offering false reassurance D. Giving information

A nurse is discussing the characteristics of a nurse client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include? (Select all that apply) a. Needs of both participants are met b. An emotional commitment exists between the participants c. It is goal directed d. Behavioral change is encouraged e. A termination date is established

C, D, E

oral iron supplements are prescribed for a 6 year old child with iron deficiency anemia. the nurse reinforces instructions to the mother and tells the mother to administer the iron with which best food item? a. milk b. water c. apple juice d. orange juice

d vitamin c increases the absorption of iron by the body.

when the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 DM. which statement by the client would indicate that teaching has been effective? a. "i will stop taking my insulin if i am too sick to eat" b. "i will decrease my insulin dose during times of illness" c. "i will adjust my insulin dose according to the level of glucose in my urine" d. "i will notify my HCP if my blood glucose level is consistently greater than 250 mg/dL"

4 during illness you should monitor the blood glucose level. and notify the HCP if the level is over 250 mg/dL. insulin should never be stopped. it may need to be increased during times of illness

A nurse educator is presenting a module on basic first aid for a newly licensed home health nurses. The nurse educator evaluates the teaching as effective when the newly licensed nurse states the client who has heat stroke will have which of the following? a. Hypotension b. Bradycardia c. Clammy skin d. Bradypnea

A nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? a. Complete a fall risk assessment b. Educate the client and family about fall risks c. Eliminate the safety hazards from the client's environment d. Make sure the client uses assistive aids in his possession

A nurse is caring for a client who has a serum sodium level of 133 mEq/L. Which of the following treatments is a risk factor for these laboratory findings? a Three tap water enemas b 0.9% NaCl IV c Dextrose 5% in water with 20 mEq of K+ IV d Spironolactone therapy

A nurse is caring for a client who has diabetes mellitus and had a morning blood glucose level of 285 mg/Dl. An assistive personnel reports that a client's finger-stick blood glucose reading 30 minutes before lunch is 58 mg/Dl. Which of the following actions should the nurse take? a. Recheck the clients blood glucose b. Complete a facility incident report c. Inform the AP to give the client 120 ml of orange juice d. Administer insulin as prescribed

A nurse is caring for a client who is receiving TPN through a central line, but the next bag of solution is not available for administration at this time. Which of the following is an appropriate action by the nurse? a. Administer 20% dextrose in water IV until the next bag is available b. Slow the infusion rate of the current bag until the solution is available c. Monitor for hypoglycemia d. Monitor for hyperosmolar diuresis

A nurse is caring for a client who was in a motor vehicle accident. The client reports chest pain and difficulty breathing. A chest x-ray indicates that the client has a pneumothorax. Which of the following ABG results should the nurse expect? a. pH 7.06; PaCO2 52 mmHg; HCO3 24 mEq/L b. pH 7.42; PaCO2 38 mmHg; HCO3 23 mEq/L c. pH 7.20; PaCO2 39 mmHg; HCO3 18 mEq/L d. pH 7.58; PaCO2 38 mmHg; HCO3 29 mEq/L

A nurse is collecting data from a client who has hyperkalemia. Which of the following disorders is a risk factor for this electrolyte imbalance? A DKA B Heart failure C Aldosterone excess D Excessive sweating

A nurse is communicating with a client who was just admitted for treatment for a substance disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication? a. Offering advice b. Reflecting c. Listening attentively d. Giving information

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? a Infuse hypotonic IV fluids b Implement a fluid restriction c Increase sodium intake d Administer sodium polystyrene sulfonate

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as risk factors for the development of this electrolyte imbalance? a. Crohn's disease b. Postoperative following appendectomy c. History of bone cancer d. Hyperthyroidism

A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a A client who has nasogastric suctioning b A client who has chronic constipation c A client who has syndrome of inappropriate antidiuretic hormone d A client who took an overdose of sodium bicarbonate antacids

A nurse us caring for a client who has metabolic acidosis. Which of the following components of the clients medical history should the nurse identify as a risk factor for this acid-base imbalance? a. DKA b. Sleep apnea c. Asthma d. Pulmonary edema

A nursing intervention for a patient with a protective device is: A. Secure the ties of a protective device to a movable part of the bed frame. B. Use a complete bow knot to secure the device to the bed frame or chair. C. Remove the device every shift. D. Check the area distal to the device every 60 minutes.

A patient does not make eye contact with the nurse and is folding his arms at his chest. Which aspect of communication has the nurse assessed? A. Nonverbal communication B. A message filter C. A cultural barrier D. Social skills

A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? a. Lethargy and constipation from hypercalcemia b. Positive Trousseau's sign from hypercalcemia c. Lethargy and constipation from hypocalcemia d. Positive Trousseau's sign from hypocalcemia

Formal patient education courses or classes would be the most appropriate strategy in which situation? a. Address needs common to a group. b. Explain self-directed learning. c. Describe nursing interventions. d. Respond to questions of a patient's family.

The nurse observes a patient who has periods of fast, deep respirations alternating with periods of apnea. What term best describes this pattern? a. Cheyne-Stokes b. Hyperventilation c. Kussmaul d. Tachypnea

The patient has severe metabolic alkalosis. Which intervention has the highest priority? a. Raise the side rails on the patient's bed. b. Measure the urine output and skin turgor. c. Teach the family about metabolic alkalosis. d. Administer intravenous NaHCO3 as ordered.

To promote safety, the nurse manager sensitive to point-of-care (sharp-end) and systems-level (blunt-end) exemplars works closely with administrators to address which organizational system exemplar? A. Care coordination B. Communication C. Diagnostic workup D. Fall prevention

A nurse is reinforcing discharge teaching with a client who has a gastrectomy due to stomach cancer. Which of the following statements should the nurse make? (Select all that apply) a. "You will need a monthly injection of vitamin B12 for the rest of your life" b. "Using the nasal spray form of vit b12 on a daily basis on a daily basis can be an option" c. "An oral supplement of vit b12 on a daily basis can be an option" d. "You should increase intake of animal proteins, legumes, and dairy products to increase vit b12 in your diet" e. "Add soy milk fortified with vit b12to your diet to decrease the risk of pernicious anemia"

A, B

A nurse is contributing to the plan of care for a client who has a hbg of 7.5 g/dL and a hct of 21.5%. which of the following interventions should the nurse include? (Select all that apply) a. Provide assistance with ambulation b. Monitor oxygen saturation c. Weigh the client weekly d. Obtain a stool specimen for occult blood e. Schedule daily rest periods

A, B, D, E

A nurse is observing an older adult client who is receiving packed RBC's. Which of the following findings should the nurse identify and fluid volume excess and report to the charge nurse? (Select all that apply) a. Dyspnea b. Edema c. Bradycardia d. Hypertension e. Weakness

A, B, D, E

A nurse is planning care for a client who has a new prescription for peripheral parenteral nutrition (PPN). Which of the following actions should the nurse include in the plan of care? (Select all that apply) a. Examine trends in weight loss b. Review prealbumin finding c. Administer an IV solution of 20% dextrose d. Add a micron filter to IV tubing e. Use an IV infusion pump

A, B, D, E

The nurse at a university health center leads a dialogue with female freshmen about rape and sexual assault. One student says, "If I avoid strangers or situations where I am alone outside at night, I'll be safe from sexual attacks." Choose the nurse's best response. a. "Your plan is not adequate. You could still be raped or sexually assaulted." b. "I am glad you have this excellent safety plan. Would others like to comment?" c. "It's better to walk with someone or call security when you enter or leave a building." d. "Sexual assaults are more often perpetrated by acquaintances. Let's discuss ways to prevent that."

ANS: D Females know their offenders in almost 70% of all violent crimes committed against them, including rape. The nurse should share this information along with encouraging discussion of safety measures. The distracters fail to provide adequate information or encourage discussion.

A nurse on a medical- surgical unit is caring for a group of clients. For which of the following clients should the nurse anticipate a prescription for fluid restriction? a. A client who has a new diagnosis of adrenal insufficiency b. A client who has heart failure c. A client who is receiving treatment for DKA d. A client who has abdominal ascites

A nurse tells a depressed patient that all depressed people feel the same way. This is an example of what type of communication block? a. False reassurance b. Pat answers c. Chiding d. Belittling

A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? a. Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. b. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. c. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. d. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.

A patient states that everything has been going great; however, the nurse observes the patient biting his nails and fidgeting. What type of communication does the nurse recognize from the patient's actions and statements? A. Linguistic B. Paralinguistic C. Explicit D. Inadequate

Which of the following strategies should a nurse use to establish a helping relationship with a client? a. Make sure the communication is equally reciprocal between the nurse and the client b. Encourage the client to communicate his thoughts and feelings c. Give the nurse-client communication no time limits d. Allow communication to occur spontaneously throughout the nurse-client relationship

Which statement is true regarding the use of silence in communication? A. The nurse passively waits for the patient to speak. B. Silence is a difficult technique to develop. C. Silence causes uneasiness in the patient. D. Silence is not a therapeutic communication technique.

Which statement most accurately reflects a nursing communication difference that was age related? a. Speaking in a loud, high voice makes it easier for an elderly patient to hear you b. Discussing with school aged patients their illness in age appropriate terms c. Giving a toddler who Is having a tantrum a special treat d. Using medical jargon and current slang to help a teenager to see you as human

a nurse is assisting with the administration of a unit of packed RBC's to a client who has a Hbg of 8 g/dL. Which of the following actions should the nurse take during the first 15 minutes of the transfusion? a. Verify the client have given informed consent for the transfusion b. Monitor for an acute hemolytic reaction c. Explain the transfusion procedure to the client d. Obtain blood culture specimens and send to the lab

A bioethical issue should be described as: A The physician's making all decisions of client management without getting input from the client B A research project that included treating all the white men and not treating all the black men to compare the outcomes of a specific drug therapy. C The withholding of food and treatment at the request of the client in a written advance directive given before a client acquired permanent brain damage from an accident. D After the client gives permission, the physician's disclosing all information to the family for their support in the management of the client.

B (The ethical issue was the inequality of treatment based strictly upon racial differences. Secondly, the drug was deliberately withheld even after results showed that the drug was working to cure the disease process in the white men for many years. So after many years, the black men were still not treated despite the outcome of the research process that showed the drug to be effective in controlling the disease early in the beginning of the research project. Therefore harm was done. Nonmaleficence, veracity, and justice were not followed.)

A nurse receives a laboratory report for a client indication a potassium level of 5.2 mEq/L. when notifying the provider, the nurse should anticipate which of the following actions? a. Starting an IV infusion of 0.9% NaCl b. Consulting with the dietician to increase intake of potassium c. Initiating continuous cardiac monitoring d. Prepare the client for gastric lavage

Which of the following is an example of one-way communication? a. "You are telling me you have pain. Where is your pain and when did it start?" b. A nurse educates and clarifies medication instructions with a patient c. "Give me your arm. I'm going to take your blood pressure." d. A nurse repeats a physician's order back to the physician for accuracy

Which type of fire extinguisher is used for electrical fires? A. Type A B. Type B C. Type C D. Type D

a nurse is preparing to initiate IV therapy for an older adult client. which of the following actions should the nurse plan to take? a. use a disposable razor to remove excess hair on the extremity b. select the back of the client's hand to insert the IV catheter c. distend the veins by using a BP cuff d. direct the client to raise his arm above his heart

The distribution of nurses to areas of "most need" in the time of a nursing shortage is an example of: A Utilitarianism theory B Deontological theory C Justice D Beneficence

C (Justice is defined as the fairness of distribution of resources. However, guidelines for a hierarchy of needs have been established, such as with organ transplantation. Nurses are moved to areas of greatest need when shortages occur on the floors. No floor is left without staff, and another floor that had five staff will give up two to go help the floor that had no staff.)

In most ethical dilemmas, the solution to the dilemma requires negotiation among members of the health care team. The nurse's point of view is valuable because: A Nurses have a legal license that encourages their presence during ethical discussions. B The principle of autonomy guides all participants to respect their own self-worth C Nurses develop a relationship to the client that is unique among all professional health care providers D The nurse's code of ethics recommends that a nurse be present at any ethical discussion about client care

C (When ethical dilemmas arise, the nurses point of view unique and critical. The nurse usually interacts with clients over longer time intervals than do other disciples.)

Marty has arrived for her first clinical experience in the nursing home. She wants to do everything right and feels she is ready because she has an elderly grandmother. What tips will you give her for getting acquainted with the residents? (Select all that apply) a. Walk in with great enthusiasm and say, "Hi grandma, how are you doing?" b. Talk loudly in the residents left ear to be sure the resident can hear her c. Say, "Good morning. My name is Latoya. I am a student nurse from the college. Can you confirm your name and date of birth?" d. Knock on the door before entering. Take time before moving into the patients personal space. e. Quietly enter the patients room and touch the person's shoulder while saying "hello"

C, D

A nurse is caring for a client who fell at a nursing home. The client Is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply) A. Place a belt restraint on the client when he is sitting on the commode B. Keep the bed in its lowest position with all side rails up C. Make sure that the client's call light is within reach D. Provide the client with nonskid footwear E. Complete a fall risk assessment

C, D, E

A nurse is caring for a client who is concerned about his impending discharge to home with a new colostomy because he is an avid swimmer. Which of the following statements should the nurse make? (Select all that apply) a. "You will do great! You just have to get used to it" b. "Why are you worried about going home?" c. "Your daily routines will be different when you get home" d. "Tell me about your support system you'll have after you leave the hospital" e. "Let me tell you about a friend of mine with a colostomy who also enjoys swimming"

C, D, E

A nurse is reviewing the hospital's fire safety policies and procedures with newly hired assistive personnel. The nurse is describing what to do when there is a fire in a client's trash can. Which of the following information should the nurse include? (Select all that apply) a. The first step is to pull the alarm b. Use a class C fire extinguisher to put out the fire c. Instruct ambulatory clients to evacuate to a safe place d. Pull the pin on the fire extinguisher prior to use e. Close all doors

C, D, E

The nurse is admitting a new patient to the psychiatric unit. Which factors will most likely contribute to a positive outcome of the interaction? Select all that apply. A. The patient is in a bad mood. B. The patient states that he or she is in pain. C. The unit is quiet. D. The patient has been admitted to the facility in the past. E. The patient is awake, alert, and oriented to person, place, and time. F. There are various interactive sessions going on in the unit today.

C, D, E

A nurse is collecting data from a client who is dehydrated due to fluid volume deficit. Which of the following findings should the nurse expect? a. Moist skin b. Distended neck veins c. Increased urinary output d. Thready pulses

a nurse manager is reviewing the facility's policies for IV therapy with the members of the team. the nurse manager should remind the team that which fo the following techniques helps minimize the rick of catheter embolism? a. performing hand hygeine before and after IV insertion b. rotating IV sites atleast every 72 hours c. minimizing tourniquet time d. avoiding reinserting the needle into the catheter

the nursing assistant tells you that a patient with diabetes has a blood glucose level of 60 mg/dL. what symptoms would the nurse be most likely to observe with the glucose level? a. confusion, tremulousness, pallor, sweating, and weakness b. dry, flushed skin, and mild irritability c. deep, rapid breathing, and abdominal pain d. incoherent moaning, combativeness, and seizure activity

a Confusion, tremulousness, pallor, sweating, and weakness are the most likely symptoms. Incoherent moaning, combativeness, and seizure activity might occur if the nurse fails to intervene quickly. Dry, flushed skin is symptomatic of hyperglycemia. Irritability could be present to high or low glucose levels. Deep rapid breathing and abdominal pain are signs of hyperglycemia.

which statement by a high school athlete being discharged after experiencing a concussion indicates the need for further teaching? a. i can go to football practice tomorrow b. i need to report a worsening headache to the provider c. ill have to be awakened every few hours when asleep d. i can expect to be more fatigued for a while

a Any patient with a concussion should rest for 48 hours after the injury, and teenagers may take longer. The student may not return to practice or play until a physician's release is obtained. Are commonly recommended practices and indications.

a nurse is reviewing the laboratory findings for a client who might have hyperthyroidism. the nurse should identify that an evaluation on which of the following substances indicates hyperthyroidism? a. triiodothyronine b. plasma free metanephrine c. urine cortisol d. urine osmolality

a increased triiodothyronine (T3) indicated hyperthyroidism

a client who has an indwelling catheter reports a need to urinate. which of the following actions should the nurse take? a. check to see whether the client is patent b. reassure the client that it is not possible for her to urinate c. recatheterize the bladder with a large gauge catheter d. collect a urine specimen for urinalysis

a a clogged or kinked catheter fills the bladder and promotes the need to urinate

The nurse is preparing to care for a patient who requires skeletal traction. The nurse knows which statement is true regarding skeletal traction? a. It has a high risk of infection. b. It is used for only fractures of the lower extremity bones. c. It uses a series of removable pins, ropes, and weights to realign bones. d. It requires nurses to frequently assess and modify the amount of weight applied.

a Because of the pins or wires inserted into the affected bone, risk of infection is high and pin care must be meticulously performed. Skeletal traction does not allow the nurse to modify the amount of weight applied. Skeletal traction is used for the management of musculoskeletal conditions not limited to fractures.

after pacemaker implantation, it is important to teach the patient to: a. stay away from microwave ovens b. count her pulse regularly c. refrain from swimming d. use a safety razor to shave legs

a Cardioversion is the procedure to convert atrial fibrillation SVT or VT with a pulse to a normal sinus rhythm. Defibrillation is used when the heart is fibrillating and there is no R wave with which to synchronize. A pacemaker does not deliver a sufficient electric stimulus to change the rhythm. Electrophysiology studies map where the focus for an aberrant electrical impulse is located that is causing a dysrhythmia.

a 44 year old patient is admitted with a sudden, severe chest tightness unrelieved by rest or nitroglycerin and profuse sweating. which test would exhibit an elevated level only if the patient has had an MI? a. serum troponin b. blood urea nitrogen c. myoglobin level d. prothrombin time

a Elevated serum troponin levels are indicative of myocardial muscle damage from a myocardial infarction (MI). BUN (blood urea nitrogen) is a test for kidney function. The myoglobin level will rise after an MI, but it is not specific for that disorder. It will be elevated with infection and in other disorders. Prothrombin time is a test for blood clotting, not for MI.

a health care provider is preparing to examine the throat of a child diagnosed with acute epiglottitis. a priority nursing responsibility would be to: a. having a tracheostomy tray at the bedside b. immobilize the childs head c. restrain the childs arm d. have oxygen available

a Epiglottitis is a life-threatening medical emergence that involves swelling of the tissues above the vocal cords. This results in narrowing of the airway inlet, with the possibility of total obstruction. The examination blade used during examination of the throat may trigger a laryngospasm and result in sudden respiratory arrest. It is a primary nursing responsibility to be sure there is a tracheotomy set at the bedside before any examination of the throat is attempted.

Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? a. Ketone bodies in the urine b. Blood glucose level of 155 mg/dL c. Pulse rate of 66 beats per minute d. Weight gain of 1 pound over the previous week's weight

a Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency.

which food has been found to reduce cholesterol measures? a. garlic b. onion c. ginger d. nutmeg

a Garlic has proven to be useful in lowering cholesterol. Onions are helpful in controlling diabetes and do help prevent heart disease, but not by lowering cholesterol. Ginger is good for nausea and for digestion, but it does not lower cholesterol. Nutmeg has no effect on cholesterol levels.

instructions for a patient with a slipped disk with acute pain and sciatica should include: a. using ice packs on the area of back pain for 5-10 minutes each hour while awake for the first 48 hours b. resting in bed for 2-3 days and walking every hour even if walking causes more pain c. obtaining a massage each day to loosen the muscle spasms in the back d. not lifting anything heavier than 10 pounds for several weeks

a Ice packs are applied for 5 to 10 minutes at a time each hour for the first 48 hours to reduce muscle spasm in the back. Resting in bed is discouraged. Massage will be painful. The acute pain should to last several weeks.

a 54year old man complains of pain when walking and numbness in his lower extremities. on examination the nurse notes that both extremities are pale and cool to touch. the highest priority nursing diagnosis would be? a. altered peripheral tissue perfusion b. altered activity tolerance c. altered fluid volume d. potential for injury

a Pale, cool extremities with pain and numbness indicate arterial insufficiency. Altered peripheral tissue perfusion is the best nursing diagnosis for this problem. Although there is most likely alteration in activity tolerance, it does not take priority over the nursing diagnosis of altered peripheral tissue perfusion. There is nothing in the data to indicate altered fluid volume. Potential for injury should be included on the nursing care plan, but it is less of a priority than altered peripheral tissue perfusion and is a potential diagnosis rather than an actual diagnosis.

a nurse is caring for a patient who is short of breath. the degree of shortness of breath can be assessed by which of the following? a. ability to speak b. breath sounds c. capnography d. nail bed color

a Patients that are severely short of breath will not be able to speak. The number of words spoken before a breath is needed is a measure of the degree of shortness of breath. Breath sounds and capnography may give information as to the reason for shortness of breath but are not a measure of speech ability. Nail bed color gives data about oxygenation and perfusion.

A patient is experiencing periods of confusion, and the family is concerned. The patient's son asks the nurse for an explanation and recommendation. What is the nurse's best response? a. "Your father may be having mini-strokes; I will notify his physician." b. "Your father is just confused about some things since he is in the hospital." c. "The confusion will pass. Your father just has to get up and move around." d. "Talk with your father about past events, and that will help with the confusion."

a Periods of confusion may be related to mini-strokes, or transient ischemic attacks (TIAs). Confusion during hospitalization does not occur with every patient. Talking with the patient or thinking the confusion may pass is not a viable solution. The patient should be assessed and the reason for the confusion identified.

a nurse is caring for a client who has hypothyroidism. which of the following is associated with the disorder? a. decreased metabolic demand b. weight loss c. increased heart rate d. diarrhea

a a decreased metabolic demand is associated with hypothyroidism

a 40 year old man comes into the clinic and asks for a prostate exam and a PSA test. he states, i know that prostate cancer is the most common cancer in med. i was to start getting screened now and then annually. screening is best for prevention. what should the nurse tell him? a. screening for prostate cancer can begin at age 45 years, depending on the results a screening prevention plan is devised based on risk b. oh you dont need to worry now. prostate screening begins at age 50 then continues annually c. prostate screening is done at the same time as your colon screening at age 50 d. we only check PSA levels now. examinations have been found to be unreliable

a Prostate screening programs are individually designed according to risk stratification. Prostate screening begins at age 45 and is then individually scheduled. PSA levels are not always checked, and examination is done routinely.

A patient on bed rest has been instructed on performing quadriceps setting exercises. What statement by the patient indicates the need for further instruction? a. "I should hold the muscle in contraction for at least a minute." b. "I should release the muscle and count to five before contracting again." c. "The exercises will benefit me most if I perform them three to four times a day." d. "These exercises are good to recondition my muscles in preparation for getting out of bed."

a Quadriceps setting exercises are a helpful tool to recondition the muscles after injury or surgery. The muscle contraction should be "held" for a count of five, not a full minute. The patient would be correct in stating that he should release the muscle and count to five before contracting again, that the most benefit will be obtained from performing them three to four times a day, and that they are good for reconditioning muscles in preparation for getting out of bed.

a nurse is caring for a patient with adrenocortical insufficiency (addison's disease). which set of laboratory values would be the primary interest for this patient? a. serum sodium, WBC count, and blood glucose b. serum calcium, serum phosphate, and vitamin D level c. urine osmolality, plasma osmolality, and urine specific gravity d. serum t4, serum t3, and TSH

a Serum sodium, white blood cell (WBC) count, and blood glucose are of primary concern because insufficient mineralocorticoids and glucocorticoids cause decreased sodium and hypoglycemia. Adrenal insufficiency increases the risk for infection, so monitoring WBC count is necessary. Serum calcium, serum phosphate, and the vitamin D level are more important for patients diagnosed with hyperparathyroidism. Urine osmolality, plasma osmolality, and urine-specific gravity are more relevant to the patient with diabetes insipidus. Serum T4, serum T3, and thyroid-stimulating hormone are relevant to the patient with a thyroid disorder.

a nurse responds to a roadside emergency and finds a middle aged man with pain and tenderness over the left leg. the nurse notes a closed bone deformity with inability to move the leg. while waiting for the paramedics what is the most important nursing action? a. immobilization of the leg b. realigning the bones c. applying warm packs d. elevating the extremity

a The most important action is to immobilize the leg so that bone fragments do not do more tissue damage and so movement doesn't cause increased pain. The nurse must not try to realign the bones. Warm packs are not applied to a fracture and the nurse wouldn't have them in this situation. Elevating the extremity would be helpful if possible after the leg is immobilized.

during initial assessment of an older adult, the nurse finds that the skin appears smooth, shiny, and thinned with little of no hair on the surface. which nursing diagnosis should be on the care plan? a. altered peripheral tissue perfusion b. potential for infection c. acute pain related to decreased perfusion d. fluid volume deficit

a Thinned, smooth shiny skin with no hair often indicates lack of perfusion. Older adults often have thinned skin and less hair, but skin tends to be wrinkled and dry, not shiny. There is no indication that there is any broken skin or other reason to suspect infection at this time. The data presented do not indicate that the patient is experiencing pain. Deficient fluid volume would present with signs of dehydration such as dry, wrinkled skin. These signs are not present.

A patient with diabetes is admitted to the emergency department with complaints of lack of feeling, yet debilitating pain in his legs and feet, constipation, and sexual impotence. These symptoms most closely correlate with which disorder? a. Diabetic neuropathy b. Diabetic retinopathy c. Diabetic ketoacidosis d. Diabetic nephropathy

a When a patient has diabetic neuropathy, the peripheral nerves are affected, causing lack of feeling, yet debilitating pain in the legs and feet, constipation, and sexual impotence. Diabetic retinopathy is visual impairment, including possible blindness, from diabetes. Diabetic ketoacidosis symptoms may be polyuria, fatigue, anorexia, abdominal pain, and a fruity smell to the breath. Diabetic nephropathy occurs from changes in the renal blood circulation.

The nurse is caring for a patient who has experienced a stroke. The nurse has implemented range-of-motion exercises. The nurse recognizes that contractures may begin within what time period? a. 1 week b. 1 month c. 2 weeks d. 24 hours

a When skeletal muscles are not regularly stretched and contracted to their normal limits, they attempt to adapt themselves to this limited use by becoming shorter and less elastic. An "adaptive shortening," or contracture, begins to form within 3 to 7 days after immobilization of a body part, and the process usually is complete in 6 to 8 weeks.

A nurse observes a patient walking in the hall. Which assessment is the nurse able to complete? a. Gait and balance b. Speech and hearing c. Mental alertness d. Ability to follow directions

a When the patient is walking, the nurse is assessing for gait and balance (mobility). Speech, hearing, mental alertness, and the ability to follow directions do not have a bearing on mobility.

the nurse is reinforcing the provider's instructions to an older adult woman who is newly diagnosed with hypertension. the patient does not speak the nurse's language and is legally blind. what is the best nursing action? a. use a certified translator to provide instruction b. speak slowly and use hand motions to describe information c. use a loud voice and speak directly in to the patient's ear d. provide written instruction for the family

a Without a translator, the patient will not understand any instructions. It is important that the translator is certified in medical terminology for the given language. Speaking slowly is important whenever giving instructions, but if the patient does not speak the language of the nurse, she won't understand what is said and hand motions will not help a blind patient. A loud voice, even when spoken in the ear, will not help understanding of a foreign language. The patient needs to understand the instructions; it is helpful for the family to understand the patient's instructions, but this is not the priority in this situation.

the nurse is reinforcing discharge teaching with a client who has cushing's syndrome. which statement by the client indicates the instructions related to dietary management were understood? a. "i can eat foods that contain potassium" b. "i will need to limit the amount of protein in my diet" c. "i am fortunate that i can eat all the salty foods i enjoy" d. "i am fortunate i do not need to follow any special diet"

a a diet low in calories, carbs, and sodium, but ample in protein and potassium content is encouraged with someone with cushing's syndrome

the nurse is told that a client will have a fenestrated tracheostomy tube inserted. the nurse should provide the client with which information about this type of tube? a. enables the client to speak b. prevents the client from speaking c. is necessary for mechanical ventilation d. prevents air from being inhaled through the tracheostomy opening

a a fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx: this type of tube allows the client to speak

a client is being discharged home after application of a plaster leg house. the nurse determines that the client understands proper care of the cast if the client makes which statement? a. i need to avoid getting the cast wet b. i will use my fingertips to lift and move the cast c. i need to cover the casted leg with warm blankets d. i can use a padded coat hanger end to scratch under the cast

a a plaster cast must remain dry to keep its strength. the cast should be handled using the palms of the hand not the fingertips until fully dry. air should circulate freely around the cast to help it dry, the cast gives off heat as it dries. the client should never scratch under a cast. a cool hair dryer can be used to help eliminate itching

a school aged child with type 1 DM has soccer practice three afternoons a week. the nurse reinforces instructions regarding how to prevent hypoglycemia during practice. what should the nurse tell the child? a. drink half a cup of orange juice before soccer practice b. eat twice the amount that is normally eaten at lunch time c. take half the amount of prescribed insulin on practice days d. take the prescribed insulin at noontime rather than in the morning

a an extra snack of 10g to 15g of carbs eaten before activities and every 30-45 minutes of activity will prevent hypoglycemia

a nurse is caring for a client who is 24 hours postop and following an inguinal hernia repair. the client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." the nurse tells the client that she will call the surgeon and ask. the surgeon hears the nurses report and prescribes a full liquid diet. the nurse used which of the following levels of critical thinking? a. basic b. commitment c. complex d. integrity

a at the basic level thinking is concrete and based on a set of rules.at the commitment level the nurse expects to have to make choices with out help from others and fully assumes responsibility for those choices, advanced knowledge and experience will prompt the nurse to request full liquid diet based on bowel sounds, and integrity is a critical thinking attitude that comes into play when the nurses attitude differs from the client

a nurse is reinforcing teaching with the parent of a child who is to have an EEG. which of the following responses should the nurse include? a. offer decaf beverages the morning of the procedure b. dont wash your childs hair the night before the procedure c. withhold all foods the morning of the procedure d. promote extra hours of sleep the night before the procedure

a caffeine will alter the results of the EEG, maintaining adequate fluid and food intake before the procedure will help the child to not go into hypoglycemia

a nurse is collecting data from a child who has short stature. the nurse should identify which of the following findings as an indication of growth hormone deficiency? a. decreased height that is proportionally equal to weight b. increased height that is proportionally greater than weight c. increased weight that is proportionally greater than height d. decreased weight that is proportionally less than weight

a children who have growth hormone deficiency present with short stature with proportional height and weight

the nurse is caring for a client with the fresh application of a plaster leg cast. the nurse should plan to prevent the development of compartment syndrome by which action? a. elevating the limb and applying ice to the affected leg b. elevating the limb and covering the limb with bath blankets c. keeping the leg horizontal and applying ice to the affected leg d. placing the leg in a slightly dependent position and applying ice

a compartment syndrome is prevented by controlling edema. this is achieved most optimally with elevation and application of ice. therefore the other options are incorrect

the nurse is assigned to care for a client after a left pneumonectomy. which position is contraindicated for this client? a. lateral position b. low fowlers position c. semifowlers position d. head of the bed elevated at 40 degrees

a complete lateral positioning is contraindicated for a client following a pneumonectomy

a nurse in a clinic is caring for a client who has suspected uterine cancer. which of the following assessment techniques should the nurse anticipate the provider performing? a. bimanual pelvic exam b. pap test with cultures c. digital rectal exam d. percussion of upper abdominal quadrants for tympany

a due to the place of the cancer the doctor should perform a bimanual pelvic exam to assess for uterine size, shape, and contour, which can be altered by a mass. pap test is for cervical cancer, digital rectal exam is for prostate or cervical cancer, and percussion of the abdomen is for detecting an abdominal mass

at the beginning of a shift, a nurse is collecting data on a client who has cushing's disease. which of the following findings are a nurse's priority? a. weight gain b. fatigue c. fragile skin d. joint pain

a fluid retention is a big risk for a person with cushing's disease

a nurse in a providers office is collecting data from a client who has hypothyroidism and recently began treatment with thyroid hormone replacement therapy. which of the following findings indicate that the client might need a decrease in the dosage of the medication? a. hand tremors b. bradycardia c. pallor d. slow speech

a hand tremors are a manifestation of hyperthyroidism that can result from thyroid hormone replacement therapy

a nurse is caring for a client scheduled for abdominal surgery. the client reports of being worried. which of the following actions should the nurse take? a. offer information on a relaxation technique and ask the client if he is interested in trying it b. request a social worker see the client to discuss meditation c. attempt to use biofeedback techniques with the client d. tell the client many people feel the same way before surgery and to think of something else

a its appropriate for the nurse to to recommend a noninvasive technique to facilitate coping and allow the client to make an informed decision about care. meditation does not require special training, biofeedback requires special training, and the last choice is not therapeutic because it is stereotyping and dismisses the clients feelings.

the nurse notes that a client with type 1 DM has lipodystrophy on both upper thighs. which further information should the nurse obtain from the client during data collection? a. plan for injection rotation b. consistency of aspiration c. preparation of the injection site d. angle at which medication is administered

a lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs when an injection site is used too much

the nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. which statement made by the client would indicate for hyperglycemia and thus warrant HCP notification? a. "i am urinating a lot" b. "my pulse is really slow" c. "i am sweating for no reason" d. "my BP is really high"

a polyuria, polydipsia, and polyphagia are all signs of hyperglycemia. slow pulse, sweating, and increased BP are not signs of hyperglycemia

the nurse reinforces instructions to the mother of a child with croup about the measures to take is an acute spasmodic episode occurs. which of the following statements made by the mother indicates the need for further teaching? a. "i will place a steam vaporizer in my childs room" b. "i will take my child out into the humid night air" c. "i will place a cool mist humidifier in my childs room" d. "i will place my child in a closed bathroom and allow my child to inhale steam from the running water"

a steam from running water and taking a child out into the humid night helps mucosal edema, cool mist humidifiers are recommended as compared to steam vaporizers which can cause burns,

a nurse is caring for a client who just experienced a generalized seizure. which of the following actions should the nurse perform first? a. keep the client side lying b. document the duration of the seizure c. reorient the client to the environment d. provide client hygiene

a the client is still at risk for aspiration, so remaining side lying is the main priority

a client has just undergone a CT scan with a contrast medium. which statement by the client demonstrates an understanding of postprocedure? a. i should drink extra fluids for the remainder of the day b. i should not take any medication for atleast 4 hours c. i should eat lightly for the remainder of the day d. i should rest quietly for the remainder of the day

a the client may resume all activities, but drink extra fluids to replace those lost with diuresis from the contrast

a nurse is reinforcing instructions for a client who has a prescription for amoxicillin and clarithromycin to treat a peptic ulcer. which of the following information should the nurse include? a. take these medications with food b. these medications make your stools turn black c. these medications can cause photosensitivity d. these medications decrease the ph of gastric juices in the stomach

a the client should take this with food to reduce GI disturbances. black stool can be a manifestation of gastric bleeding, tatracycline can cause photosensitivity, and antacids cause neutralization of the gastric juices in the stomach.

the nurse is assisting in planning care for a client with a diagnosis of immune deficiency. the nurse should incorporate which as a priority in the plan of care? a. protecting the client from infection b. providing emotional support to decrease fear c. encouraging discussion about lifestyle changes d. identifying factors that decreased the immune function

a the client with an immune deficiency has inadequate or absent immune bodies and is at risk for infection. the priority nursing intervention would be to protect the client from infection. options b, c, and d may be components of care but not the priority

a nurse in the ED is caring for a client who sustained minor injuries in a motor vehicle crash. the client's spouse was killed in the accident. which of the following actions should the nurse take first? a. determine if the client has thoughts of self-harm b. ask the client how the accident occurred c. assist the client in setting short term treatment goals d. instruct the client on use of coping strategies

a the greatest risk for this patient is the risk of harming themself or others. the nurse should do the other things also, but a is the top priority

a nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. the nurse asks the client whether she has been vomiting or nausea. which of the following pain characteristics is the nurse attempting to determine? a. presence of associated manifestations b. location of the pain c. pain quality d. aggravating and relieving factors

a the nurse should attempt to identify manifestations about the pain. the nurse should ask about the other options, but it is asking for what manifestations the nurse is trying to ask

a nurse is caring for a client who has a prescription for a 24 hour urine collection. which of the following actions should the nurse take? a. discard the first voiding b. keep the urine in a single container at room temp c. ask the client to urinate and pour the urine into the specimen container d. ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen cup

a the nurse should discard the first voiding of the 24 hour urine specimen and note the time

a nurse is planning care for a client who is on bed rest. which of the following interventions should the nurse include? a. encourage the client to perform antiembolic exercises every 2 hours b. instruct the client to cough and deep breathe every 4 hours c. restrict the clients fluid intake d. reposition the client every 4 hours

a the nurse should encourage the patient to perform antiembolic exercises every 1-2 hours to promote venous return. the nurse should instruct the client to cough and deep breathe every 1-2 hours, the nurse should increase the intake of fluid, and the nurse should repositon every 1-2 hours to prevent pressure ulcers

a nurse is assisting with the plan of care for a client who is to undergo genetic testing for suspected cancer. which of the following interventions should the nurse include? a. ensure the client signs an informed consent form b. withhold all medications prior to the procedure c. verify the prescription for a tumor marker assay d. place the client in a recovery position after testing

a the nurse should ensure the client signs an informed consent form prior to the procedure. medication, a tumor marker essay, and recovery positioning are not related to genetic testing

a nurse is reviewing the plan of care for a client who has a platelet count of 10,000/mm. which of the following interventions should the nurse expect to implement? a. apply prolonged pressure to puncture site after blood sampling b. administer epoetin alfa c. place the client in a private room d. have the client use an oral topical anesthetic before meals

a the nurse should implement bleeding precautions for the client who has thrombocytopenia. epoetin alfa is for anemia, the person who has neutropenia should be put in the room alone, and the nurse should teach the client to use an oral topical for mucositis

a nurse is reinforcing teaching with a client who has a new diagnosis of rheumatoid arthritis. which of the following instructions should the nurse give? a. you can experience morning stiffness when you get out of bed b. you can experience abdominal pain c. you can experience weight gain d. you can experience low blood sugar

a the nurse should reinforce in the teaching that someone with RA can experience stiff joints when they wake up. the cleint with RA does not experience abdominal pain but pleuritic pain. they experience weight loss not gain. they do not experience low blood sugar

a nurse is assessing a client as part of an admission history. the client reports drinking an herbal tea every afternoon at work to relieve stress. the nurse should suspect the tea includes which of the following ingredients? a. chamomile b. ginseng c. ginger d. echinacea

a the nurse should suspect that the tea contains chamomile. ginger helps with nausea. ginseng improves physical endurance. echinacea boosts the immune system

a nurse is reinforcing teaching with a client who has a new diagnosis of RA. which of the following instructions should the nurse give? a. you can experience morning stiffness when you get out of bed b. you can experience abdominal pain c. you can experience weight gain d. you can experience low blood sugar

a the nurse should tell the client that they will experience RA with stiffness in the morning. people with RA experience pleuritic pain but abdominal pain, can experience weight loss not gain, and they do not experience low blood sugar

a nurse is reinforcing teaching with a client who has a new prescription for nitroglycerin transdermal patches to treat angina pectoris. which of the following instructions should the nurse include? a. remove the patch each evening b. cut each patch in half if angina attacks are under control c. take off the nitroglycerin patch for 30 minutes if a headache occurs d. apply a new patch every 48 hours

a to prevent a tolerance to nitroglycerin, the client should remove the patch for 10-12 hours during each 24 hour period

a nurse is teaching an adolescent client who has a new prescription for fluoxtine to treat OCD. which of the following instructions should the nurse include? a. wear sunscreen when outdoors b. check your weight daily c. take this medication at bedtime d. the effects of this medication are immediate

a wearing protective clothing and sunscreen when outdoors will decrease reactions caused by photosensitivity, an adverse effect of SSRI medications. the client should check their weight weekly. the client should take this medication in the morning to prevent insomnia. the nurse should instruct the client that it may take 1-3 weeks for the medication to take effect

a nurse is caring for a client who ha several risk factors for hearing loss. which of the following medications that the client currently takes should alert the nurse to further risk for ototoxicity? select all that apply a. furosemide b. ibuprofen c. cimetidine d. simvastatin e. amiodarone

a, b furosemide can cause hearing loss as well as blurred vision, and ibuprofen can cause hearing loss as well as vision loss. cimetidine decreases gastric acid and has no effect on hearing, simvastatin helps lower cholesterol, and has no effect on hearing. amiodarone an antidysrhythmic medication is more likely to cause blurred vision instead of hearing loss

a nurse is caring for a client who is suspected of having HIV. which of the following diagnostic tests and lab values are used to confirm HIV infection? select all that apply a. western blot b. indirect immunofluorescence assay c. CD4+ t-lymphocyte count d. HIV RNA quantification test e. cerebrospinal fluid analysis

a, b positive western blot and indirect immunofluorescence confirm the presence of HIV. CD4+ determines what stage of HIV. HIV RNA classifications are to determine the viral level and to monitor treatment. CSF analysis is used to determine meningitis

the nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. the nurse should check the client for which signs of preeclampsia? select all that apply a. proteinuria b. hypertension c. low-grade fever d. increased pulse rate e. increased respiratory rate

a, b signs of preeclampsia are hypertension and proteinuria. a low grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia

the nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). which interventions should be included in the plan of care? select all that apply a. place the infant in a private room b. place the infant in a room near the nurse's station c. ensure that the infant's head is in a flexed position d. wear a mask at all times when in contact with the infant e. place the child in a tent that delivers warm, humidified air f. position the infant side lying, with the head lower than the chest

a, b the infant must be placed in an isolated room near the nurses station or in a room with another RSV diagnosed child, the child should be positioned in a semi-fowler like position with cool humidified air to help promote breathing

a 24 year old woman limps into the ED after twisting her ankle during a soccer game. on examination there is local swelling and difficulty maintaining balance. what immediate therapeutic measures should the nurse provide? select all that apply a. application of elastic bandage b. application of an ice pack c. elevation of the ankle d. ankle rest and limited weight bearing e. application of topical anesthetic

a, b, c Elevation, application of ice, and then wrapping with an elastic bandage are immediate measures used in the emergency department for a sprained ankle. Ankle rest and limited weight bearing should occur after leaving the E. R. A topical anesthetic is not used for an ankle sprain.

regarding sexuality of the older adult: select all that apply a.rates of HIV are decreasing but other STIs are increasing in the older population b. older women are more vulnerable than older men to acquiring a new HIV infection c. HCPs are less likely to ask the older patients about their sex practices d. people living with HIV/AIDS typically do not live into their older adult years e. older adults are at low risk for STIs because condom use is a well developed habit

a, b, c Health care providers are less likely to ask the older patient about risky behaviors that might place them at risk for HIV. The percentage of older adults infected with HIV and other STIs is increasing, partly because people are living longer with the HIV virus, but also because the use of condoms in this population is low. In addition, women are at greater risk than men because of the normal changes of aging (vaginal dryness) and risk of tearing of the vaginal wall.

after reviewing risk factors for cardiac disease, a patient is prescribed atorvastatin (lipitor) to reduce cholesterol levels. the nurse must include which instruction(s)? select all that apply a. report any muscle weakness b. avoid exposure to sunlight c. keep appointments for laboratory work d. drink grapefruit juice e. maintain a low protein diet

a, b, c Statin drugs can cause muscle myopathies (muscle damage), so muscle pain should be reported. Lipitor causes photosensitivity. Drug acts in, and is metabolized in, the liver and adversely affects the liver in some patients. Liver function is monitored initially and as clinically indicated thereafter. Grapefruit juice may interfere with the action of the drug. There is no need for a low-protein diet; a low-fat diet should be followed.

The patient presents to the clinic after falling from her bike and is diagnosed with a Grade II ankle sprain. The nurse should make which statements to the patient regarding the treatment of her sprained ankle? Select all that apply. a. "Rest your ankle as much as possible." b. "Prop your ankle on pillows while resting." c. "You should wrap your ankle with an elastic bandage." d. "Take stimulant laxatives with your narcotic pain medication." e. "Place an ice pack on your ankle for 30 minutes every 4 hours." f. "Begin walking on your injured ankle after 24 hours, and increase your ambulation as tolerated."

a, b, c The nurse should educate the patient about the acronym RICE: rest, ice, compression, and elevation. The patient will not likely be prescribed a narcotic pain medication for a grade II sprain. In addition, increased fluids and dietary fluids would be recommended first, then a stool softener, and, lastly, a laxative. The patient should use an ice pack for 10 to 20 minutes every 1 to 2 hours. The patient should not walk on the ankle until cleared by the physician.

the nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. which instructions should the nurse include on the list? select all that apply a. keep the casts and extremity elevated b. the cast needs to be kept dry and clean c. allow the wet cast 24-72 hours to dry d. expect tingling and numbness in the extremity e. use a hair dryer set on warm to hot setting to dry the cast f. use a soft padded object that will fit under the cast to scratch the skin under the cast

a, b, c a plaster cast takes about 24-72 hours to dry (synthetic casts take about 20 minutes to dry). the cast and extremity may be elevated to reduce edema. a wet cast is handled with the palms of the hand until the cast is dry. a cool setting on a hair dryer may be used. heat causes the cast to warm and can cause burns under the cast. the cast needs to be kept clean and dry. instruct the client to not use anything to scratch under the cast, because it could cause an infection instruct the client to report and pain swelling, discoloration, tingling, numbness or coolness, or diminished pulse.

a nurse is reinforcing teaching with a group of parents about the risk factors for seizures. which of the following factors should the nurse include? select all that apply a. febrile episodes b. hypoglycemia c. sodium imbalances d. low serum sodium levels e. presence of diphtheria

a, b, c febrile episodes, hypoglycemia, hyponatremia and hypernatremia are all risk factors for seizures

a nurse is assisting with admitting a child who has HIV. the nurse should identify which of the following findings as indications that the child is in the moderately symptomatic category (B)? select all that apply a. herpes zoster b. bronchitis c. oral candidiasis d. mycobacterial pneumonia e. TB

a, b, c herpes zoster, bronchitis, and oral candidiasis are all in the moderate category. mycobacterium pneumonia and TB are in the severe category

a nurse is caring for a child who has absence seizures. which of the following findings should the nurse expect? select all that apply a. loss of consciousness b. appearance of daydreaming c. dropping held objects d. falling to the floor e. having a piercing cry

a, b, c loss of consciousness for 5-10 seconds, behavior that resembles daydreaming, and dropping objects are all manifestations of absence seizures

a nurse is reinforcing education about trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. which of the following information should the nurse include in this review? select all that apply a. avoid overwhelming fatigue b. remove caffeinated products from the diet c. limit looking at flashing lights d. perform aerobic exercise e. limit episodes of hypoventilation f. use of aerosol hairspray is recommended

a, b, c overwhelming fatigue, caffeinated products, and flashing lights can trigger a seizure by stimulating abnormal electrical neuron activity

a nurse is reviewing a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. which of the following nursing actions are appropriate? select all that apply a. repeat the details of the prescription to the provider b. have another nurse listen to the phone prescription c. obtain the providers signature on the prescription within 24 hours d. decline the verbal prescription within 24 hours e. tell the charge nurse that the provider has prescribed morphine by telephone

a, b, c the nurse should repeat the medication information, having another nurse listen to the phone is a safety precaution, and the provider must sign the prescription within 24 hours. unrelieved pain could become an emergency situation. there is no need to inform a charge nurse every time an order is given over the phone

a nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. which of the following steps should the nurse take? select all that apply a. warm the enema solution prior to installation b. position the client on the left side with the right leg flexed forward c. lubricate the rectal tube or nozzle d. slowly insert the rectal tube about 5 cm (2 in) e. hang the enema container 61 cm (24 in) above the clients anus

a, b, c warming the solution can help prevent cramping, placing the client in this position to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon, and lubricating prevents trauma or injury to the rectal mucosa

nursing care of a patient who just had a seizure includes which nursing interventions? select all that apply a. assess for injuries b. check the glucose level c. reassure and reorient the patient d. provide uninterrupted periods of sleep and rest e. provide a 24 hour sitter

a, b, c, d Assess for injuries and stay with him until he regains consciousness. The glucose level is checked. Reassure the patient and orient him. Provide plenty of uninterrupted time so the patient may rest. It is not necessary to have someone sit with him after the seizure once he is conscious.

Which of the following processes have the strongest links to intracranial regulation? Select all that apply. a. Cognition b. Mobility c. Oxygenation d. Perfusion e. Safety

a, b, c, d Cognition, mobility, oxygenation, and perfusion have the strongest links to intracranial regulation and include processes that are essential for the nurse to consider when caring for a patient with intracranial concerns. Cognitive function is dependent on an optimally functioning brain. Mobility is frequently affected by intracranial regulation problems, with the most common example being a cerebrovascular accident. Perfusion and oxygenation are intimately involved with intracranial regulation, and without adequate perfusion and oxygenation, the brain cannot function. Other processes that may be closely related include clotting and pain, and interpersonal violence may also be a consideration. Safety (E) refers to the prevention of injuries or freedom from accidents, both of which could be related to intracranial regulation but would not be the strongest links for the nurse to consider.

a nurse is reviewing the health record of a client who has hyperglycemic-hyperosmolar state (HHS). which of the following factors can cause HHS? (select all that apply) a. evidence of recent myocardial infarction b. BUN 35 mg/dL c. takes a calcium channel blocker d. age 77 years e. fluid volume excess

a, b, c, d a myocardial infarction, BUN level of 35 mg/dL,a calcium channel blocker, and older age puts you at risk for HHS

a nurse is reviewing treatment options with a parent of a child who has worsening seizures. which of the following treatment options should the nurse include in the discussion? select all that apply a. vagal nerve stimulator b. additional antiepileptic medications c. corpus callostomy d. focal resection e. radiation therapy

a, b, c, d a vagal nerve stimulator is an option to prevent seizures, additional antiepileptic medications are helpful for preventing seizures, corpus callostomy can be performed can be performed for uncontrolled seizures, and focal resection can be performed for uncontrolled seizures

a nurse is caring for a child who has a short stature. the nurse should expect which of the following diagnostic tests to be completed to confirm growth hormone (GH) deficiency? (select all that apply) a. CT scan of the head b. bone age scan c. GH stimulation test d. serum IGF-1 e. DNA testing

a, b, c, d ct scan is done to determine structural component of short stature. bone scan is done to see bone development. GH stimulation test is done to confirm GH deficiency. serum IGF-1 is a preliminary test to determine GH deficiency

a nurse is discussing risk factors for asthma with a group of parents. which of the following conditions should the nurse include? select all that apply a. family history of asthma b. family history of allergies c. exposure to smoke d. low birth weight e. being underweight

a, b, c, d family history of asthma, exposure to smoke, low birth weight, and family history of allergies are risk factors for asthma,

a nurse is screening a toddler for hearing loss. which of the following findings are indications of hearing impairment? select all that apply a. uses monotone speech b. yells to express emotions c. wants to repeat conversations d. appears shy e. is overly attentive to the surroundings

a, b, c, d monotone speech, yelling, need for repeated conversations, and shyness are manifestations of hearing impairment. being nonattentive to surroundings is a manifestation of hearing impairment, not overly attentive

the nurse in a medical unit it caring for a client with heart failure. the client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. the nurse immediately notifies the RN and expects which interventions to be prescribed? select all that apply a. administering oxygen b. insert a foley catheter c. administering furosemide (lasix) d. administering morphine sulfate through IV e. transport the client to the coronary care unit f. placing the client in a low-fowler's side lying position

a, b, c, d pulmonary edema is life threatening. doing everything to help the airway what needs to be done

a nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. which of the following information should the nurse include? select all that apply a. clients who smoke should consider cessation programs b. clients who have DM should maintain blood glucose within the expected reference range c. unplug electrical equipment when performing repairs d. clients who have vascular disease should maintain good foot care e. wait 2 hours after taking pain medication to drive

a, b, c, d smoking cessation, regulating blood glucose and maintaining good foot care can help prevent arteriosclerosis. unplugging equipment prevents electrocution. driving under the influence of medication could lead to an amputation

a client with a seizure disorder is being admitted to the hospital. which should the nurse plan to implement for this patient? select all that apply a. pad the patients bedside b. place an airway at the bedside c. place oxygen equipment next to the bedside d. place suction equipment next to the bedside e. tape a padded tongue blade to the wall at the head of the bed

a, b, c, d the nurse should plan for seizure precautions, which include oxygen available, padded side rails, an airway, and suction equipment. a tongue blade put between clenched teeth could possibly damage the teeth and mouth

a nurse is collecting data from a client who has a seizure disorder. the client reports sensing an aura and is about to have a seizure. which of the following actions should the nurse take? select all that apply a. provide privacy b. ease the client to the floor if standing c. move furniture away from the client d. loosen the clients clothing e. protect the clients head with padding f. restrain the client

a, b, c, d, e provide privacy to decrease embarrassment, ease to the floor to prevent injury, move furniture to prevent injury, loosen clothes to minimize restriction of movement, and protect the clients head by placing in lap or on a pillow

a nurse reinforces discharge instructions to a patient who is diagnosed with chronic venous insufficiency. which instruction(s) should be included? select all that apply a. take a low dose aspirin everyday b. consider swimming for exercise c. avoid wearing tight clothing d. reapply elastic wraps in the afternoon e. decrease fluid intake to help prevent edema f. elevate the legs above the level as the heart as much as possible

a, b, c, d, f Taking aspirin helps prevent clots; swimming is a good exercise as it puts light pressure on the legs, encouraging venous return; tight clothing is to be avoided as it may interfere with venous return from the legs; when elastic wraps are used for compression support, they should be applied twice a day; the legs should be elevated above heart level as often as possible. Wearing support hose and elevating the legs above heart level will decrease edema. It is not necessary to decrease fluid intake and reduction of fluid intake may increase blood viscosity, promoting clotting.

a nurse is caring for a client who has experienced a right-hemispheric stroke. which of the following findings should the nurse expect? select all that apply a. impulse control difficulty b. left hemiplegia c. loss of depth perception d. aphasia e. lack of situational awareness

a, b, c, e a client who has experienced a right-hemispheric stroke can experience impulse control difficulty, left sided hemiplegia, loss in depth perception, and lack of awareness around them

a nurse is caring for a child who has a fracture. which of the following are manifestations of a fracture? select all that apply a. crepitus b. edema c. pain d. fever e. ecchymosis

a, b, c, e a fracture will leave bone fragments that will exhibit a grating sound like crepitus, swelling, pain, and bleeding under the skin are manifestations of a fracture. fever after a fracture is unexpected, it could mean there is an infection

a nurse is reviewing information with a client who has osteoarthritis of the hip and knee. which of the following instructions should the nurse reinforce? select all that apply a. apply heat to joints to alleviate pain b. iced inflamed joints following activity c. install an elevated toilet seat d. take tub baths e. complete high energy activities in the morning

a, b, c, e applying heat helps to relieve temporary pain, applying ice to inflamed joints decreases edema, elevated toilet seat can help to reduce strain on the affected joints, and encouraging high activity in the morning helps promote independence. taking a tub bath increases strain on affected joints

a nurse is collecting data from a client who has increased ICP. which of the following findings should the nurse expect? select all that apply a. disoriented to time and place b. restlessness and irritability c. unequal pupils d. ICP 15 mmHg e. headache

a, b, c, e changes in consciousness, behavior changes, unequal pupils, and headache are all manifestations of increased ICP

a nurse is assisting with a presentation about nutrition habits that prevent type 2 DM for a group of clients. which of the following should the nurse include? (select all that apply) a. eat less meat and processed foods b. decrease intake of saturated fats c. increase daily fiber intake d. limit unsaturated fat intake to 15%of daily caloric intake e. include omega-3 fatty acids in the diet

a, b, c, e decrease eating processed foods, lower LDL fats increasing dietary fiber, eat omega-3 fatty acids to lower the risk for heart disease

a nurse is caring for a client who has chronic cancer pain and a permanent epidural catheter for administration if a fentanyl/bupivacaine solution. the nurse should monitor for which of the following adverse side effects of epidural analgesics? select all that apply a. respiratory depression b. hypotension c. sedation d. muscle spasticity e. incontinence

a, b, c, e respiratory depression, hypotension, sedation, and incontinence are all adverse effects of analgesics. muscle weakness is an adverse effect not spasticity

a nurse is contributing to the plan of care for a client who has dysphagia and a new dietary prescription. which of the following interventions should the nurse include in the plan? select all that apply a. have suction equipment nearby b. feed the client thickened liquids c. place food on the unaffected side of the clients mouth d. assign an assistive personnel to feed the client slowly e. instruct the client to swallow with her neck flexed

a, b, c, e suction equipment should be near because the risk of aspiration, the client should be given think liquids to prevent aspiration, placing food on the unaffected side will help have more control over the food, and the client should be taught to flex their neck

a nurse is caring for a client following a below the elbow amputation. which of the following actions should the nurse take? select all that apply a. encourage dependent positioning of the residual limb b. inspect for presence and amount of drainage on the dressing c. implement shrinkage intervention of the residual limb d. wrap the residual limb in a circular manner using gauze e. observe for body image changes

a, b, c, e the limb should be placed in a dependent position to improve circulation, the nurse should note drainage on the dressing, the nurse should shrink the limb so that it fits into a prosthetic, and the nurse should monitor the clients feelings.

a nurse in an outpatient clinic is collecting data from a client who reports night sweats and fatigue. the clients oral is 100.6 degrees F. the client is afraid he has HIV. which of the following actions should the nurse take? select all that apply a. measure vital signs b. determine when manifestation began c. weigh the client d. reinforce teaching about opportunistic infections e. obtain a sexual history

a, b, c, e the nurse should measure VS, determine first signs, weight and sexual history about the clients condition. the nurse should not teach about opportunistic infections until a diagnosis is made

a nurse in an outpatient clinic is collecting data from a client who reports night sweats, fatigue, cough, nausea, and diarrhea. the client asks the nurse is it is possible he has HIV. which of the following actions should the nurse take? select all that apply a. measure vital signs b. determine when manifestations began c. obtain a weight d. reinforce teaching about HIV transmission e. obtain a sexual history from the client

a, b, c, e the nurse should measure vitals to collect data about the clients condition. the nurse should should gather more data to determine whether manifestations are acute or chronic. the nurse should weigh the client. the nurse should obtain a sexual history to determine how the client might have acquired the illness. the nurse should not reinforce teaching about transmission until there is a diagnosis.

The nurse is providing education to a middle-aged female about her changing health needs. The nurse should be sure to include information on which age-related changes? Select all that apply. a. Loss of bone mass b. Decrease in height c. Increased circulation d. Decreased muscle mass e. Increased mineral exchange

a, b, d Osteoporosis is especially prevalent in women and is partially responsible for the decrease in height of both genders. Loss of muscle mass and strength is also a function of aging. Mineral exchange and circulation decrease with age.

which statement(s) is/are true regarding HIV transmission? select all that apply a. breast milk can harbor the virus b. proper use of PPE reduces the risk of transmission c. needle exchange programs facilitate the spread of the virus d. being assessed two hours after a blood-bourne pathogen exposure reduces the risk conversion e. monogamous relationships provide the best defense from the virus

a, b, d The virus can be found in the breast milk of HIV-positive women. Appropriate use of personal protective equipment (PPE) minimizes the risk of exposure to health care workers. Needle exchange programs decrease the spread of HIV. The health care worker must be seen by a health care provider and started on postexposure prophylaxis (PEP) therapy within 2 hours of a significant exposure to HIV-positive blood or body fluids. Abstinence provides the best defense from the virus.

a nurse is caring for a client who has lung cancer and is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). which of the following findings should the nurse report to the provider? select all the apply a. behavioral changes b. client reports of headache c. urine output 40ml/hr d. client reports of nausea e. increased urine specific gravity

a, b, d behavioral changes, headache, and nausea indicate cerebral edema due to SIADH. urine output of 40 ml/hr and increased urine specific gravity is a finding consistent with SIADH.

a nurse is reinforcing teaching with a parent of a child who has a growth hormone (GH) deficiency. the nurse should identify which of the following as complications of untreated GH deficiency? (select all that apply) a. delayed sexual development b. premature aging c. advanced bone aging d. bone stature e. premature epiphyseal closure

a, b, d complications of untreated growth hormone deficiency include delayed sexual development, premature aging, and short stature

a school nurse is teaching a high school health class about the possible causes of a negative nitrogen balance. which of the following causes should the nurse include in the teaching? (select all that apply) a. illness b. malnutrition c. adolescence d. trauma e. pregnancy

a, b, d illness, malnutrition, and trauma are all possible causes of negative nitrogen balance

a nurse is preparing to administer a dose of prednisone to a client who has COPD. the nurse should monitor for which of the following adverse effects of this medication? select all that apply a. hypokalemia b. tachycardia c. fluid retention d. nausea e. black, tarry stools

a, c, e all of these are adverse effects of prednisone

nursing ethics is balanced on principles of moral autonomy, beneficence, fidelity, justice, non-maleficence, and veracity. these principles of moral conduct can be distinctly involved in which of the following? select all that apply a. caregiving relationships between nurse and client's family members b. patients right to self-determination c. working relationship between nurse and attending physician d. nursing responsibilities to dose management

a, b, d nursing ethics apply most directly to relationships, responsibilities, and actions of nursing providers with clients

a nurse is caring for a client with cushing's disease. clients who have cushing's disease are at increased risk for which of the following? (select all that apply) a. infection b. gastric ulcer c. renal calculi d. bone fractures e. dysphagia

a, b, d suppression of the immune system places the client at risk for infection, overproduction of cortisol inhibits the production of the mucous lining of the stomach and can put the patient at risk for gastric ulcers, and people with cushing's disease are more at risk for bone fractures because decreased calcium absorption

a charge nurse is conducting a nutritional class for a group of newly licensed nurses regarding basal metabolic rate (BMR). the charge nurse should inform the class that which of the following factors increases BMR? (select all that apply) a. lactation b. prolonged status c. malnutrition d. puberty e. age older than 60 years old

a, b, d the charge nurse should include that lactation increases BMR, stress increases BMR, and puberty increases BMR

a nurse is instructing a client who has an injury to the left lower extremity, about the use of a cane. which of the following instructions should the nurse include? select all that apply a. hold the cane to the right side b. keep two points of support on the floor c. place the cane 15 inches in front of the feet before advancing d. after advancing the cane, move the weaker food forward e. advance the stronger leg so that it aligns evenly with the cane

a, b, d the client should hold the cane on the uninjured side of the body, the client should keep two sides of support, and the client should advance the weaker leg first and then the stronger leg.

a nurse is discussing occurrences that will require completion of an incident report with a newly licensed nurse. which of the following should the nurse include in the teaching? select all that apply a. medication error b. needlesticks c. conflict with provider and nursing staff d. omission of prescription e. missed specimen collection of a prescribed laboratory test

a, b, d the nurse should complete an incident report regarding a medication error, a needlestick, and omission of a prescription. the nurse should report a conflict with staff to a nurse manager, and a missed specimen should be reported.

a patient newly diagnosed with diabetes and is given diet instructions. what should the nurse do to effectively motivate the patient to comply with dietary recommendations? (select all that apply) a. emphasizes good food choices b. apply diet prescriptions to patient preferred foods c. instill guilt to self regulate when "cheating" occurs d. focus on the benefits of diet compliance e. involve meal preparers in diet teaching

a, b, d, e These options are good strategies. Fear and guilt create a situation where the patient will be reluctant to tell the truth to others. There will be times when the patient will not follow the diet (e.g., it may be very difficult during the holidays); however, the patient should be able to admit the deviation from the plan and then get back on schedule.

immediate therapeutic measures provided for a patient entering the hospital with an acute MI include which measures? select all that apply a. morphine sulfate b. oxygen therapy c. furosemide d. nitroglycerin e. aspirin

a, b, d, e MONA (morphine, oxygen, nitroglycerin, aspirin) is the standard treatment begun as soon as a patient experiencing an MI presents to the hospital. Furosemide is a diuretic medication and is not indicated for an MI. It is used for heart failure and other problems.

a nurse is collecting data from an older adult who has arteriosclerosis and is scheduled for a right lower extremity amputation. which of the following are expected findings in the effected extremity? select all that apply a. skin cool to touch mid calf to toes b. lower leg appearing dusky c. palpable pounding pedal pulse d. lack of hair on lower leg e.. blackened areas on several toes

a, b, d, e coolness, dusky, decreased hair growth, and blackened areas on the toes like gangrene could lead to devascularization.

a nurse is reinforcing discharge teaching on home safety for an older adult who has osteoporosis. which of the following information should the nurse include? (select all that apply) a. remove throw rugs in the way b. use prescribed assistive devices c. remove clutter from the environment d. walk with caution on icy surfaces e. maintain lighting of doorway areas

a, b, d, e removing throw rugs, using assistive devices, removing clutter, and good lighting can prevent the risks of falls

the nurse should watch for potential complications in a young adult patient with a fractured femur with internal fixation and a long leg cast, such as: a. infection or osteomyelitis b. compartment syndrome c. pneumonia or stroke d. pulmonary fat embolus e. electrolyte imbalance f. nonunion oof the bone

a, b, d, f A fat embolus is a threat when a long bone such as the femur is fractured; infection and possible osteomyelitis, compartment syndrome, and non-union of the bone are other potential complications for which to watch. Pneumonia or stroke is not likely in a young adult. Electrolyte imbalance is a possibility for any patient undergoing injury and surgery but would be more likely in an older adult.

a nurse is reviewing a clients medication history. the client has an admission blood glucose level of 260 mg/dL and no documented history of diabetes mellitus. which of the following types of medication should alert the nurse to the possibility that the client has developed an adverse effect of pharmacological therapy? (select all that apply) a. diuretics b. corticosteroids c. oral anticoagulants d. opioid analgesics e. antipsychotics

a, b, e diuretics and corticosteroids can cause hyperglycemia. antipsychotics can cause new onset DM

a nurse is collecting data from a client who has a new diagnosis of multiple sclerosis. which of the following findings should the nurse expect? select all that apply a. areas of paresthesia b. involuntary eye movements c. alopecia d. increased salivation e. ataxia

a, b, e loss of skin sensation, nystagmus, and ataxia are all findings in a person with MS. hair loss and dysphagia are not manifestations of MS

a nurse in a providers office is assisting with the plan of care for a client who has a new diagnosis of grave's disease and a new prescription of methamazole. which of the following interventions should the nurse include? (select all that apply) a. monitor cbc b. monitor triiodothyronine (T3) c. instruct the client to increase consumption of shellfish d. advise the client to take the medication at the same time everyday e. inform the client that an adverse effect of this medication is iodine toxicity

a, b, e methimazole causes hematologic effects, which needs to be checked with a CBC, and reduces thyroid hormone production, which is why you check T3, and should be taken everyday at the same time to maintain blood levels

a nurse in an outpatient clinic is collecting data from a client who has RA. the client reports increased joint swelling and tenderness. which of the following findings should the nurse expect? select all that apply a. recent influenza b. decreased ROM c. hypersalivation d. increased BP e. pain at rest

a, b, e some conditions like recent influenza can exacerbate RA, clients with RA usually experience decreased ROM, and often have pain. people with RA report xerostomia not hypersalivation and increased BP is not indicative of RA

a nurse in an outpatient clinic is collecting data from a client who has rheumatoid arthritis. the client reports increased joint tenderness and swelling. which of the following should the nurse expect? select all that apply a. recent influenza b. decreased ROM c. hypersalivation d. increased BP e. pain at rest

a, b, e some recent illnesses can exacerbate RA, they experience decreased ROM, and have pain. clients who has RA can experience xerostomia not hypersalivation. increased BP doesnt relate to RA.

a nurse is contributing to the plan of care for a client who has global aphasia (both receptive and expressive). which of the following interventions should the nurse include in the plan of care? select all that apply a. speak to the client at a slower rate b. assist the client to use the flash cards with pictures c. speak to the client in a loud voice d. complete sentences that the client cannot finish e. give the instructions one step at a time

a, b, e speaking slower will help the client understand easier, flash cards will help to improve communication, and one instruction at a time will help understanding

a nurse is collecting data from a client following a gunshot wound to the chest. for which of the following findings should the nurse monitor to detect a pneumothorax? select all that apply a. tachypnea b. deviation of the trachea c. bradycardia d. decreased use of accessory muscles e. pleuritic pain

a, b, e tachypnea can be from having a pneumothorax and respiratory distress, trachea deviation is present in a pneumothorax, and the pleura being inflammed from an infection

a nurse is determining a clients ability to self monitor blood glucose with a monitor. which of the following abilities should the nurse confirm that the client has before proceeding with caution? (select all that apply) a. finger dexterity b. visual acuity c. color vision d. basic literacy e. demonstration ability

a, b, e the patient must be able to cleanse and puncture the site as well as be able to see, and use the glucometer safely and effectively

a nurse is reinforcing teaching with a child who has asthma about how to use a peak flow meter. which of the following information should the nurse include? select all that apply a. zero the meter before each use b. record the average of the attempts c. perform 3 attempts d. deliver a slow, long breath into the meter e. sit in a chair with feet on the floor

a, c zero the monitor for accurate results and do it 3 times to achieve accurate results

in determining the optimal therapy for a client infected with HIV, what would the nurse consider in developing a nursing care plan? place in order of priority a. clinical data b. compliance with therapy c. medication tolerance d. support system e. patient expectations

a, c, b, e, d Clinical data provides current health status of patient by report. If there are too many side effects, the patient is more likely to stop taking the medication. A noncompliant patient will be more difficult to treat. It is the patient's expectations that help drive successful therapy. A reliable support system will assist the HIV/AIDS patient in managing their disease.

A child must experience mobility so he or she can explore and learn about the world. Lack of mobility in a child may interfere with which developmental milestone? a. Physiological bonding and growth b. Speech and hearing development c. Intellectual and psychomotor function d. Childhood play interaction

a, c, d Patients who experience immobility often have psychological issues such as helplessness, anger, and anxiety. Hunger, increased communication, and improved self-worth are usually the opposite of what is experienced.

a nurse is admitting a patient with a possible skull fracture. which clinical findings would likely confirm the diagnosis. select all that apply a. battle sign b. partial blindness c. ecchymosis around the eyes d. rhinorrhea e. swallowing difficulty

a, c, d Signs of skull fracture are usually: Battle sign, ecchymosis around the eyes, and rhinorrhea are signs of skull fracture. Partial blindness is not a sign of skull fracture.

a nurse is teaching a client about high fiber foods that can assist with lowering the LDL. which of the following foods should the nurse include in the teaching? select all that apply a. beans b. cheese c. whole grains d. broccoli e. yogurt

a, c, d beans, whole grains, and broccoli are all high in fiber

a nurse is caring for a client following a thoracentesis. which of the following manifestations should the nurse recognize as risks for complication? select all that apply a. dyspnea b. localized bloody drainage on the dressing c. fever d. hypotension e. report of pain at the puncture site

a, c, d dyspnea can mean a recaccumulation of fluid or a pneumothorax, fever can indicate an infection, and hypotension can indicate intrathoracic bleeding

a nurse is collecting data from a child who has severely symptomatic HIV. the nurse should recognize that which of the following conditions is part of the severely symptomatic category? select all that apply a. kaposi's sarcoma b. hepatitis c. wasting syndrome d. pulmonary candidiasis e. cardiomyopathy

a, c, d kaposi's sarcoma, wasting syndrome, and pulmonary candidiasis are severe symptoms for someone with HIV. hepatitis and cardiomyopathy are moderate symptoms.

a nurse is teaching a group of nursing students on complimentary and alternative therapies that can incorporate into their practice without the need for specialized licensing or certification. which of the following should the nurse encourage the students to use? select all that apply a. guided imagery b. massage therapy c. meditation d. music therapy e. therapeutic touch

a, c, d nurses may use guided imagery, meditation, and music therapy with clients when they understand the general principles of these therapies. massage therapy and therapeutic touch practitioners require training and certification

a nurse is caring for a client following a thoracentesis. which of the following supplies should the nurse ensure are in the clients room? select all that apply a. oxygen equipment b. incentive spirometer c. pulse oximeter d. sterile dressing e. suture removal kit

a, c, d oxygen is necessary incase the client becomes short of breath, pulse oximeter is necessary to monitor the O2 saturation, and sterile dressing is necessary to keep over the puncture site

a nurse is reviewing discharge teaching with a parent of a child who has HIV. which of the following information should the nurse include. select all that apply a. obtain yearly influenza vaccine b. monitor a fever for 24 hours before seeking medical care c. avoid individuals who have colds d. provide nutritional supplements e. administer aspirin for pain

a, c, d yearly vaccine, avoiding people with colds, and nutritional supplements are recommended to protect the child. the child who has HIV should receive prompt medical care for a fever. the parent should administer acetaminophen, NSAIDS, or opioids for pain.

a nurse is caring for a client who had a thyroidectomy. what should the nurse monitor for? (select all that apply) a. bleeding and swelling b. hypothermia c. increase in pulse d. difficulty swallowing e. difficulty breathing

a, c, d, e Watch for signs of bleeding and swelling at the operative area. Any rise in temperature, pulse, or respiration rate should be reported immediately, as it may indicate a high level of thyroxine in the bloodstream. External swelling may cause constriction of the bandage around the neck. Difficulty in swallowing or breathing also should be reported immediately, as it may indicate internal edema and pressure on the esophagus and trachea. There would be no reason for the patient to be hypothermic

a nurse is reinforcing dietary teaching to a client who has type 2 DM. which of the following instructions should the nurse include in the teaching? (select all that apply) a. carbohydrates should compromise 55% of daily caloric intake b. use hydrogenated oils for cooking c. you can add table sugar to cereal d. you can drink one alcoholic beverage with a meal e. use the same portion sizes to exchange carbohydrates

a, c, d, e carbs should be 45-60% of the daily caloric intake, sugar can be eaten if insulin is administered, alcoholic beverages can be drank with meals, and the client can exchange carbohydrates as long as portion sizes remain the same

a nurse is teaching a client who has cancer about ways to increase protein and calories in foods. which of the following actions should the nurse include? select all that apply a. use peanut butter as a spread on crackers b. add water in place of milk in soups c. top fruit with yogurt d. dip chicken in eggs before cooking e. sprinkle cheese on a baked potato

a, c, d, e peanut butter, yogurt, eggs, and cheese adds calories and protein to other foods. the client should substitute whole milk for cream to increase protein.

the nurse promotes lifestyle modifications to a 39 year old man who is diagnosed with prehypertension. which lifestyle modification(s) should be recommended? select all that apply a. smoking cessation b. restrict sodium intake to 4000 mg/day c. exercise 30 minutes/day most days of the week d. limit alcohol intake to two drinks per day e. low-fat diet f. stress reduction measures

a, c, d, e, f Blood pressure can be lowered by smoking cessation, regular exercise, limiting alcohol intake, sticking to a low-fat diet to decrease atherosclerosis, and decreasing stress. The low-sodium diet for prehypertension should contain no more than 3000 g sodium per day.

on initial assessment of a patient diagnosed with an acute exacerbation of COPD, the nurse is likely to find which S/S? select all that apply a. tensing of the shoulder muscles b. inability to tolerate sitting up c. flaring of the nostrils d. ability to complete sentences with no effort e. sternal retraction

a, c, e During an acute exacerbation of chronic obstructive pulmonary disease (COPD), the patient is likely to be sitting and hunched forward in an attempt to open the thoracic cavity. Other signs of respiratory distress include nasal flaring, use of accessory muscles, and gasping for breath between words.

a nurse is caring for a group of clients. which of the following clients are at risk for pulmonary embolism? select all that apply a. a client who has a BMI of 30 b. a client who is post menopausal c. a client who has a fractured femur d. a client who is a marathon runner e. a client who has chronic atrial fibrillation

a, c, e a bmi of 30 increases the risk of a blood clot, a fractured bone is a risk for a fat emboli, and turbulent flow through the heart like a-fib is at increased risk for a blood clot

a nurse is reviewing complimentary and alternative therapies with a group of nursing students. the nurse should classify which of the following interventions as a mind body therapy? select all that apply a. art therapy b. acupressure c. yoga d. therapeutic touch e. biofeedback

a, c, e art therapy allows the client to express emotions about their health, yoga helps mind-body therapy, and biofeedback increases mental awareness. acupressure focuses on the body structures and systems and therapeutic touch is an energy therapy because it involves using the hands to balance energy fields

a nurse is providing information to a client who has a new diagnosis of type 1 DM. which of the following information should the nurse include? (select all that apply) a. a viral infection can trigger the onset of type 1 DM b. alpha cells in the pancreas are damages in type 1 DM c. type 1 DM usually occurs before age 30 d. type 1 DM is treated with oral antiglycemic medications e. regular exercise can reduce insulin requirements in type 1 DM

a, c, e viral infections or genetic links can trigger an autoimmune response that triggers type 1 DM, type 1 DM usually occurs before age 30, and regular exercise can reduce insulin

which teaching technique(s) would be most useful for older adult patients with diabetes? (select all that apply) a. set a time for the teaching session that is agreeable with the patient b. invite the patient to join a teaching session for newly diagnosed patients with diabetes c. allow time for the patient to jot down important points d. use bold type printed materials with a white type on a dark blue or black background e. keep the sessions at a limit of 1 to 2 hours and give frequent breaks f. teach all necessary information in one session g. repeat key concepts frequently; if the patient does not understand, try rephrasing the concept

a, c, g Setting a specific time, allowing additional time to write down information, and repeating key concepts are good strategies. Group learning may work for some older patients, but generally it is more advisable to have less distraction and more time for individualized attention. Use dark type on white backgrounds for optimal visual clarity. Attempting to cover all material in long sessions is not ideal, even if you give the patient frequent breaks.

a patient received large doses of radioactive iodine for hyperthyroidism. which nursing intervention(s) should be included? (select all that apply) a. monitor vital signs b. restrict fluids c. encourage low fat, high fiber diet d. properly handle contaminated materials e. encourage physical activity

a, d Vital signs are monitored in all postprocedure patients; however, in this case the nurse should be vigilant for thyroid crisis. The radioactive substance is excreted via the urinary system, so contaminated equipment must be handled properly. Fluid and diet do not play a role in the therapy. There is no procedural benefit from increased physical activity.

The nurse is talking with a patient who was just diagnosed with a urinary tract infection. The patient asks the nurse how to prevent such infections in the future. The nurse should make which appropriate recommendations for the patient? Select all that apply. a. Drink 6 to 8 glasses of noncaffeinated fluids daily. b. Exercise daily. c. Increase fiber in the diet. d. Void when the urge is felt. e. Eat fruit twice daily.

a, d Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract infection.

a nurse is caring for a client who reports difficulty hearing. which of the following assessment findings indicate a sensorineural hearing loss in the left ear? select all that apply a. weber test showing lateralization to the right ear b. light reflex at 10 oclock in the left ear c. indications of obstruction in the left ear canal d. rinne test showing less time for air and bone conduction e. rinne test showing air conduction less than bone conduction in the left ear

a, d weber test demonstrates lateralization to the unaffected ear, and with sensorineural hearing loss in the left ear, length of time is decreased for both air and bone conduction. a light reflex at 10 oclock indicates air or fluid are in the tympanic membrane, obstruction in the ear canal indicates conductive hearing loss, and air conduction is greater than the bone conduction in the left ear.

The nurse is participating in a patient care conference to plan the care for a patient with osteoporosis. Which issues should be discussed for inclusion in this patient's care plan? Select all that apply. a. Pain b. Difficulty breathing c. Potential for excessive fluid d. Difficulty providing own hygiene e. Difficulty moving about the house and/or work setting(s)

a, d, e Pain, difficulty providing own hygiene, and moving about the house are common issues that should be discussed when planning the patient's care. There is no indication the patient has difficulty breathing or managing fluid intake.

a patient with an immune disorder is very susceptible to infection. which interventions would be used in the care of this patient? select all that apply a. all health care workers should perform scrupulous hand hygiene b. the patient should be instructed how to wear PPE c. the patient is placed in contact isolation d. caregivers with any type of infection should not be assigned to this patient e. a high protein diet with nutritional supplements is encouraged

a, d, e Performing hand hygiene, providing protection from exposure to known infectious sources, and giving protein to make antibodies and strengthen the immune system are appropriate interventions. The patient generally will not don PPE (those entering the room will don PPE). The patient will be placed in transmission-based isolation, not Contact Isolation.

a nurse is reviewing factors that increase the risk of UTI's with a client who has recurrent UTI's. which of the following factors should the nurse include? select all that apply a. frequent sexual intercourse b. lowering of testosterone levels c. wiping from front to back d. location of the urethra in relation to the anus e. frequent catheterization

a, d, e having frequent sexual intercourse, distance of urethra to anus, and frequent catheterization are all risk factors for a UTI

a nurse is collecting data from a client who has osteoarthritis of the knees and fingers. which of the following manifestations should the nurse expect to find? select all that apply a. heberden's nodes b. swelling of all joints c. small body frame d. enlarged joints size e. limp when walking

a, d, e heberdens nodules are enlarged nodules on the distal interphalangeal joints in the hands and feet of a client who has osteoarthritis, a client can manifest large joints and a limp from osteoarthritis. swelling and small body frame are signs of RA

a nurse is providing teaching to a client who has a vitamin b12 deficiency. which of the following foods should the nurse instruct the client to consume? select all that apply a. meat b. flaxseed c. beans d. eggs e. milk

a, d, e meat, eggs, and milk are all foods high in vitamin b 12

a nurse is collecting data from a client to identify risk factors for HIV. which of the following are risk factors associated with this virus? select all that apply a. perinatal exposure b. pregnancy c. monogamous sex partners d. older adult woman e. occupational exposure

a, d, e perinatal exposure, older female, and occupational exposure are risk factors for HIV. pregnancy and monogamous sex partner are not risks of HIV

a nurse is reviewing a sick day management with a parent of a child who has type 1 DM. which of the following instructions should the nurse include in the teaching? (select all that apply) a. monitor blood glucose levels every 3 hours b. discontinue taking insulin until until feeling better c. drink 8 oz of fruit juice every hour d. test urine for ketones e. call the provider if blood glucose is greater than 240 ml/dL

a, d, e a client experiencing illness can have waning blood glucose levels. urine should be tested for ketones to help assist early detections of ketoacidosis. the HCP should be notified for a level above 240 mg/dL

Exercise and activity are included in a cardiac rehabilitation program for which purposes? Select all that apply. a. Increase cardiac output b. Increase serum lipids c. Increase blood pressure d. Increase blood flow to the arteries e. Increase muscle mass f. Increase flexibility

a, d, e, f A cardiac rehabilitation program seeks to increase cardiac output, blood flow to the arteries, muscle mass, and flexibility. The rehabilitation program does not want to increase serum lipids or blood pressure.

It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus? Select all that apply. a. Hypertension b. History of pancreatic trauma c. Weight gain of 30 pounds during pregnancy d. Body mass index greater than 25 kg/m e. Triglyceride levels between 150 and 200 mg/dL f. Delivery of a 4.99-kg baby

a, d, f Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.

the nurse educator is asking the nursing student to recall the s/s of hypothyroidism. the nurse educator determines that the student understands this disorder if which are included in the students response? select all that apply a. dry skin b. irritability c. palpitations d. weight loss e. constipation f. cold intolerance

a, e, f signs of hypothyroidism include dry skin, hair and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesias; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement and goiter. irritability, palpitations, and weight loss are signs of hyperthyroidism

a nurse determines the finger stick blood glucose reading for a patient with diabetes is 750 mg/dL. what is the nurses priority action? a. immediately notify the RN and the HCP b. assess the vital signs of the patient c. check the record to verify whether the patient has type 1 or 2 diabetes d. administer prescribed sliding scale insulin

b The patient should be assessed immediately for responsiveness and additional signs and symptoms. Notifying the RN and the physician after the patient has been assessed are appropriate actions. Checking the record to verify type 1 or type 2 diabetes is not incorrect, but hopefully the nurse would know this information from shift report. Administering the insulin should not happen until further assessment is completed.

the home health nurse is visiting an older adult patient who has successfully managed her type 2 diabetes for years. during the visit, the nurse notes that the patient has severe arthritis, poor vision, and several dry, red areas on the lower extremities. what is the priority patient problem? a. potential for noncompliance due to social circumstances b. potential for ineffective self-health management due to aging c. potential for infection due to poor peripheral perfusion d. potential for disturbed sensory perception due to degenerative changes

b This patient has had type 2 diabetes for years, but now changes related to aging place the patient at risk for ineffective self-health management. Risk for noncompliance is an inappropriate diagnosis. Patient does not have a history of noncompliance but now needs interventions related to aging to maximize self-care. Patient does have risk for infection and problems with sensory input; however, again, the nurse should use interventions that address the problems of aging, so that the patient can continue self-care.

a nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 DM. which of the following actions should the nurse take? a. check blood glucose immediately after breakfast b. administer insulin when breakfast arrives c. hold breakfast for 1 hour after insulin administration d. clarify the prescription because insulin should not be administered at this time

b administering insulin aspart when breakfast arrives can prevent a hypoglycemic episode. insulin aspart is rapid acting and should be administered 5-10 minutes before breakfast

a postoperative patient is having incisional pain. as part of the nurse's assessment, the nurse notes that the patient is grimacing when he or she changes positions. the patient's grimace can be useful in the assessment and can be described in what manner? a. nursing diagnosis b. cue c. diagnosis d. inference

b A cue is a piece of data that influences clinical decisions. In this example, the grimacing of a postoperative patient "cues" the nurse that the patient may be experiencing discomfort.

a nurse assesses an 83 year old patient and finds a diastolic murmur on auscultation of the heart. the priority action for the nurse should be to: a. stop the examination and call the provider b. document the finding in the chart c. inquire if other members of the family have a murmur d. realize that such a murmur is normal in this age group

b A diastolic murmur is abnormal in this age group; a systolic murmur is often present and benign. The murmur should be documented. The discovery of a diastolic murmur is not urgent and the nurse should not call the physician about it. Inquiring if family members have a murmur is not relevant as there are many reasons for a murmur to occur. Inquiring about heart disease in family members is more pertinent.

a nursing assistant is attending to the needs of a patient with a head injury who is lethargic and has an increased ICP. which action by the NA indicated a need for further instruction? a. stopping the patient from coughing up secretions b. monitoring the BP every 2 hours c. dangling the patient on the side of the bed d. reporting blood on the dressing

b A patient who has increased intracranial pressure should have the blood pressure (BP) checked every 15 to 30 minutes, not just every 2 hours.

a nurse is caring for a client who has had diarrhea for 4 days. when assessing the client, the nurse should expect to see which finding? select all that apply a. bradycardia b. hypotension c. elevated temp d. poor skin turgor e. peripheral edema

b, c, d dehydration which leads to low blood pressure, increased temp, and poor skin turgor

a nurse is assisting an older adult at home who has rheumatoid arthritis in the hands and wrists. the nurse would intervene to teach the patient about joint protection if the patient: a. turned the door knob counterclockwise b. used the palms of the hands to push up and off the bed c. carried groceries into the house using both hands d. pushed the door open with their arms

b A patient with rheumatoid arthritis in the hands and wrists should not use the palms of the hands to push up off the bed as this puts undue pressure on the wrists. Turning the doorknob either direction should be done slowly and gently to prevent pain in the fingers and wrists. Groceries should be carried using both arms and hands and by holding the package close to the chest. Pushing the door open with an arm rather than the wrist and hand is appropriate.

a patient is admitted with a cardiac dysrhythmia. the morning laboratory values show potassium 6.1 mg/dL. what action is most important to take? a. encourage extra intake of fluid b. notify the provider immediately c. check the breakfast tray for sodium containing foods before serving d. check the patients vital signs

b A potassium level of 6.1 is above normal limits. Particularly in a patient with a heart problem, a high level of potassium may cause a serious dysrhythmia and the level should be lowered as quickly as possible. Call the physician and report the high level. Extra fluid is not indicated in this instance. Potassium, not sodium, is the problem. Increasing sodium intake is not recommended for a patient with heart problems. Monitoring the patient's vital signs is wise. Check to see if the heart rhythm is irregular, but the most important thing is to report the value to the physician.

a type of fracture in a child that may be indicative of child abuse is: a. greenstick fracture of the tibia b. spiral fracture of the femur c. pathological fracture of the fibula d. aligned fracture of the wrist

b A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.

During infancy, childhood, and adolescence, which nutrients are critical for the musculoskeletal development? a. Vitamins and minerals b. Protein and calcium c. Fats and carbohydrates d. Zinc and potassium

b Adequate stores of protein and calcium allow the developing musculoskeletal system to grow properly. Without the proper vitamins, minerals, and protein, the bones would not develop as they should.

a young patient returns from the OR after a BKA and is alert and quiet. the stump is elevated with the dressing dry and intact. what is the priority problem for this patient? a. altered body image b. potential for bleeding c. altered mobility d. insufficient knowledge

b After an amputation, a risk for bleeding is a priority safety concern. Disturbed body image will occur but is not the priority at this time. Impaired mobility has occurred but is not the priority nursing diagnosis at this time. Deficient knowledge is a probability regarding stump care, adjusting to a prosthesis, and using crutches or a wheelchair as well as maintaining balance while up but is not the priority at this time.

The nurse manager of a neuro-medical surgical unit reviewing potential manifestations of seizures with an orientee would become concerned if the new nurse included which of the following dysfunctions as a manifestation? a. Autonomic b. Family c. Motor d. Sensory

b Although family dysfunctions can result from long-term stress, this would not be a manifestation of a seizure. Autonomic dysfunctions (A) can be evident in a number of body systems, including the respiratory system (affecting breathing) and the cardiac system (affecting heart rate). Motor dysfunctions (C) are the common manifestations seen with seizure disorders such as the tonic-clonic type. Sensory dysfunctions (D) are manifestations such as the aura preceding a seizure that is often described by patients.

a patient asks what causes angina pectoris? an accurate response will be: a. it is caused by the decreased blood flow to the coronary arteries resulting from shunting of the blood b. it is caused by a decreased blood flow to the myocardium resulting from partial obstruction of the coronary arteries c. it is caused by poor oxygenation of the coronary arteries resulting from poor gas exchange across the alveolar basement membrane d. it is caused by the inflammation of the sternal cartilage

b Angina is caused by decreased flow through a coronary artery; the area of the heart supplied by the affected artery receives insufficient blood to function properly. Blood is not shunted anywhere. Angina is not related to poor oxygenation due to a problem in the lungs. The pain of angina is not caused by inflammation of the cartilage at the sternum.

when providing care for a patient with cardiac disease, the nurse understands that the patient is at risk for alteration in cardiac output. which of the following has the most potential to affect cardiac output? a. antihypertensive medications b. dysrhythmias c. chest pain d. atherosclerosis

b Antihypertensive medications may cause the heart rate to slow or the blood vessels to dilate, but at therapeutic doses should not significantly affect cardiac output. Chest pain and atherosclerosis may be associated with cardiac disease but they do not directly affect cardiac output. Major disturbances in cardiac rhythm can significantly alter cardiac output.

in providing nursing care for a patient who has undergone a thoracotomy, has a chest tube, and has pain and dyspnea, it is important to reduce anxiety because it: a. increases the pulse and BP b. causes tense muscles, which need more oxygen c. causes needless fear and worry d. delays recovery and healing of injured tissues

b Anxiety causes increased oxygen demand, which further increases the work of breathing.

a patient with PAD is prescribed a daily dose of aspirin. the nurse accurately explains the prescription by stating: a. aspirin controls the body temperature to reduce vasoconstriction b. aspirin helps prevent formation of clots c. aspirin protects the blood vessels from injury d. aspirin reduces pain associated with inadequate tissue perfusion

b Aspirin decreases platelet aggregation, thereby promoting better blood flow and decreasing the chance of clot formation. The dose of aspirin given is not sufficient to affect fever or pain. While preventing clots may decrease vessel injury, aspirin does not have a direct protection effect on blood vessels. The main purpose of aspirin for peripheral arterial disease is to decrease platelet aggregation and prevent clot formation.

a nurse is reviewing the medical record of a client who has rheumatoid arthritis. the nurse should review which of the following lab results when monitoring the disease? select all that apply a. urinalysis b. ESR c. BUN d. ANA titer e. WBC counts

b, d, e ESR, ANA titer, and WBC are labs that help diagnose RA. urinalysis detects kidney function. BUN detects kidney failure

a patient who has TURP complains of increasing bladder spasms. which is an appropriate initial nursing action? a. medicate with a B&O suppository b. check the urinary catheter tubing for kinks and obstruction c. teach relaxation exercises d. encourage use of PCA

b Before giving medication, the nurse checks to see that the tubing is not kinked and the catheter is draining well, as obstruction can cause bladder spasm. This is not an initial action. Abdominal distention may be a sign of catheter obstruction as well. Relaxation is not effective to eliminate spasms. The patient who has had a radical procedure may have a patient-controlled analgesia pump to control pain.

the patient's temperature is 100.4 degrees F. the skin on her forehead is warm and dry. she has been incontinent and her bed is wet. she complains of being very tired. which nursing intervention would be the highest priority? a. allow patient to rest b. change the bed linens and gown c. medicate for headache pain d. apply lotion to skin

b Changing the bed would take priority, and then administering medication for the headache would come next.

a nurse is assuming recovery room care of a 54 year old patient who has carpal tunnel repair. on receiving the patient, what is the priority nursing assessment? a. sensation in the fingertips b. color, warmth, and capillary refill c. condition of the dressing d. ROM

b Checking circulation in the hand by checking color, warmth and capillary refill is the priority nursing assessment after carpal tunnel surgery. Sensation in the fingertips will be important after any local anesthetic has worn off. The condition of the dressing is checked but is not the greatest priority. Range of motion of the wrist is not checked at this time so soon after surgery.

a patient has HF and atherosclerosis. which patient statement regarding healthy food choices demonstrates a need for further teaching? a. i can have an egg two to three times per week b. i need to watch my red meat intake, but can have all the cheese i want c. i should read labels to see how much sodium a serving contains d. canned goods are often high in sodium

b Cheese is high in sodium and should not be eaten freely in the diet. Two or three eggs per week are allowed, but that should include eggs in baked and other goods as well as fixed separately. Labels should be checked for both sodium and fat, particularly saturated fat content. Canned goods are higher in sodium than most frozen or fresh-prepared foods. Canned goods should be avoided when possible.

The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? a. Eat foods high in fiber. b. Drink 6 to 8 glasses of noncaffeinated fluids daily. c. Exercise in the morning and evening. d. Visit the urologist once yearly.

b Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.

The appearance of a petechial rash and respiratory distress 2 to 3 days after a fracture should be reported promptly because they may be symptomatic of which life-threatening complication? a. Infection b. Fat embolism c. Nerve damage d. Vitamin deficiency

b Fat embolism is a rare but serious complication of a bone fracture that has an abundance of marrow fat. The fat globules released when fat-bearing bone marrow is fractured must be large enough or sufficient in number to occlude a blood vessel, either partially or completely. Rupture of small venules in the area permits entrance of fat globules into the circulation. Signs and symptoms of fat embolism include a change in mental status followed by respiratory distress, tachypnea, crackles and wheezes that are heard when auscultating the lungs, rapid pulse, fever, and petechiae.

a nurse is reinforcing teaching with a group of adolescents about HIV/AIDS. which of the following statements should the nurse include? a. you can contact HIV through causal kissing b. HIV is transmitted through IV substance abuse c. HIV is now curable if caught in the early stages d. Medications inhibit transmission of the HIV virus

b HIV is spread by via blood, semen, vaginal secretions, and breast milk. IV or needle use is another way to contract HIV if an infected needle was used. casual kissing does not spread HIV. antiretroviral therapy slows the progression of HIV, but does not cure it. medications can suppress the progression and can reduce the risk of transmission, but medications can not completely prevent HIV.

Intracranial regulation would be a priority concern for the nurse caring for a patient with which admitting diagnosis? a. Failure to thrive b. Traumatic brain injury c. Upper respiratory infection d. Urinary tract infection

b Intracranial regulation would be a concern for a patient who suffered a traumatic brain injury. The primary concern for a patient with failure to thrive would be nutrition. The primary concern for a patient with an upper respiratory infection would be oxygenation. Concerns for the patient with a urinary tract infection would be thermoregulation and pain.

a nurse keeps a post craniotomy patient's neck in midline position and ensures that there is no excessive hip flexion. the rationale for the nurses action would be that this position: a. restores neutral position of the joints b. prevents further increase in ICP c. promotes comfort and rest d. prevents the formation of blood clots

b Keeping the neck in midline ensures proper drainage of fluids from the head; preventing excessive hip flexion seems to prevent increased intracranial pressure. A neutral position is not necessarily recommended. The midline position may not be comfortable for the patient. The midline position does not prevent formation of blood clots.

a nurse attends to the nutritional needs of a patient with chronic respiratory disease by providing oral care. what is the best rationale for this nursing action? a. low energy states diminished appetite b. respiratory secretions leave a bad taste c. chewing is believed to induce coughing spells d. nasal congestions reduces the flavor of food

b Mouth care is especially needed before meals, when the taste or odor of the sputum may adversely affect appetite. Low energy, coughing, and nasal congestion may be present, but are not relieved by oral hygiene.

a nurse is collecting data from an infant. the nurse should identify that which of the following findings indicates that the infant is experiencing pain? select all that apply a. pursed lips b. loud cry c. lowered eyebrows d. rigid body e. pushes away stimulus

b, c, d infants experiencing pain may have a loud cry, low and drawn together eyebrows, and rigid body. they also have an open mouth, not pursed lips.

a nurse has just received shift report on four assigned orthopedic patients. which patient should the nurse check on first? a. a young trauma patient with a BKA who is having phantom pain b. an older adult woman with a with a total hip replacement who needs assistance with the bedpan c. a women with an external fixation who has a fever and foul odor at the pin sites d. a man with a full leg cast who reports persistent pain despite elevation and pain medication

b Obtaining assistance for the hip replacement patient needing help with the bedpan should be handled first so that the patient does not have an accident with feces or urine in the bed that might contaminate her wound and dressing; a nursing assistant could be sent to attend to the patient. The patient with phantom pain needs assistance but does not take priority. The woman with an external fixation device who has a fever and foul odor at the pin site is experiencing an infection and the surgeon needs to be notified so that treatment can be started. This would be the nurse's second action. The man with the full leg cast experiencing pain needs to be reassessed and pain relief sought.

which is a correctly stated expected outcome? a. sit in the chair 3 times a day b. patient will walk to the end of the hall this week c. use the incentive spirometer every 2 hours for 3 days d. patient will respond to pain medication

b Patient will walk to the end of the hall this week is the correctly written expected outcome because it contains a subject, an action, and a time frame for the action to be accomplished.

A patient is questioning the nurse about circulation and perfusion. What is the nurse's best response? a. Perfusion assists the body by preventing clots and increasing stamina. b. Perfusion assists the cell by delivering oxygen and removing waste products. c. Perfusion assists the heart by increasing the cardiac output. d. Perfusion assists the brain by increasing mental alertness.

b Perfusion delivers much needed oxygen to the cells of the body and then helps to remove waste products. Perfusion does not prevent clots, does not increase cardiac output, and does not increase mental alertness.

A patient who is undergoing surgery will have an intravenous solution to which insulin will be added. Which type of insulin must be used? a. Lente b. Regular c. Ultralente d. Neutral protamine Hagedorn (NPH)

b Regular insulin is the only type that may be administered intravenously. NPH, Lantus, and Ultralente may be administered only subcutaneously.

a nurse is evaluating teaching to a client who has a new prescription for sequential compression devices. which of the following statements should indicate to the nurse that the client understands the teaching? a. this device will keep me from getting sores on my skin b. this thing will keep the blood pumping through my leg c. with this thing on my leg muscles wont get weak d. this device is going to keep my joints in good shape

b SCDs promote venous return in the deep veins of the legs and thus help prevent thrombus prevention. the nurse assesses the skin under the SCDs every 8 hours, continuous passive motions machines keep the muscles and joints active

a young man is admitted to the ED after an injury to the left leg sustained playing football. he is complaining of pain around the knee and upper tibia. which data from the nurses assessment would indicate a fracture of the tibia rather than a connective tissue injury of the knee? a. pain and soft tissue swelling around the knee and an abrasion on the knee b. pain, ecchymosis below the knee, and crepitation with any movement of the knee c. pain, swelling, and loss of function in the foot d. limping when walking, facial grimace, and some swelling of the lower knee and lower leg

b Signs of fracture include pain, swelling, ecchymosis into the tissues surrounding the fracture and crepitation upon movement of the affected bone. An abrasion of the knee, pain, and soft-tissue swelling most likely indicate a connective tissue injury. Loss of function of the foot would not occur with a fracture of the upper tibia. The patient would be unable to walk with a fracture of the upper tibia due to extreme pain when trying to walk.

The nurse is reviewing skin care of an immobilized patient with an unlicensed assistive employee. The nurse knows the employee understands the importance of skin care when making which statement? a. "Proper care of the skin is important because the immobilized patient does not want to smell bad." b. "Proper care of the skin is important because the immobilized patient is at high risk for breakdown." c. "Proper care of the skin is important because the immobilized patient will have many visitors." d. "Proper care of the skin is important because the immobilized patient will be incontinent."

b Skin care is important for an immobilized patient because the patient is prone to skin breakdown from pressure and body fluids. Body odor (smell) is embarrassing to the patient, but it does not pose a risk to the skin. Not every immobilized patient is incontinent. Having visitors does not pose a risk to the skin.

The nurse is assessing injuries on a patient admitted to the unit who had fallen at home several hours ago. When looking at the patient's history, the nurse notices that he has smoked at least four packs of cigarettes per day for the past 60 years. What impact does smoking have on the musculoskeletal health of a patient? a. Smoking increases the risk of more falls in the elderly. b. Smoking increases the risk of developing osteoporosis. c. Smoking decreases the risk of developing osteoporosis. d. Smoking decreases the risk of a hip fracture as you age.

b Smoking has a significant impact on the musculoskeletal health of a patient because it increases the risk of developing osteoporosis, increases the risk of a hip fracture with aging, increases the risk of developing exercise-related injuries, has a detrimental effect on fracture and wound healing, has a detrimental effect on athletic performance, and is associated with low back pain and rheumatoid arthritis.

a patient with diabetes asks if a slice of cake can be added to the meal for dessert. the best response by the nurse would be: a. "diabetic patients should not eat cake" b. "yes, but you must omit other carbohydrates of equal value from the meal" c. "you will have to check with your HCP" d. "yes, but don't do this too often"

b Sweets can be consumed by a person with diabetes, but moderation is the key, since carbohydrate value of foods must be understood and consistent in the diet in order to avoid hyperglycemia. It is advised that sweets be limited because they are usually limited in protein and other nutrients.

a client with benign prostatic hyperplasia (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation postoperatively. which are the s/s of transurethral resection (TUR) syndrome? a. tachycardia and diarrhea b. bradycardia and confusion c. increased urinary output and anemia d. decreased urinary output and bladder spasms

b TUR syndrome is increased absorption of nonelectrolyte irrigating fluid used during surgery.

a 48 year old patient patient is admitted for tachycardia, shortness of breath, and chest pain eased by sitting up and leaning forward. the nurse auscultates for a high pitched scratchy sound at the left sternal border of the chest. the patient most likely has: a. heart failure b. pericarditis c. pneumonia d. aortic stenosis

b Tachycardia, shortness of breath, and chest pain that is relieved when leaning forward plus a high-pitched scratchy sound on auscultation are signs of pericarditis and pericardial friction rub. Although dyspnea is a sign of heart failure, the other signs listed are not signs of heart failure. Pneumonia pain does not ease with leaning forward, and there will be no pericardial friction rub present. Aortic stenosis may cause chest pain, but it does not cause a pericardial friction rub.

The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement? a. The patient must remain in the restraints all day. b. The patient needs to be toileted to maintain a regular toileting schedule. c. The patient needs to be provided with adult briefs for incontinence. d. The patient will use the call bell when he or she feels the urge to void.

b The correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.

A patient newly diagnosed with diabetes is learning to administer his injections of NPH and regular insulin. Which statement indicates that the patient understands the nurse's teaching regarding proper insulin administration? a. "I will draw up the NPH before the regular insulin." b. "I will draw up the regular insulin before the NPH." c. "I will give myself the NPH and the regular insulin in two different injections." d. "It doesn't matter which insulin I draw up first, as long as the amount is correct."

b The dose of regular insulin is drawn up into the syringe before the NPH to prevent accidentally contaminating the rapid-acting insulin (regular) with time-released insulin (NPH). Regular and NPH can be given mixed in one injection, as long as the regular insulin is drawn up before the NPH.

a nurse finds a patient who is unresponsive and calls for help. the patient is not breathing and does not have a pulse. the nurse begins CPR with 30 compressions and attempts to ventilate. the chest does not rise. the head is retilted and another attempt to ventilate is unsuccessful. what does the nurse do next? a. perform abdominal thrust b. continues CPR with chest compression c. retilts the head and attempts to ventilate again d. performs a blind finger sweep

b The patient has an obstructed airway. Abdominal thrusts and blind finger sweeps are no longer recommended for unconscious obstructed airway patients.

The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? a. Confusion and reliance on another person for insulin injections b. Requirements for intensive therapy with small, frequent insulin doses c. Visual impairment affecting the ability to draw up insulin accurately d. Frequent episodes of hypoglycemia

b The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.

a nurse is assessing a client who has hypoglycemia.which of the following findings should the nurse expect? a. fruity breath b. diaphoresis c. ketones in urine d. polyuria

b a client who has hypoglycemia can have diaphoresis and cool, clammy skin

the client was seen and treated in the ED for a concussion. before discharge the nurse explains the s/s of a worsening condition. the nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which s/s? a. vomiting b. minor headache c. difficulty speaking d. difficulty awakening

b a patient with a concussion has confusion, difficulty awakening or speaking, one sided weakness, vomiting or severe headache

the nurse is caring for a client after a mastectomy. which finding would indicate that the client is experiencing a complication related to the surgery? a. mild pain on the incisional site b. arm edema on the operative side c. sanguineous drainage in the drainage tube d. complaints of decreased sensation near the operative site

b arm edema on the operative side is a complication after mastectomy that can occur immediately, months or even years after surgery. options 1, 3, 4 are all normal findings after a mastectomy

a nurse is caring for a client who has heart failure and reports increased shortness of breath. the nurse increases the oxygen per protocol. which of the following actions should the nurse take first? a. weight the client b. assist the client into the high fowlers position c. auscultate lung sounds d. check oxygen saturation with pulse oximeter

b assisting to the high fowlers position makes it easier for the person to breathe.

a nurse is reinforcing teaching with a client who has angina pectoris and is learning how to treat acute anginal attacks. the client asks, what is my next step if i take one tablet, wait 5 minutes but still have anginal pain? which of the following responses should the nurse make? a. take two more sublingual tabs at the same time b. call the emergency response team c. take a sustained release nitroglycerin capsule d. wait another 5 minutes and take a second sublingual tab

b call the team and then take another sublingual tab. if the tab doesnt work it could mean that the client is having an MI

a client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. which teaching information should the nurse reinforce upon discharge? a. keep insulin vials refrigerated at all times b. rotate the injection sites systemically c. increase the amount of insulin before unusual exercise d. monitor the urine acetone level to determine the insulin dosage

b changing sites can prevent dramatic changes in daily insulin absorption

a nurse is assisting with a group discussion about fractures. which of the following actions information should the nurse include? a. children need a longer time to heal from a fracture than an adult b. epiphyseal plate injuries can result in altered bone growth c. a greenstick fracture is a complete break in the bone d. bones are unable to bend so they break

b detection of plate injury is crucial to prevent altered bone growth. children heal faster than adults. a greenstick fracture is a partial break in the bone. childrens bones are pliable and can bend 45 degrees before they break

a nurse is teaching a client who is undergoing cancer treatment about interventions to manage stomatitis. which of the following statements by the client indicates understanding of the teaching? a. i will try chewing larger pieces of food b. i will avoid tasting my bread c. i will consume more food in the morning d. i will add more citrus foods to my diet

b dry coarse foods such as toast can worsen manifestations of stomatitis. the client should cut their food into smaller pieces to reduce the mucous membrane irritation, this intervention is indicated for the client who has fatigue due to cancer treatment, and acidic foods can increase mucous membrane irritation in someone who has stomatitis and is undergoing cancer treatment

a nurse is reinforcing teaching with a client who has a new prescription for omeprazole for heartburn. which of the following information should the nurse include? a. take this medication at bedtime b. this medication decreases the production of gastric acid c. take this medication 2 hours after eating d. this medication can cause hyperkalemia

b omeprazole reduces stomach acid by inhibiting the gastric acid production enzyme. his medication should be taken in the morning, with food and water, and it can cause hypomagnesemia, not hyperkalemia

the most opportunistic infection in clients with HIV infection is: a. aphthae b. candidiasis c. cytomegalovirus (CMV) d. herpes simplex (HSV)

b oral candidiasis or thrush is the most common opportunistic infections in HIV clients. although CMV and HSV are opportunistic infections that are typically seen in full blown AIDS. aphthae or canker sores are not opportunistic infections

a nurse is reviewing the prescriptions for a client who has a pneumothorax. which of the following actions should the nurse perform first? a. check the clients pain b. obtain a large bore IV needle for decompression c. administer lorazepam d. prepare for chest tube insertion

b priority action ABC, airway, breathing, circulation

a nurse is reinforcing instructions with a client who has grave's disease and a new prescription for propranolol. which of the following information should the nurse include? a. "an adverse effect of this medication is jaundice" b. "take your pulse before each dose" c. "the purpose of this medication is to decrease production of thyroid hormone" d. "you should stop taking this medication if you have a sore throat"

b propranolol causes bradycardia, so you should take your pulse before you take it

the nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. the client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? a. polyuria b. shakiness c. blurred vision d. fruity breath odor

b shakiness is a sign of hypoglycemia. polyuria, blurred vision, and fruity breath are signs of hyperglycemia

a nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. the nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? a. hypothermia b. respiratory distress c. hematoma of the left groin d. discomfort in the left groin

b signs of an allergic reaction are localized itching, edema, respiratory distress, stridor, and decreased BP

a nurse is collecting data from a client who has anemia. which of the following integumentary aspects should the nurse expect? a. absent turgor b. spoon shaped nails c. shiny, hairless legs d. yellow mucous membranes

b spoon shaped nails and other nail deformities are expected with anemia. absent skin turgor is related to dehydration, shiny, hairless legs are with PVD, and yellow mucous membranes are for jaundice

the nurse is evaluating the clients use of a cane for left sided weakness. the nurse should intervene and correct the client if the nurse observed that the client performed which action? a. holds the cane on the right side b. moves the cane when the right leg is moved c. leans on the cane when the right leg swings through d. keeps the cane 6 inches out to the side of the right foot

b the cane is help on the stronger side to minimize stress on the affected extremity and provide a wide base of support. the cane is help 6 inches lateral to the fifth great toe. the cane is moved forward with the affected leg. the client leans on the cane for added support while the stronger side swings through

the nurse is planning to reinforce instructions to the client about how to stand on crutches. in the instructions the nurse should plan to tell the client to place the crutches in which position? a. 3 inches infront of the foot and side of the clients toes b. 8 inches infront of the foot and side of the clients toes c. 15 inches to the front and side of the clients toes d. 20 inches to the front and side of the clients toes

b the classic tripod position is taught to the client before giving instructions on gait. the crutches are placed anywhere from 6-10 inches in front and to the side of the client depending on the clients body size. this provides a wide base of support to the client and improves balance

a nurse is caring for a client who has diabetes mellitus and is shaky and weak. which of the following actions should the nurse take? a. provide subcutaneous insulin for the client b. offer the client 120 ml (4 oz) of fruit juice c. give the client IV potassium d. administer IV sodium bicarbonate

b the client has manifestations of hypoglycemia, so offer juice to help bring it up

b the client should not drive because the device impairs the range of vision

the nurse has provided discharge instructions to a client with an application of a halo device. the nurse determines that the client needs further teaching if which statement is made? a. i will use a straw for drinking b. i will drive only during the day time c. i will use caution because the device alters balance d. i will wash the skin daily under the lambs wool liner of the vest

b the client should not drive because the device impairs the range of vision

a nurse is assisting in the care of a client immediately following vertebroplasty of the thoracic spine. which of the following actions should the nurse take? a. apply heat to the puncture site b. place the client in supine position c. turn the client every 1 hour d. ambulate the client within the first hour of the procedure

b the client should remain in a supine position with the bed flat for the first 1-2 hours following the procedure

a client is complaining of skin irritation from the edges of a cast applied the previous day. the nurse should plan for which intervention? a. massaging the skin at the rim of the cast b. petaling the cast edges with adhesive tape c. using a rough file to smooth the cast edges d. applying lotion to the skin at the rim of the cast

b the edges of the cast can be petaled with adhesive tape to minimize skin irritation. if a client has a cast applied and returns home, the client can be taught to do the same. massaging and applying lotion will not alleviate the skin irritation from the cast edges. filing the edges could cause pieces to fall off and irritate the skin

a nurse is planning to use healing intention with a client who is recovering from a lengthy illness. which of the following is the priority action the nurse should take before attempting this particular mind-body intervention? a. tell the client the goal of the therapy is to promote healing b. ask whether the client is comfortable with using prayer c. encourage the client to participate actively for best results d. instruct the client to relax during the therapy

b the first step to take in the action process is to assess what the client wants or feels. the other options are correct but they are not the very first step you take

a nurse is caring for a client who has a pulmonary embolism and a new prescription for heparin therapy. which of the following statements by the client should indicate an immediate concern for the nurse? a. i am allergic to morphine b. i take antacids several times a day for stomach ulcer c. i had a blood clot in my leg several years ago d. it hurts to take a deep breath

b the greatest risk to the client is the possibility of bleeding from a peptic ulcer. the priority intervention is to notify the provider

a nurse is receives a prescription for an antibiotic for a client who has cellulitis. the nurse checks the clients medical record, discovers that she is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. which of the following critical thinking attitudes did the nurse demonstrate? a. fairness b. responsibility c. risk taking d. creativity

b the nurse is responsible for administering medications in a safe manner and according to standards of practice

a nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased ICP. which position should require intervention by the nurse? a. head midline b. head turned to the side c. neck in neutral position d. head of bed elevated 30-45 degrees

b the nurse should avoid flexion of the neck. the neck needs to be in midline position

a nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractures following a BKA 24 hours ago. which of the following actions should the nurse include in the plan of care? a. limit any types of exercise to the residual limb for the first 48 hours b. position the client prone several times a day c. wrap the stump in a figure 8 pattern d. encourage sitting in a chair during the day

b the nurse should position the client prone 20-30 minutes a day to prevent flexion.

a nurse in an oncology clinic is caring for a client who is undergoing treatment for cancer and reports difficulty eating due to inability to taste food. which of the following interventions should the nurse recommend? a. avoid citrus juices b. use plastic utensils to eat c. eat foods that are warm d. increase foods high in pectin

b the use of plastic utensils enhances the taste of food and reduces the metallic taste. a patient who is undergoing cancer treatment can have altered taste should try to add tart food to their diet, eating cold foods increases sensation, and they should add pectin-rich food to increase the bulk of the stool and lengthen transition time in the colon

a nurse is reviewing a client health record that includes a report of weight gain in the abdomen and laboratory findings of elevated blood glucose and elevated triglycerides. the nurse should identify that these findings are manifestations of which of the following conditions? a. anemia b. metabolic syndrome c. heart failure d. hypertension

b weight gain in the abdomen, elevated blood glucose, and elevated triglycerides are manifestations associated with a metabolic syndrome

a nurse is reinforcing dietary teaching about calcium rich foods to a client who has osteoporosis. which of the following foods should the nurse include in the instructions? a. white bread b. white beans c. white meat of chicken d. white rice

b white beans are a good source of calcium

a nurse in a providers office is reviewing the health record of a client who is undergoing evaluation for grave's disease. which of the following laboratory results is an expected finding? a. decreased thyrotropin receptor antibodies (TRAb) b. decreased thyroid stimulating hormone (TSH) c. decreased free thyroxine index (T4) d. decreased triiodothyronine (T3)

b with graves disease low TSH is expected

a nurse answers the call light if a patient admitted with HF. the patient states he is short of breath and appears to be in distress. identify the actions of the nurse in priority order. a. apply supplemental oxygen b. raise the head of the bed c. notify the provider d. check the vital signs e. listen to lung sounds

b, a, d, e, c Raising the head of the bed can help immediately in easing breathing. Oxygen should be applied to supplement oxygen until further assessment can be done. Vital signs with pulse oximetry and assessment of lung sounds all need to be rechecked due to the patient's change in condition and to have the most current information available for the provider.

a nurse is discussing the risk factors for somatic symptoms with a newly licensed nurse. which of the following risk factors should the nurse include? select all that apply a. age older than 65 years b. anxiety disorder c. female gender d. coronary artery disease e. obesity

b, c

an infant is admitted with a diagnosis of RSV. the type of transmission based isolation precaution the nurse would set up would be: select all that apply a. standard precautions b. droplet precautions c. contact precautions d. airborne infection isolation precautions

b, c RSV is spread by direct contact with respiratory secretions. Contact isolation precautions are used to prevent fomite spread. RSV can be spread when droplets containing the virus are sneezed or coughed into the air by an infected person. Such droplets can linger briefly in the air, and if someone inhales the particles or the particles contact his or her nose, mouth, or eye, he or she can become infected; therefore droplet precautions are implemented as well.

a nurse is collecting data from a client who has a chest tube and a drainage system. which of the following findings should the nurse expect? select all that apply a. continuous bubbling in the water seal chamber b. gentle constant bubbling in the suction control chamber c. rise and fall in the level of water in the water seal chamber with inspiration and expiration d. exposed sutures without dressing e. drainage system upright at chest

b, c gentle bubbling is expected as air is being removed, and rise and fall on inspiration and exhalation show that the drainage system is functioning properly

a nurse is reviewing documentation with a group of newly licensed nurses. which of the following guidelines should be followed when documenting in a clients record? select all that apply a. cover errors with correction fluid, and write in correct information b. put the dates and time on all entries c. document objective data, leaving out opinions d. use as many abbreviations as possible e. wait until the end of the shift to document

b, c the day and time confirm the recording of the correct sequence of events and documentation should be factual, descriptive, and objective without judgement or criticism. correction fluid implies the nurse was trying to hide something, too many abbreviations will make it too difficult to understand, and documentation should be current, waiting til the end of the day could result in data omission

a 40 year old man with a t4 spinal injury suddenly complains of severe headache, increased pulse rate, sweating, and flushing above the level of spinal cord lesion and goose bumps below the level of injury. which immediate nursing actions should be included? select all that apply a. place in flat bed b. identify the cause of the spasm c. decreased blood pressure d. provide measures to facilitate bowel movement e. clamp indwelling catheter

b, c, d Identify and gently relieve the cause of the autonomic dysreflexia reaction, decrease the blood pressure by elevating the head of the bed 45 degrees or sit the patient up, and institute measures to evacuate the bowel, will not resolve the problem and may exacerbate it.

a patient is receiving a drug that may cause postural hypotension. for safety, the nurse should instruct the patient to do what? select all that apply a. increase fluid intake to prevent dehydration b. arise slowly from a lying to a sitting position c. sit on the side of the bed until not light headed before standing d. stand holding onto the bed rail to stabilize before walking e. always ask for assistance when up and moving around

b, c, d Instructing to always change position slowly, sit on the edge of the bed until not dizzy, and to arise slowly and stand holding onto the bedrail are all appropriate safety measures. Postural hypotension from medication side effects is not related to fluid status, and increasing fluids will not prevent it in this situation. It is not necessary to always have someone assist when up and about unless there is a need to ambulate and the patient is still dizzy and unsteady.

a nurse admits a 23 year old patient with possible appendicitis. the nurse anticipates which s/s? a. increased red cell count. select all that apply b. abdominal tenderness c. anorexia and vomiting d. mild fever e. dark black stools

b, c, d Tenderness, nausea, anorexia, and fever are part of the clinical picture for appendicitis. The white blood cell (not the red blood cell) count is likely to be high. Dark, black stool is more associated with GI bleeding than appendicitis.

a nurse is contributing to the plan of care for a child who has asthma. which of the following interventions should the nurse recommend during an asthma exacerbation? select all that apply a. perform chest percussion b. place the child in an upright position c. monitor oxygen saturation d. administer bronchodilators e. administer dornase alfa

b, c, d a child needs to be placed upright, oxygen monitoring and bronchodilators to promote ventilation

a nurse is collecting data from a client who has suspected cancer. which of the following findings should the nurse expect? select all that apply a. temp 102 degrees for more than 48 hours b. presence of a sore that does not heal c. difficulty swallowing d. unusual discharge e. weight gain of 4 lbs in 2 weeks

b, c, d a sore throat, difficulty swallowing, and unusual discharge are not warning signs of cancer. weight loss is more a sign of cancer and a prolonged fever is not a sign of cancer

a nurse is caring for a child who is in skeletal traction. which of the following actions should the nurse take? select all that apply a. remove the weights to reposition the child b. check the childs position frequently c. observe pin sites every 4 hours d. ensure the weights are hanging freely e. ensure the ropes knot is in contact with the pulley

b, c, d checking position ensures alignment, observing pin sites often will help to monitor for infection, and ensure the weights are hanging freely to allow for prescribed traction. only the provider should remove the weights except for in emergency situations. the knot rope should not touch the pulley as this will alter the weight of the traction

a nurse is reinforcing discharge teaching with a client who has addison's disease and is taking hydrocortisone. which of the following instructions should the nurse include? (select all that apply) a. take the medication on an empty stomach b. notify the provider of any illness or stress c. report any manifestations of weakness or dizziness d. do not discontinue the medication suddenly e. eat a low sodium diet

b, c, d stress increases the need for hydrocortisone, weakness or dizziness are indications of adrenal insufficiency, and rapid discontinuation can result from adverse effects

a nurse is preparing to initiate bladder retraining program for a client who has incontinence. which of the following actions should the nurse take? select all that apply a. establish a schedule of urinating prior to meal times b. have the client record urination times c. gradually increases the urination levels d. remind the client to hold urine until the next scheduled urination time e. provide a sterile container for urine

b, c, d the nurse should tell the client to keep a record of progress toward the goal of 4 hour intervals, gradually increasing the urination intervals helps the client reach the goal of 4 hour intervals, and remind the client to hold the urine until the next scheduled urination time

a nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. which of the following information should the nurse include? (select all that apply) a. weight gain will occur while taking this medication b. do not discontinue medication without the advice of the provider c. have follow up serum TSH levels performed d. take the medication on an empty stomach e. use fiber laxatives for constipation

b, c, d dont discontinue the medication without talking to a HCP, serum TSH levels monitor the effectiveness of the medication, and taking the medication on an empty stomach promotes absorption

a nurse is collecting data from a client who has a suspected flail chest. which of the following findings should the nurse expect? select all that apply a. bradycardia b. cyanosis c. hypotension d. dyspnea e. paradoxic chest movement

b, c, d, e all of those are manifestations of flail chest

a nurse is collecting data from a client who has DKA and ketones in the urine. the nurse should expect which of the following findings? (select all that apply) a. weight gain b. fruity odor of breath c. abdominal pain d. kussumal respirations e. metabolic acidosis

b, c, d, e fruity odor to breath, abdominal pain, kussumal respirations, and metabolic acidosis are all manifestations of DKA or ketones in the urine

a nurse is assisting in the admission of an older adult client who has suspected osteoporosis. which of the following findings should the nurse expect? (select all that apply) a. history of consuming one glass of wine daily b. loss in height of 5.1 cm (2 in) c. BMI of 21 d. kyphotic curve at upper thoracic spine e. history of lactose intolerance

b, c, d, e loss of two inches could be from a fracture in a vertebra column, low body weight for a heavier person can be a risk factor for osteoporosis, kyphosis is a curvature of the spine which causes shortening and a risk for osteoporosis, lack of calcium is a risk factor for osteoporosis

a nurse is discussing the HIPPA privacy rule with nurses during new nurse orientation. which of the following information should the nurse include? select all that apply a. a single electronic records password is provided for the nurses on the same unit b. family members should provide a code prior to receiving client health information c. communication if client information can occur at the nurses station d. a client can request a copy of her medical record

b, c, d, e many hospitals have a security code to ask about the patients health status, communication about patient status should only happen in a private setting, clients have the right to read and obtain a copy of their medical record, and the client can only photocopy a patients record to give to another facility. each staff should have their own password to protect the patients information

a nurse is contributing to the plan of care for a client who is undergoing chemotherapy and is on neutropenic precautions. which of the following interventions should the nurse recommend? select all that apply a. encourage a high fiber diet b. remove plants from the room c. have the client wear a mask when leaving the room d. have client specific equipment remain the the room e. eliminate raw foods from the clients diet

b, c, d, e neutropenic precautions include no plants, the client wearing a mask when out of the room, the client have their own equipment, and no raw foods. there is no benefit to a high fiber diet for someone with neutropenic precautions

a nurse is collecting data from a child who has asthma. which of the following findings should the nurse identify as indicating the childs respiratory status is deteriorating? select all that apply a. o2 sat 95% b. wheezing c. retracting of sternal muscles d. agitation e. nasal flaring

b, c, d, e wheezing is present in asthma, increased work of breathing causes retraction, agitation, and nasal flaring

a nurse is collecting an admission history from a female client who has hypothyroidism. which of the following findings should the nurse apply? (select all that apply) a. diarrhea b. menorrhagia c. dry skin d. increased libido e. hoarseness

b, c, e abnormal menstrual periods, dry skin, and hoarseness are all manifestations of hypothyroidism

the nurse is assisting the plan of care for a client with a chest tube. the nurse should suggest to include which intervention? select all that apply a. pin the tubing to the bed linens b. be sure all connections remain airtight c. be sure all connections are taped and secure d. empty the drainage from the drainage collection chamber daily e. monitor closely for tubing that is kinked or obstructed by the weight of the client

b, c, e don't pin the tube to anything incase the patient moves and it comes out, never open the system

a nurse is caring for a child who sustained a fracture. which of the following actions should the nurse take? select all that apply a. place a heat pack on the site of injury b. elevate the affected limb c. check the neurovascular status frequently d. encourage ROM of the affected limb e. stabilize the injury

b, c, e elevating the limb with decrease risk for swelling, checking neurovascular status helps determine blood flow to the extremity, and stabilizing will help prevent further injury. an ice pack is placed to help prevent swelling and the nurse should encourage ROM on the unaffected limb

a nurse is collecting data from an infant. the nurse should identify which of the following findings as manifestations of acute otitis media? select all that apply a. decreased pain in the supine position b. rolling head side to side c. loss of appetite d. increased sensitivity to sound e. crying

b, c, e rolling head, loss of appetite, and crying are normal because of the pressure built up in the ears. infants have increased pressure in the supine position. they have decreased sensitivity to sound because of the fluid built up

a nurse is collecting data from a client who is having an acute asthma attack. which of the following findings should indicate to the nurse that the client's respiratory status is declining? select all that apply a. SaO2 95% b. wheezing c. retraction of sternal muscles d. pink mucous membranes e. premature ventricular complexes (PVCs)

b, c, e wheezing and retraction of sternal muscles are indicators of bronchoconstriction, and PVCs are manifestations of hypoxemia

older adults are more prone to respiratory problems because aging causes which to change? select all that apply a. thinning of the alveolar membrane b. decreased elasticity of respiratory tissues c. increased secretion production d. decreased efficiency of the immune system

b, d Older adults have decreased elasticity of many body tissues, including the pulmonary system. This decreased elasticity leads to the lung tissue losing some of its elastic recoil and increasing the likelihood of retaining secretions that can become a medium for bacterial growth. In addition, older adults have a less responsive immune system, allowing infections to take hold before evidence of the infection is obvious.

a nurse in a providers office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. the client relates a history of three vaginal births, but no serious accidents or illnesses. which of the following interventions should the nurse suggest for helping to control or eliminate the clients incontinence? select all that apply a. limit total daily fluid intake b. decrease or avoid caffeine c. take calcium supplements d. avoid drinking alcohol e. use the Credè maneuver

b, d caffeine and alcohol are bladder irritants and can worsen stress incontinence

a nurse is caring for a client who is at risk for increased ICP. which of the following actions should the nurse take to decrease the potential for raising the clients ICP? select all that apply a. suction the client frequently b. decrease the noise level in the clients room c. elevate the clients head onto two pillows d. administer a stool softener e. keep the client well hydrated

b, d decreasing the noise level will help keep ICP down and administering a stool softener will decrease the need to bear down during bowel movements which can increase ICP

a nurse is caring for a client who is in labor and has HIV. which of the following procedures should the nurse identify as being safe for his client? select all that apply a. vacuum extraction b. oxytocin infusion c. use of forceps d. cesarean birth e. internal fetal monitoring

b, d oxytocin infusion is a noninvasive procedure and has less risk of exposing the baby to the mothers blood. c-section birth is recommended for people with HIV to reduce the risk of transmission to the baby. vacuum extraction, use of forceps, and internal fetal monitoring pose an increased risk at spreading the virus to the baby, so those should be avoided.

a nurse is screening a client for hypertension. which of the following actions by the client increases the risk for hypertension? select all that apply a. drinking 8 oz nonfat milk daily b. eating popcorn at the movie theater c. walking 1 mile daily at 12 min/mile pace d. consuming 36 oz beer daily e. getting a massage once a week

b, d popcorn has a high amount of sodium and fat in it which increases the risk for hypertension, and consuming more than 24 oz of beer a day for men and 12 oz of beer a day for women put them at risk for hypertension

a patient complains of severe muscle cramping and muscle twitching after a thyroidectomy. the following orders are obtained. place them in order or priority. a. seizure precaution b. administer calcium gluconate c. high calcium diet d. place on ECG monitor

b, d, a, c There is a possibility that an accidental removal of the parathyroid gland occurred during surgery; parathormone is essential for calcium regulation. Calcium gluconate should be given to correct the deficiency. Alterations in calcium levels can cause dysrhythmias so cardiac monitoring should be quickly implemented. Further decline in calcium levels can lead to seizures. Administration of calcium can prevent the cardiac dysrhythmias and seizures so it takes priority. Maintaining calcium levels can be helped by diet.

the patient's temperature is 100.4 degrees F. the skin on her forehead is warm and dry. she has been incontinent and her bed is wet. she complains of being very tired. which data is subjective? select all that apply a. temp of 100.4 b. states i am very uncomfortable c. bed is wet d. complains of being very tired e. states i have a headache

b, d, e "I'm very uncomfortable"; complains of being very tired; and states, "I have a headache" are all subjective data.

which statement(s) regarding drug use and the risk of cardiac disease is/are true? select all that apply a. the vasodilation effects of cocaine hasten atherosclerosis b. sudden cardias death is associated with cocaine use c. methamphetamine dilates blood vessels d. cigarette smoking contributes heavily to heart disease e. methamphetamine can cause myocardial infarction

b, d, e Cocaine can cause sudden cardiac death because of its vasoconstrictive action on vessels, including the coronary arteries. Nicotine in cigarettes causes vasoconstriction and also causes changes in the vessel walls leading to arteriosclerosis. Methamphetamine speeds up electrical conduction in the heart and can cause dysrhythmia that may lead to myocardial infarction. Cocaine causes constriction, not vasodilation. Methamphetamine causes vasoconstriction, not vasodilation.

a nurse is reviewing the medical record for a client who has RA. the nurse should review which of the following lab results when monitoring this disease? select all that apply a. urinalysis b. erythrocyte sedimentation rate (ESR) c. BUN d. antinuclear antibody (ANA) titer e. WBC count

b, d, e ESR, ANA, and WBC diagnoses RA. urinalysis and BUN detect kidney function

The patient presents to the clinic with a compound fracture of the right leg. The nurse anticipates the administration of which classes of medications? Select all that apply. a. Aspirin b. Tetanus booster c. Hepatitis B vaccine d. Intravenous (IV) morphine e. IV antibiotics

b, d, e The nurse should anticipate administering a tetanus immunization or booster, IV narcotic pain medications, and IV prophylactic antibiotics to prevent infection and control pain in the patient who has suffered an open fracture. The patient has an open wound, so aspirin is not appropriate due to the risk of bleeding. The hepatitis B vaccine is not necessary for this patient.

when interviewing the patient complaining of moderate chest pain, what question(s) should be asked? select all that apply a. who witnessed the pain b. what does the pain or discomfort feel like? c. what relaxation strategies were implemented? d. where is the pain located? e. to where does the pain radiate?

b, d, e These questions are part of the standard interview process for the patient experiencing chest pain. See Focused Assessment box, Data Collection for the Cardiovascular System. The patient is the best judge of the pain. What relaxation strategies were implemented is not a pertinent question at this time. It is an appropriate question when assessing coping techniques for stress.

a nurse is reinforcing teaching with an adolescent who has diabetes mellitus about manifestations of hypoglycemia. which of the following findings should the nurse include? (select all that apply) a. increased urination b. hunger c. manifestations of dehydration d. irritability e. sweating and pallor f. kussumal respirations

b, d, e hunger, irritability, and sweating and pallor are all manifestations of hypoglycemia

a nurse is caring for a client who recently had a CVA and has aphasia. which of the following interventions should the nurse use to promote communication with this client? select all that apply a. increase the volume in your voice b. make sure only one person speaks at a time c. avoid discouraging the client by saying that you do not understand him d. allow plenty of time for the client to respond e. use brief sentences with simple words

b, d, e trying to understand more than one voice at a time is confusing, allowing time for the client to respond helps enhance communication, and brief sentences are easier to understand. the nurse should speak in a normal tone, no yelling. and feigning understanding shows a lack of respect for the clients needs and blocks further communication

a nurse is caring for a client who is experiencing a crisis. which of the following medications should the nurse plan to administer? select all that apply a. lithium carbonate b. paroxetine c. risperidone d. haloperidol e. lorazepam

b, e SSRI antidepressants like paroxetine, and benzodizepines like lorazepam can be used to decrease anxiety. lithium carbonate is a mood stabilizer, and c, d are antipsychotics

a nurse is caring for a client who is postoperative. which of the following interventions should the nurse take to reduce the risk of thrombus development? select all that apply a. instruct the client to perform the valsalva maneuver b. apply elastic stockings c. review lab values for total protein level d. place pillows under the client's knees and lower extremities e. assist the client to shift positions often

b, e elastic stockings promote venous return and prevent thrombus formulation and frequent position changes prevents venous stasis. valsalva maneuver does not affect peripheral circulation, the total protein level is important for healing and preventing skin breakdown, and placing pillows under the extremity could impair circulation.

a 50 year old woman was recently diagnosed with type 2 diabetes mellitus and desires to start a healthy lifestyle to control her disease. what is the initial recommendation that the nurse should make? a. engage in brisk walk b. lose 10 to 15 pounds c. maintain adequate glucose control d. develop an exercise schedule

c Once the patient has learned how to manage and monitor her glucose level, she can begin to balance her diet with exercise and gradually lose some weight.

a nurse determines that the appropriate problem statement for a patient with status ellipitcus would be potential for injury due to seizure activity. an appropriate expected outcome would be? a. everyone will stay calm during the episodes b. the caregiver will stay with the patient during the episodes c. the patient will be free from any injuries associated with the seizures d. standing orders will be obtained to medicate acute seizure episodes

c Interventions should prevent injuries to the head or extremities from seizure activity. Sometimes it is impossible to prevent biting of the tongue. Turning the patient to the side and suctioning the oral cavity helps prevent aspiration. Staying calm or staying with the patient does not prevent injury. Standing orders for medication do not preclude injury to the patient during the seizure but may shorten the seizure episode and stop it.

a 30 year old woman is admitted for a UTI with sepsis. a urinalysis reveals presence of ketones, glucose, and nitrates. which question would the nurse ask to further assess possible diabetes mellitus? a. "have you noticed an extra roundness to your face?" b. "have you had more gas or abdominal bloating?" c. "have you been thirstier than usual? do you find you urinate more now?" d. "have you experienced any pain or discomfort with urination?"

c Polydipsia, polyuria, and polyphagia (thirst, urinary frequency, and hunger, respectively) are signs of diabetes. A round moon face is characteristic of Cushing disease. Abdominal bloating is more associated with thyroid problems. Asking about pain with urination is appropriate to assess for urinary tract infection (UTI). There is an increased risk for UTI with diabetes, but asking about occurrence or frequency of UTIs is a better question to assess for possible diabetes.

the nurse is caring for a hospitalized infant with bronchiolitis. diagnostic tests have confirmed RSV. on the basis of this finding, which should be the appropriate nursing action? a. initiate strict enteric precautions b. wear a mask when caring for the child c. plan to move the infant to a room with another child with RSV d. leave the infant in the present room, RSV is not contagious

c RSV is spread by touch not airborne so putting two children with RSV in the same room is fine

the nurse is caring for a client who has had skeletal traction applied to the left leg. the client os complaining of severe left leg pain. which action should the nurse take first? a. provide pin care b. call the HCP c. check the client alignment in bed d. medicate the client with an analgesic

c a client who complains of severe pain may need realignment or may have had traction weights prescribed that are too heavy. the nurse calls the HCP if the realignment doesnt help. once traction is established severe pain indicates a problem. medicating the client should be done last after trying to find the cause. providing pin care is unrelated to the problem prescribed

a nurse is caring for a preschooler who is experiencing mild pain. which of the following types of medication should the nurse administer first? a. opioid analgesic b. antianxiety medication c. nonsteroidal antiinflammatory drug d. sedative

c according to evidence based practice the nurse should administer a nonopioid medication. opioids can only be given if moderate to severe pain. only give an antianxiety and sedative if nonopioid analgesic doesnt work.

the nurse is assigned to assist with caring for a client who has a chest tube. the nurse notes fluctuations of the fluid level in the water seal chamber. based on this observation, which action would be appropriate? a. empty the drainage b. encourage the client to deep breathe c. continue to monitor, because this is an expected finding d. encourage the client to hold his or her breath periodically

c fluctuations in the fluid level in the water seal chamber indicates a patent drainage system

the nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed for the client. the nurse determines that this medication has been prescribed for which reason? a. treat thyroid storm b. prevent cardiac irritability c. treat hypocalcemic tetnay stimulate the release of parathyroid hormone

c hypocalcemia can develop after thyroidectomy if the parathyroid gland is accidentally removed or damaged during surgery. manifestations occur 1-7 days after surgery.

a nurse is reinforcing discharge teaching with a client who has a new prescription for prednisone to treat asthma. which of the following client statements indicates an understanding of the teaching? a. "i will decrease my fluid intake while taking this medication" b. "i will expect to have black, tarry stools" c. "i will take my medication with meals" d. "i will monitor for weight loss while on this medication"

c this medication should be taken with food because if taken on an empty stomach can cause GI problems

The nurse is assessing a female patient at the neighborhood clinic. The patient is complaining of "feeling tired all the time." The nurse knows that fatigue may be an underlying symptom of which condition? a. Ischemia b. Pneumonia c. Myocardial infarction d. Peptic ulcer disease

c Fatigue is an atypical symptom of myocardial infarction in women. Ischemia is associated with pain. Pneumonia is associated with pain and shortness of breath. Peptic ulcer disease is associated with pain and intestinal discomfort.

a 75 year old patient who fell and hit his head a week ago is admitted for apparent personality changes, decreased level of consciousness, and irritability. the provider suspects a possible subdural hematoma. a family member asks about the condition. an accurate explanation would be: a. it is the presence of bleeding in the brain parenchyma b. bleeding occurs between the skull and the dura mater c. it is the collection of blood between the brain and the inner surface of the dura mater d. it is the intermittent blockage of circulation in various areas of the brain

c (3) A subdural hematoma occurs beneath the dura, between the brain and the dura. (1) The parenchyma is not between the brain and the inner surface of the dura mater. (2) The bleeding is on the other side of the dura mater. (4). A hematoma is not necessarily intermittent and occurs in a specific location.

a patient has experienced an MI and has ST-segment elevation on the ECG. the priority problem would be: a. altered gas exchange b. limited coping ability c. altered tissue perfusion d. altered activity tolerance

c Altered tissue perfusion is the correct choice since cardiac damage has been caused by insufficient blood supply to an area of the myocardium. Oxygen is used for the therapy for MI, but it is for the purpose of preventing further ischemia of the heart muscle and not because of an oxygenation problem. The patient may display limited coping, but this is a psychosocial issue and does not take precedence over the physical problem of altered tissue perfusion. Activity intolerance will occur during the acute stage of an MI, but it is the result of ineffective tissue perfusion.

the surgeon inserts an intraventricular catheter into the lateral ventricle of a patient with increased ICP. when asked by a relative about the procedure an accurate response would be: a. the catheter allows direct visualization of the brain tissue b. the catheter is used to monitor brain waves c. the catheter is used to remove excess fluid inside the brain d. the catheter is used to infuse fluids and medications to the brain

c An intraventricular catheter is used to drain off excess cerebral spinal fluid. The catheter does not allow visualization of the brain tissue. The catheter does not have a mechanism to monitor brain waves. Fluids and medications are not infused into the brain through the intraventricular catheter.

which critical thinking skill is important to apply when formulating a nursing care plan? a. having the nursing assistant help with the assessment b. reading the history and physical in the chart c. analyzing the data to determine appropriate nursing diagnoses d. including the patient in formulating the care plan

c Analyzing the data from all areas of the assessment is use of critical thinking. (1) Utilizing the nursing assistant is part of delegation. (2) Reading the history and physical in the chart is appropriate, but not a use of critical thinking. (4) Including the patient during care planning is appropriate, but not a use of critical thinking.

a nurse should observe for and report which abnormal breathing pattern that is most likely to occur in patients with increased intracranial pressure? a. cheyne-stokes respirations b. kussumal respirations c. biots respirations d. apneistic respirations

c Biot respiration is seen in patients with increased intracranial pressure. Cheyne-Stokes respiration is often seen in patients in coma resulting from a disorder affecting the central nervous system. Kussmaul respiration is often seen in patients with diabetic acidosis and coma. Apneustic respiration (apnea) is indicative of damage to the respiratory centers in the brain.

The patient presents to the clinic with symptoms indicative of osteoporosis. The nurse anticipates which study will be performed in order to confirm the diagnosis? a. Chest x-ray b. Nuclear scan c. Bone density d. Computed tomography (CT) scan

c Bone density evaluation is the most relevant diagnostic for osteoporosis. A CT scan and chest x-ray can provide information about damage associated with osteoporosis. A nuclear scan would not be helpful for the patient with osteoporosis.

which is an example of clinical judgement? a. weighing the pros and cons of which school to send your children to b. deciding which midterm test to study for first c. prioritizing which call bell to answer first d. answering the primary care providers question in a diplomatic manner

c Clinical judgment is critical thinking in the clinical setting. Although the first and second choices involve critical thinking, they do not occur in the clinical setting.

the nurse is reinforcing teaching concerning the use of a cromolyn sodium inhaler for a 10 year old with asthma. which would be an accurate concept to emphasize? a. you should use the inhaler whenever you have difficulty breathing b. you should use the inhaler between meals c. you should use the inhaler regularly every day even if you are symptom free d. you can discontinue using the inhaler when you are feeling stronger

c Cromolyn sodium (Intal) is a nonsteroidal, anti-inflammatory medication that is inhaled using a Spinhaler. It is used as a prophylactic, or preventive, medication. Daily doses are prescribed to ensure an adequate blood level.

a 46 year old woman is diagnosed with generalized anxiety disorder. which behavior is more likely to be displayed with this diagnosis? a. runs out of the room when she sees a spider in the corner b. continuously checks to see if doors are shut and locked c. has difficulty concentrating and excessively worries about her family d. wakes at night screaming because of recurrent nightmares

c Difficulty concentrating and excessive worry are part of diagnostic criteria for general anxiety disorder (GAD). Excessive fear of spiders is an example of phobic disorder; Repetitive checking and rechecking doors is an example of behavior associated with obsessive-compulsive disorder; Recurrent nightmares are associated with post-traumatic stress disorder (PTSD).

A patient with type 1 diabetes mellitus (DM) plays tennis and asks if she will be able to continue with that sport. The nurse should base his response on which information? a. It would be better to take up walking or some quiet sport. b. She can play tennis, but she will need an extra dose of insulin. c. She can play tennis, but she will need to eat more before she plays. d. She cannot play tennis because heavy exercise is not permitted with this type of diabetes.

c Exercise is recommended for the patient with diabetes. Exercise will require changes in both diet and insulin use. Eating before exercise will aid in the prevention of hypoglycemia.

Intracranial function can be disrupted by which degenerative disease of the brain? a. Encephalitis b. Meningitis c. Parkinson's disease d. Brain tumors

c Parkinson's disease is an exemplar of the degenerative diseases that can affect intracranial regulation. Encephalitis is an exemplar of the inflammatory disorders that can affect intracranial regulation, as is meningitis. Brain tumors are exemplars of a third type of pathological process that can affect intracranial regulation.

a patient with a plaster cast of the right arm complains of itching underneath the cast. what should the nurse do to alleviate the symptom? a. encourage deep breaths and scratch the other arm b. insert a cotton tip applicator under the cast c. forcefully inject 50 mL air underneath the cast d. administer pain medications

c Forcefully injecting 50 mL of air underneath the case helps relieve itching. For some people scratching the other arm will help relieve itching and this could be suggested if the air injection isn't helpful. Nothing should ever be inserted under the cast to help relieve itching. Pain medication does not usually relieve itching.

the nurse reinforces the providers orders to draw blood for HIV genotyping. the patient asks "how does that help in my treatment?" what is the best explanation for the test? a. confirms the presence of a viral automimmune disease b. informs how much of the virus has been replicated c. determines the presence of any mutations in the virus d. reveals the viral load or count of the virus

c HIV genotyping is the correct test to identify mutations in the virus. Not all autoimmune diseases are caused by viruses. Phenotyping test is what tells about viral replication. Viral load test is HIV RNA quantitative.

A patient recently diagnosed as having hypoglycemia says, "Hypoglycemia! I can't live with that. My neighbor, Joseph, had that and he acted crazy!" Which response by the nurse is most appropriate? a. "You seem to be overreacting to the problem." b. "You're right; it would be difficult to live with hypoglycemia." c. "Hypoglycemia has been successfully treated by diet modifications." d. "Taking care of yourself years ago would have prevented the problem."

c Hypoglycemia refers to a low serum blood glucose level. It is best managed with dietary management. Telling the patient that the condition is hard to manage would be counterproductive and inaccurate. Making the patient's concerns appear trivial or discussing past self-care would not further the relationship between the nurse and patient.

when the patient experiences apprehension and urticaria while receiving a blood transfusion, the nurse: a. slows the transfusion and takes vital signs b. observe the child for further transfusion reaction signs c. stops the transfusion, allows ns to run slowly and notifies the charge nurse d. stops what he or she is doing and takes a history

c If a reaction to the blood transfusion occurs, then stop the infusion, keep the vein open with normal saline solution, and notify the charge nurse. Take the patient's vital signs and observe closely.

which patient is at greatest risk for pulmonary embolism? the patient who: a. has a central line that was started two days ago b. is 3 months pregnant with her first child c. has been immobile for a week and is mildly dehydrated d. is ambulating 2 days after abdominal surgery

c Immobility and dehydration are risk factors for developing thrombi and emboli. Emboli do occur in relation to central lines or childbirth but are not the highest risk factors. Ambulation is an intervention that decreases the likelihood of deep vein thrombosis or pulmonary emboli.

which is a priority nursing diagnosis in a child admitted with acute asthma? a. risk for infection b. imbalanced nutrition c. ineffective breathing pattern d. disturbed body image

c In acute asthma, the patient coughs, wheezes, and has difficulty breathing. Shortness of breath accompanied by restricted breath sounds and rising respiratory rate may indicate imminent respiratory failure and should be reported promptly to the health care provider. In acute asthma, an ineffective breathing pattern would be a priority diagnosis with nursing actions aimed at increasing oxygenation and decreasing respiratory distress.

The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form? a. Elevate the head of the bed. b. Have a padded tongue blade at the bedside. c. Position the client face down or in a side-lying position. d. Apply pressure and massage the injection site for 5 minutes.

c Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice.

which principle should the nurse teach the parent concerning administering liquid iron preparations to the child with iron deficiency anemia? a. allow the preparation to mix with saliva and bathe the teeth before swallowing b. warm the medication before administering c. administer between meals d. administer in a bottle of formula

c Iron is given orally two or three times a day between meals. Vitamin C aids in the absorption of iron; therefore, it is suggested that juice be given at the same time. Liquid preparations are taken through a straw to prevent the teeth from being temporarily discolored. Oral iron supplements should not be given with milk or milk products because milk interferes with iron absorption.

the patient asks "why am i taking lisinopril (zestril)? an accurate statement by the nurse would be: a. the medication increases the force of contraction of the heart b. the medication increases the heart rate c. the medication helps prevent vasoconstriction d. the medication causes excretion of excess fluid

c Lisinopril is an angiotensin-enzyme inhibitor and works to lower blood pressure and afterload by preventing vasoconstriction. This drug does not increase contractility of the heart. Lisinopril does not increase the heart rate. Lisinopril does not have a diuretic effect.

The nurse is educating the patient with osteoporosis on the best diet choices to improve bone density. The patient would demonstrate an understanding of the teaching by selecting which food choice that has the highest calcium content? a. 1 cup spinach b. 1 cup chopped kale c. 1 cup low-fat yogurt d. 1 ounce sliced carrots

c Low-fat yogurt is the best source for well-absorbed calcium. Spinach, kale, and some other green leafy vegetables do contain calcium, but it is not as readily absorbed. Carrots are not a source of calcium.

a nurse is caring for a client who is receiving morphine via PCA pump after abdominal surgery. which of the following statements indicated that the client knows how to use the device? a. ill wait to use the device until absolutely necessary b. ill be careful about pushing the button too much so i dont get an overdose c. i should tell the nurse if the pain doesnt stop while i am using this device d. i will ask my adult child to press the dose button when i am sleeping

c PCA allows the client to self administer pain meds when needed. the nurse should remind the patient to use the pump when pain starts to better control pain, PCA pumps have a timer that controls how much is being released at intervals they cannot get more medicine at other intervals, and the nurse should instruct the patient that nobody else needs to push the button except the client

When planning care for a diabetic patient with microalbuminuria, it is important to include which goal to reduce the progression to renal failure? a. Decrease the total percentage of calories from carbohydrates. b. Decrease the total percentage of calories from fruits. c. Decrease the total percentage of calories from proteins. d. Decrease the total percentage of daily caloric intake.

c Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure.

a patient is admitted to the hospital with a diagnosis of heart failure (HF). patient education related to nutritional therapy for HF should include: a. reduction of fat and protein b. increasing calories and fluids c. reduction of sodium intake d. increasing simple carbohydrates

c Sodium intake should be reduced, since sodium encourages the body to "hold on" to water, thus increasing edema and intravascular volume.

a 30 year old man is admitted to the ED after a motor vehicle accident. after examination, the patient is diagnosed with a T6 spinal cord injury. he has flaccid paralysis, slowed heart rate, low BP, and no bowel sounds. the patient must be developing: a. autonomic dysreflexia b. muscle spasms c. spinal shock d. diabetes insipidus

c Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. Autonomic dysreflexia is characterized by excessively high blood pressure. Muscle spasms cause pain in muscular areas. Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine.

the nurse administers two consecutive sublingual nitroglycerin tabs to a patient complaining of moderate chest pain. if the patients blood pressure is 148/88 mmHg with continued chest pain, the next nursing action should be to: a. administer morphine sulfate b. get an IV cannula inserted c. give another sublingual nitroglycerin d. provide emotional support

c Standard protocol for chest pain of probable cardiac origin is to administer up to three sublingual nitroglycerin tablets. Morphine is not indicated at this time. Wait to see if the nitroglycerin makes the pain subside, an IV cannula is not indicated at this time. There are no data yet to indicate that the patient is having a myocardial infarction or is suffering severe pain. Although emotional support is important, it is required to give the third nitroglycerin tablet first. Then offering support and comfort may help the patient relax.

A patient with a history of cardiac problems talks with the nurse about bowel elimination. The nurse stresses to the patient not to strain during bowel movements. Straining can put pressure on the vagas nerve and cause bradycardia. The nurse is explaining which physiological action? a. First-degree heart block b. Eupnea c. Valsalva maneuver d. Tachypnea

c The Valsalva maneuver happens when the cardiac patient strains to have a bowel movement. First-degree heart block is not brought on by straining. Eupnea means normal respirations and tachypnea means fast respirations; neither has any connection to straining during a bowel movement.

the ankle-brachial index test is ordered for a patient experiencing signs of PVD. which patient statement indicates the need that further teaching about the test needs to occur? a. "ill be lying down for this examination" b. "the test is noninvasive" c. "my brachial and pedal pulses will be checked and compared" d. "my brachial and ankle blood pressure will be taken"

c The ankle-brachial index (ABI) test compares blood pressure between the brachial artery and the artery in the ankle. It does not use pulse assessments. The patient is supine for the test. The test is noninvasive. Blood pressure is measured at the ankle and the brachial artery.

If a patient has a colostomy in the area known as the "ascending colon," what would the nurse expect of the stool in the colostomy device? a. Stool would be dark. b. Stool would be formed. c. Stool would be loose. d. Stool would have flecks of blood.

c The correct answer is C because stool in the ascending colon is loose or watery. Stool should not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because the colon has not reabsorbed the water yet.

what is the purpose of the initial health history and assessment? a. to collect data about a specific health problem b. to identify life threatening problems c. to compare current health status to baseline data d. to establish a database to identify the patient's current health status

c The initial health history and assessment provides a database of information on the patient's health status at the time of admission. It is the baseline against which subsequent data will be compared.

An infant born with hydrocephalus is to be discharged after insertion of a ventriculoperitoneal shunt. Which common complication of this type of surgery should the nurse explain to the home caregivers to prepare them for the patient's discharge? a. Excessive fluid accumulation in the abdomen b. Eyes with sclera visible above the irises c. Fever accompanied by decreased responsiveness d. Violent involuntary muscle contractions

c The most common complication of surgery would be infection as evidenced by fever and decreased responsiveness. This is true for a patient of any age. The fluid in the peritoneum would be reabsorbed; excessive accumulation is not common. The setting sun sign, or eyes with the sclera visible above the irises, is a late sign of increased intracranial pressure. The early signs are taught prior to discharge. Seizures are not a common complication of ventriculoperitoneal shunt surgery.

The patient in the outpatient surgery center has just returned from surgery to decompress the medial nerve as treatment for carpal tunnel syndrome. Which assessment finding immediately after surgery would alert the nurse to a possible complication? a. Nail beds that are pink b. Numbness of the fingertips c. 5-second nail bed capillary refill d. Fingertips that are warm to the touch

c The nurse should assess the perfusion of the hand. A capillary refill time of more than 3 seconds may indicate a problem and should be reported to the surgeon immediately. Right after surgery, the patient is not expected to have sensation in the fingers. Pink, warm skin is a normal finding.

a nurse is assessing a client who has HIV. which of the following findings should the nurse identify as a manifestation of HIV associated muscle wasting? a. unintentional weight loss of 15% of body weight in 6 months b. fecal impaction c. diminished strength d. report of increased fat gain on the back of the neck

c a client with muscle wasting will report having diminished strength due to GI malabsorption.HIV associated weight loss is 5% in 6 months. they may have diarrhea instead of fecal impaction. increased fat on the back of the neck can mean that there is HIV associated lipodystrophy not muscle wasting.

A patient with diabetes asks her nurse about foot care when she is discharged home. What is the nurse's best response? a. "Cut your toenails in a V shape to prevent ingrown toenails." b. "Soak your feet in hot water each night before going to bed." c. "Inspect each foot daily for cuts, cracks, blisters, or abrasions." d. "There are no special instructions for your feet when you have diabetes."

c The nurse should instruct the patient to inspect each foot daily for cuts, cracks, blisters, abrasions, or discoloration of the toes and to report any abnormality to the health care provider. The patient should use a mirror if unable to bend to see the bottom of the foot. The patient should be certain to check between the toes and should wash the feet in warm (not hot) water, using mild soap. The patient should not soak the feet because this can cause cracking of the skin. The nails should be cut straight across, not in the shape of a V, to prevent ingrown toenails.

a difference in the postoperative care of a client with a knee replacement compared with a patient after a hip replacement is that the patient with a hip replacement: a. has less chance of developing a DVT b. remains on bed rest for several days c. is allowed to stand at the side of the bed first day post op d. has a CPM machine to exercise the joint

c The patient with a hip replacement is gotten up to stand at the side of the bed on the 1st postoperative day. Both patients have a risk of developing a deep venous thrombosis. The patient with a hip replacement is not on bed rest. Only the patient with a knee replacement has a continuous passive motion machine to exercise the joint.

after sustaining a rotator cuff tear, a patients arm is placed in a sling. the patient is instructed to rest and take ibuprofen for pain. which patient statement indicates the need for further teaching? a. i will have less stomach upset if i take the medicine with food b. i will not be able to play tennis for a while c. i need to rest in my bed for the next 2 days d. the sling must be worn most of the time

c The patient with a rotator cuff tear does not need bed rest. Taking ibuprofen with food is advisable to prevent stomach irritation. The patient will not be able to play tennis for a while. The sling should be worn most of the time.

the nurse explains the importance of reducing salt in the diet to a hispanic man who was recently diagnosed with HF. the nurse realizes that the relatives are at the bedside with the patient. an appropriate nursing action would be to: a. involve the youngest male in the family to translate b. ensure the patient privacy by directing the relatives out of the patients room c. determine who does the cooking in the family d. include all the family in the diet teaching

c The person who does the cooking should be directly involved in the dietary teaching. It is best to have a trained translator rather than a family member translate. The youngest male member of the family is not a good choice. Because hypertension and heart disease are common problems in Hispanics, there is no harm in letting the relatives stay for dietary teaching if they desire to be included, but the patient should be consulted about their staying before the teaching begins. The immediate family should always be included in the dietary teaching so they know what the patient is allowed.

while discussing HF with a student, a nurse explains that the underlying weakness of the left ventricle results in reduced cardiac output and back up of fluid in the pulmonary system. the student nurse anticipates which S/S? a. edema in the sacrum, legs, feet, and ankles b. hepatomegaly c. crackles in the lungs d. ascites

c This patient has systolic heart failure because of difficulty in ejecting blood from the ventricle, and the signs and symptoms include crackles in the lungs. Peripheral edema will eventually occur but is not an acute sign of systolic failure. Hepatomegaly and ascites are late signs of heart failure.

a patient is diagnosed as having angina pectoris attacks. as part of the discharge instructions, the patient is instructed on the appropriate storage and use of sublingual nitroglycerin. which of the following patient statements indicates the need for further teaching? a. the tablets should be kept in a cool, dark place b. i need to lie down after i take this medication c. i can take the medication every 15 minutes for angina pectoris d. the expiration date on the bottle is important

c When pain is not relieved within 5 minutes by the first nitroglycerin tablet, the patient is to take another; a third tablet may be taken 5 minutes after the second tablet for unrelieved pain. If pain continues, the patient should contact the health care provider and get to the hospital.

The nurse is assisting the patient to use the 4-point gait with crutches. Which behavior by the patient demonstrates understanding? a. The patient initially advances the left foot. b. The patient initially advances the right foot. c. The patient initially advances the left crutch. d. The patient initially advances the right crutch.

c When performing the 4-point crutch gait, the patient should begin by advancing the left crutch followed by advancing the right foot.

The nurse is caring for a patient who has had a knee replacement. Within 2 to 3 days, the LPN/LVN can likely anticipate which change in the plan of care? a. Walker training b. Enemas until clear c. Quadriceps setting exercises d. Cessation of pain medication

c Within 2 to 5 days, quadriceps-strengthening exercises, and straight-leg raising are started. Quadriceps setting exercises are accomplished by lying supine, straightening the legs, and pushing the back of the knees into the bed. Exercises are taught by the physical therapist, and the nurse often assists the patient in performing them. The arthroplasty patient then progresses to ambulation with a walker or crutches. There is no need to administer enemas to the patient. Pain medication may be needed for several days after the surgery.

the nurse is preparing information for change of shift report. which of the following information should the nurse include in the report? a. intake and output for the shift b. BP from the pervious day c. bone scan scheduled for today d. medication routine from the MAR

c a bone scan is important because the nurse might have to modify the clients care to accommodate leaving the unit. unless there is a significant change in i&o, BP, and medication routine the oncoming nurse can read that stuff in the chart

a nurse is collecting data from a client who has suspected HIV associated muscle wasting. which of the following findings supports this diagnosis? a. BMI 26 b. fecal impaction c. report of fever for 30 days d. report of high alcohol consumption

c a client who has HIV- muscle wasting will report elevated temperature for over 30 days duration. a BMI of 26 is not a clinical finding for this disease, a client with this disease will have diarrhea not fecal impaction, and a client report of high alcohol consumption is not a clinical finding for this disease.

the nurse is caring for a client who has undergone a craniotomy with a supratentorial incision. the nurse should plan the place the client in which position postoperatively? a. head of bed flat, head and neck midline b. head of bed flat, head turned in the nonoperative side c. head of bed elevated 30-45 degrees, head and neck midline d. head of bed elevated 30-45 degrees, head turned to the operative side

c after a supratentorial surgery the head of bed needs to be elevated 30-45 degrees and head in midline always after that surgery

which is a recommended guideline for safe computerizing? a. passwords to the computer system should only be changed if lost b. computer terminals may be left unattended during client care activities c. accidental deletions from the computerized file need to be reported to the nursing manager or supervisor d. copies of printouts from computerized files should be kept on a clip board at the nurses station for other nurses to access

c after any inadvertent deletions of permanent computerized records, the nurse should type up an explanation into the computer file with the time, date, and his or her initials. the nurse should also contact the supervisor with a written explanation of the situation. options 1, 2, and 4 represent unsafe charting actions

a nurse is reviewing prescribed medications for a newly admitted client. which of the following medications decreases the body's rate of metabolism? a. prednisone b. levothyroxine c. amitriptyline d. epinephrine

c amitriptyline is tricyclic antidepressant used for treating depression and decreases the body's rate of metabolism

a nurse is reinforcing teaching about self care with a child who has type 1 DM. the nurse should identify which of the following statements by the child indicates understanding? a. "i should skip breakfast when i am not hungry" b. "i should increase my insulin with exercise" c. "i should drink a glass of milk when i am feeling irritable" d. "i should draw up the NPH insulin into the syringe before the regular insulin"

c an early manifestation of hypoglycemia is irritability. drinking a glass of milk indicates understanding of this teaching

the nurse is caring for the client who has suffered a spinal cord injury. the nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication for which s/s is noted? a. sudden tachycardia b. pallor of the face and neck c. severe, throbbing headache d. severe, sudden hypotension

c anybody with a spinal cord injury above the T7 level is at risk for autonomic dysreflexia, s/s are severe, sudden, throbbing headache, flushing of the face and neck, bradycardia and severe hypotension

a nurse is reinforcing discharge teaching with a client who has COPD and a new prescription for albuterol. which of the following client statements indicates understanding of the teaching? a. "the medication can increase my blood sugar levels" b. this medication can decrease my immune response" c. "i can have an increase in my heart rate when taking this medication" d. "i can have mouth sores while taking this medication"

c bronchodilators can increase heart rate which cause tachycardia

the nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. which statement made by the client indicates the need for further teaching? a. "ill eat a balanced meal plan" b. "i need to drink diet soft drinks" c. "i need to buy special diabetic foods" d. "i will snack on fruit instead of cake"

c diabetics should eat diabetic foods, but rather eat a balanced meal

the nurse is reinforcing discharge instructions to a client with cancer of the prostate after a prostatectomy. the nurse should reinforce which discharge instruction? a. avoid driving a car for 1 week b. restrict fluid intake to prevent incontinence c. avoid lifting objects heavier than 20 pounds for atleast 6 weeks d. notify the health care provider if small blood clots are noticed during urination

c driving a car and sitting for long periods are restricted for atleast 3 weeks. daily limit of fluids are 2-2.5 L should be maintained to limit clot formation and prevent infection. small clots can be passed up to 2 weeks after surgery

a nurse is caring for a client who had a left-hemispheric stroke. which of the following manifestations should the nurse expect? a. impulse control difficulty b. poor judgement c. frustrated about deficits d. loss of depth perception

c due to the stroke they can experience depression and frustration regarding physical limitations

the nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). the nurse should observe for which early sign of HF? a. pallor b. cough c. tachycardia d. slow and shallow breathing

c early s/s of heart failure are tachycardia, profuse scalp sweating, fatigue, irritability, sudden weight gain and respiratory distress

an older adult client is a victim of elder abuse, and the clients family has been attending weekly counseling sessions. which statement by the abusive family member indicated the client has learned positing coping skills? a. i will be more careful to make sure that my fathers needs are met b. now that my father is moving into my home, i will need to change my ways c. i feel better able to care for my father now that i know where to obtain assistance d. i am so sorry and embarrassed that the abusive event occurred. it wont happen again

c elder abuse sometimes occurs with family members who are being expected to care for their aging parents. this can cause family members to become over extended, frustrated, or financially depleted. knowing where in the community to turn for assistance in caring for aging family members can bring much needed relief. taking advantage of these alternatives is a positive alternative coping strategy.

a pregnant client with known HIV infection is admitted to the hospital in active labor. which method for assessing the fetus is most appropriate for the nurse to perform at this time? a. fetal scalp sampling b. chorionic villi sampling c. external fetal monitoring d. internal fetal monitoring

c external fetal monitoring minimizes the risk of exposing the fetus to the mother's HIV infected blood. external monitoring is the only non-invasive option listed.

a nurse is reinforcing discharge teaching to a client who has seizures and received a vagal nerve stimulator to decrease seizure activity. which of the following statements should the nurse include? a. i will have a sore throat after placement of the stimulator b. this stimulator will stop my tonic/clonic seizures c. i can expect to have a temporary voice change d. the device is inserted under local anesthesia

c the client should expect to have a temporary voice change due to stimulation of the device on the vagal nerve

a nurse is assisting with teaching about colon cancer to a group of female clients. which of the following statements should the nurse include in the teaching? a. colonoscopies for individuals with no family history of cancer should begin at age 40 b. a sigmoidoscopy is recommended every 5 years beginning at age 60 c. fecal occult blood test should be done annually beginning at age 50 d. an endoscopy provides a definitive diagnosis of colon cancer

c fecal occult blood test should be done annually at age 50-75. a colonoscopy is recommended to be done every 10 years starting at age 50, a sigmoidoscopy is recommended every 5years beginning at age 50, and a biopsy done during the procedure gives a definite diagnosis.

a parent of a school aged child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. which of the following responses should the nurse make? a. "injections are usually continued until age 10 for girls and age 12 for boys" b. "injections continue until your child reaches the fifth percentile on the growth chart" c. "injections should be continued until there is evidence of epiphyseal closure" d. "injections will need to be continued throughout your child's entire life"

c injections are continued until there is evidence of epiphyseal closure on radiographic tests

a nurse in an urgent care clinic is obtaining a history from a client who has type two diabetes and a recent diagnosis of hypertension. this is the second time in a week that the client experienced hypoglycemia. which of the following client data should the nurse report to the provider? a. takes a psyllium daily as a fiber laxative b. drinks skim milk daily as a bedtime snack c. takes metaprolol daily after meals d. drinks grapefruit juice daily with breakfast

c metaprolol can mask the effects of hypoglycemia in clients who have diabetes

a nurse is caring for a client who had am amphetamine overdose and has sensory overload. which of the following interventions should the nurse implement? a. immediately complete a thorough assessment b. put the client in a room with a client who has hearing loss c. provide a private room and limit stimulation d. speak at a higher volume to the client and encourage ambulation

c minimizing stimuli helps clients who have sensory overload. brief assessments are better to not overwhelm the client, rooming with someone with hearing loss and speaking louder increases stimuli.

a client has sustained a closed fracture and just had a cast applied to the affected arm. the client is complaining of intense pain. the nurse has evaluated the limb, applied an ice pack, and administered an analgesic, which was ineffective in relieving the pain. the nurse interprets that this pain may be caused by which condition? a. infection under the cast b. the anxiety of the client c. impaired tissue perfusion d. the newness of the fracture

c most pain associated with fractures can be minimized with rest, elevation, application of a cold compress, and administration of analgesics. pain that is not relieved with these measures needs to be reported to theRN and HCP because is may be the result of impaired tissue perfusion, tissue breakdown, or necrosis. because this is a new closed fracture and cast, infection would not have time to set in

a client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath., and the client is visibly anxious. the nurse understands that a life threatening complication of this condition is which? a. pneumonia b. pulmonary edema c. pulmonary embolism d. myocardial infarction

c pulmonary embolism is a life threatening complication of deep vein thrombosis and thrombophlebitis. chest pain is the most common symptom, which is sudden onset and may be aggravated by breathing. other s/s include dyspnea, cough, diaphoresis, and apprehension

a nursing assistant voices concern for personal safety when assigned care for a client with AIDS. which information from the nurse is best for allaying the nursing assistants fears? a. the life expectancy for AIDS clients is longer than previous years b. AIDS is commonly transmitted by contact with blood or body fluids c. standard precautions can prevent HIV transmission d. if infected, workers comp will cover the cost of care

c reinforcing the fact that standard precautions can block the transmission of the virus from the client to the healthcare worker is the best information among the choices

the nurse is checking the casted extremity of a client. the nurse should check for which sign indicative of infection? a. dependent edema b. diminished distal pulse c. presence of a hot spot on the cast d. coolness and pallor of the extremity

c s/s of infection under a casted area include odor or purulent drainage from the cast or the presence of hot spots, which are areas of the cast that are warmer than others. the HCP should be notified if any of these occur. signs of impaired circulation in the distal limb are coolness and pallor, diminished arterial pulse, and edema

a nurse is planning to reinforce teaching to a client who is being evaluated for addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. the nurse should base her instructions to the client on which of the following information? a. the ACTH stimulation test measures the response by the kidneys to ACTH b. in the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH c. ACTH is a hormone produced by the pituitary gland d. the client will take a dose of ACTH by mouth the evening before the test

c secretion of corticotropin releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH

a nurse is reinforcing teaching with a client who is taking sucralfate PO to treat peptic ulcer disease and has a new prescription for phenytoin to control seizures. which of the following instructions should the nurse include? a. take an antacid with the sucralfate b. take sucralfate with 8oz milk c. allow a 2 hour interval between taking these medications d. chew sucralfate thoroughly before swallowing it

c sucralfate can interfere with the absorption on phenytoin so the client should allow 2 hours between taking the who medications. antacids interfere with the absorption of sucralfate so there needs to be 30 minutes between taking the two medications, sucralfate should be taken on an empty stomach and 1 hour before bedtime, and the client should swallow the sucralfate whole

a mother of a 6 year old child with type 1 DM calls the clinic nurse and tells the nurse that the child has been sick. the mother reports that she checked the child's urine and it showed positive ketones. what should the nurse instruct the mother to do? a. hold the next dose of insulin b. come to the clinic immediately c. encourage the child to drink liquids d. administer an additional dose of regular insulin

c the child should drink liquids so that they get rid of the ketones

a client is wearing a continuous monitor which begins to alarm at the nurses station. the nurse sees no electrocardiographic complexes on the screen. the nurse should do which first? a. call a code blue b. call the HCP c. check the client status and lead placement d. press the recorder button on the ECG console

c the loss of complexes could be from electrode displacement, so checking the placement is the priority

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 patients teeth b. encourage increased intake of citrus fruit juices c. obtain a culture of the lesions d. provide an alcohol based mouthwash for oral hygiene

c the nurse should obtain a culture of the oral lesions to identify pathogens and determine a treatment. a person with mucositis should avoid glycerin based swabs, acidic foods, and nonalcoholic mouthwashes.

a nurse is collecting data from a client who is reporting pain and despite taking analgesia. which of the following actions should the nurse take to determine the intensity of the clients pain? a. ask the client what precipitates the pain b. question the client about the location of the pain c. offer the client a pain scale to measure the pain d. use open ended questions to identify the patients pain sensations

c the nurse should use the pain scale to help identify the patients pain level. what precipitates, location, and open ended questions about pain sensations do not tell the intensity of the pain

a nurse is reinforcing teaching with a client who has RA and a new prescription for methotrexate. which of the following client statements indicates understanding? a. a will be sure to return to the clinic every year to have my blood drawn while im taking methotrexate b. i will take this medication on an empty stomach c. i will let the doctor know if i develop sores in my mouth while taking this medication d. i should stop taking oral contraceptives while taking methotrexate

c ulcerations are the first sign of toxicity. the blood levels are monitored frequently, methotrexate should be taken with food to reduce GI distress, and oral contraceptives have no effect on methotrexate

a nurse is caring for a client who has a deep vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. two days ago, the provider also prescribed warfarin. the client asks the nurse about receiving both heparin and warfarin at the same time. which of the following statements should the nurse make? a. i will remind your provider that you are already taking heparin b. your lab findings indicated that two anticoagulants were needed c. it takes 3-4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued d. only one of these medications is being given to treat your DVT

c warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. it takes 3-4 days for the clotting factors that are present to decay and for the therapeutic effects of warfarin to occur

the nurse is caring for a client on a cardiac monitor who is alone in a room at the end of the hall. the client has a short burst of ventricular tachycardia (VT), followed by ventricular fibrillation (VF). the client suddenly loses consciousness, which intervention should the nurse do first? a. go to the nurses station quickly and call a code b. run to get a defibrillator from an adjacent nursing station c. call for help and initiate CPR d. start oxygen by nasal cannula at 10 liters/min and lower the head of the bed

c when VF occurs the nurse remains with the client and initiates CPR until a defibrillator is available and attached to the client

the nurse witnesses a client sustain a fall and suspects the client's leg may be fractured. which action is the priority? a. take a set of vital signs b. call the radiology department c. immobilize the leg before moving the client d. reassure the client that everything will be fine

c when a fracture is suspected it is imperative that the area is splinted before the client is moved. emergency help should be called if the client is not hospitalized. a HCP is called for the hospitalized client. the nurse should remain with the client and provide realistic reassurance. the nurse does not prescribe radiology tests

a nurse attempts to collect a capillary blood specimen via fingerstick for a blood glucose monitoring from a client who has diabetes mellitus. the nurse is unable to obtain an adequate drop of blood for the reagent strip. which of the following actions should the nurse take first? a. puncture another finger to obtain a capillary specimen b. test the urine with a urine reagent strip c. wrap the hand in a warm moist cloth d. perform a venipuncture to obtain a venous sample

c when providing client care, the nurse should use the least restrictive intervention

a patient diagnosed with peripheral arterial disease complains of sudden onset of pain in the right foot. identify the priority is order for actions of the nurse. a. notify the provider b. note the color, temp, and cap refill on the foot c. check for pedal and posterior tibial pulses d. check vital signs

c, b, d, a The first assessment should be pulses, pedal, and posterior tibial, to identify if the acute pain is related to the arterial disease. Color, temperature, and capillary refill all need to be checked to round out the peripheral vascular assessment. Since this is a change in condition, a complete set of vital signs (including pain level) needs to be taken. After all data is available, the provider needs to be notified of the findings.

The nurse is providing discharge teaching to a patient recently diagnosed with type 2 DM. The nurse should include information on which long-term consequences of poor glycemic control? Select all that apply. a. Depression b. Hypertension c. Recurrent infections d. Delayed wound healing e. Peripheral vascular disease

c, d, e Long-term consequences of poor glycemic control can result in recurrent infections, delayed wound healing, and peripheral vascular disease. Depression and hypertension are not direct consequences of poor glycemic control.

The nurse is teaching a class on diabetes to a group of adults in the community. The nurse should be sure to include information on which classic symptoms of diabetes? Select all that apply. a. Hypertension b. Vision changes c. Excessive thirst d. Frequent urination e. Increased appetite f. Recurrent urinary tract infections (UTIs)

c, d, e Polyuria, polydipsia, and polyphagia are the classic symptoms of diabetes. Vision changes may occur after years of poor glycemic control. Hypertension is not a symptom of diabetes. The patient may experience recurrent UTIs due to diabetes, but this is not one of the three classic symptoms.

a nurse is helping admit a child who has HIV. the nurse should identify which of the following findings as indications that the child is in the mildly symptomatic category of HIV? select all that apply a. herpes zoster b. anemia c. dermatitis d. hepatomegaly e. lymphadenopathy

c, d, e mildly symptomatic includes atleast two manifestations like dermatitis, hepatomegaly, and lymphadenopathy. herpes and anemia are in the moderate symptomatic category

a nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. which of the following effects should the nurse anticipate? select all that apply a. urinary incontinence b. diarrhea c. bradypnea d. orthostatic hypotension e. nausea

c, d, e opioid analgesia can cause respiratory depression, orthostatic hypotension, and nausea and vomiting. urinary retention and constipation are adverse effects of opioid analgesia

a nurse is reinforcing teaching about foot care with a client who has DM. which of the following information should the nurse include in the teaching? (select all that apply) a. remove calluses using over the counter remedies b. apply lotion between the toes c. perform nail care after bathing d. trim toenails straight across e. wear closed toe shoes

c, d, e toenails are easier to trim after a shower, cutting the nails straight across can help reduce the risk for injuring the skin, and wear closed toe shoes to prevent injury to the feet

a nurse is assisting with monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. which findings should the nurse expect to note? select all that apply a. excessive bubbling in the water seal chamber b. vigorous bubbling in the suction control chamber c. 50 mL of drainage in the drainage collection chamber d. the drainage system is maintained below the clients chest e. an occlusive dressing is is in place over the chest tube insertion site f. fluctuation of water in the tube of the water seal chamber during inhalation and exhalation

c, d, e, f fluctuation in the water seal chamber is expected, an absence may indicate an obstruction, 50 ml of drainage is expected right after surgery, a dressing os over the insertion site to block air going in the body, positioning the system below the client helps ensure of drainage

the nurse weighs a patient with CHF and determines that there is a net weight gain of 3 pounds within the last 24 hours. the patient states the she is short of breath. place in order the nursing actions to take. a. listen to lung sounds b. place nasal cannula on O2 starting at 2L/min c. raise the head of the bed d. notify the provider e. take vitals including pulse oximetry

c, e, b, a, d Raising the head of the bed will immediately ease breathing. Current vital signs including pulse oximetry are necessary to determine the urgency of the situation. Placing oxygen is indicated for decreased pulse oximetry readings. Listening to lung sounds completes the respiratory assessment for reporting to the provider and obtaining an order for the oxygen.

a nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive romberg sign. which of the following actions should the nurse take to check for this manifestation? a. stroke the lateral aspect of the sole of the foot b. ask the client to blink his eyes c. observe for facial drooping d. have the client stand erect with eyes closed

d a positive romberg sign is indicated when a client loses his balance while attempting to stand erect with his eyes closed

a nurse is reinforcing teaching with an adolescent about the prescribed use of his asthma medications. which of the following medications should the nurse instruct the client to use as needed before exercise? a. fluticasone/salmeterol b. montelukast c. prednisone d. albuterol

d albuterol is a bronchodilator to help open the airway

a nurse is collecting data from a client who is being admitted to an acute care facility. the client has a SaO2 of 91%, exhibits audible wheezing, and is using accessory muscles when breathing. which of the following classes of medications should the nurse expect to administer? a. antibiotic b. beta blocker c. antiviral d. beta2 antagonist

d beta2 antagonist causes dilation of the bronchioles which improves oxygen exchange

the nurse is collecting data from a client who has benign prostatic hyperplasia (BPH) in the past. to determine if the client is currently experiencing exacerbation of BPH, the nurse should ask the client about the presence of which early symptom? a. nocturia b. urinary retention c. urge incontinence d. decreased force in the stream of urine

d decreased force is an early sign of BPH

a nurse is caring for a client who has a prescription for cyclosporine for RA. which of the following medications increases the risk of toxicity when take concurrently with cyclosporine? a. phenytoin b. rifampin c. carbamazepine d. erythromycin

d erythromycin increases cyclosporine levels, so taking the two together causes toxicity. the other medications decrease cyclosporine levels

a nurse is teaching a client about dietary recommendations to lower blood pressure. which of the following statements by the client indicates an understanding of the teaching? a. my daily sodium consumption should be 3000 mg b. i should consume foods low in potassium c. my limit is 3 cigarettes a day d. i should consume low fat dairy products

d low fat dairy products should be encouraged. they promote calcium intake and assist with lowering systolic and diastolic BP as well as cholesterol

a nurse is caring for a patient who has a thoracentesis with the removal of 800cc of fluid. what finding would the nurse expect in the physical assessment of the patient postprocedure? a. slow heart rate b. clear lung sounds c. increased BP d. improved vetilation

d A pleural effusion compresses the lung, restricting it from expanding. Removal of fluid allows for full lung expansion, improving ventilation—the ability of the body to move gases in and out of the body. Vital signs should not be affected by the procedure and lung sounds may or may not be clear depending on what other conditions the patient may have.

clinical reasoning is most important when: a. planning would care for a pressure injury b. organizing nursing care for several patients c. collaborating with other health team members d. drawing sound conclusions from the assessment data

d Although critical thinking skills may be used in any of the answer choices, the most comprehensive answer choice is #4, because drawing conclusions requires an analysis of data and synthesizing it.

a client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. the nurses response based on the understanding that Buck's extension traction has which primary function? a. allows bony healing to begin before surgery b. provides a rigid immobilization to the fracture site c. lengthens the fractured leg to prevent severing of blood vessels d. provides comfort by reducing muscle spasms and provides fracture immobilization

d Buck's extension traction is a type of skin traction often applied after a his fracture, before the fracture is reduced in surgery. it reduces muscle spasms and helps immobilize the fracture. it does not lengthen the leg for the purpose of preventing blood vessel severance. it also does not allow for bony healing to begin

The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? a. Be sure to aspirate prior to injecting insulin. b. Massage the site after injecting insulin. c. Use a 1-inch needle for the injection. d. Allow the insulin to warm to room temperature before injecting it.

d Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.

In discussing DM with a patient, it is important to base the discussion on which information regarding the disease? a. It can often be cured by insulin therapy. b. It has no cure and is considered "hopeless." c. It has no specific treatment other than use of insulin. d. It can often be controlled by diet and regular exercise.

d DM can be controlled with diet, exercise, and medications. The condition is not hopeless; many people lead productive lives after having the diagnosis. Treatments are multifaceted. Each patient's plan of care is individualized based on the type of diabetes and specific health history. Diabetes is a chronic condition and is not curable but managed.

When teaching a patient with type 1 diabetes about home care, the LPN/LVN would be sure to include which signs of diabetic ketoacidosis? a. Dark, scanty urine, and diarrhea b. Cool, clammy skin, and nervousness c. Hunger, headache, and tremulousness d. Thirst, dry mucous membranes, and dry skin

d Diabetic ketoacidosis is a condition associated with excessively high blood glucose levels. It may be caused by illness, stress, or significant lack of insulin. Early manifestations include thirst, dry mucous membranes, and dry skin. Cool, clammy skin; headache; and hunger are noted with hypoglycemia. Diarrhea and low urine output are not linked to ketoacidosis.

A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? a. "Jogging for 20 minutes 5 to 7 days a week would most efficiently help you to lose weight." b. "One hour of vigorous exercise daily is needed to prevent progression of disease." c. "Avoid all forms of exercise because of your diabetic complications." d. "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."

d Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient.

a 40 year old woman complains of leg pains that are associated with fullness during walking. she describes itching on her lower leg and on inspection has a twisted-appearing swelling in her legs. the patient most likely will be treated for? a. venous stasis ulcers b. deep vein thrombosis c. arterial insufficiency d. varicose veins

d Heaviness when standing, itching of skin, and twisted tortuous veins are signs of varicose veins. Venous stasis ulcer is an area of skin breakdown. Deep vein thrombosis signs are pain in the leg with swelling and possible redness. Arterial insufficiency signs are dependent rubor, diminished pedal pulses, intermittent claudication, and loss of hair on the lower extremity.

Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? a. Elevated specific gravity b. Ketone bodies in the urine c. Glucose in the urine d. Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg

d Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.

A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? a. Serum chloride level of 90 mmol/L b. Serum calcium level of 8 mg/dL c. Serum sodium level of 132 mmol/L d. Serum potassium level of 2.5 mmol/L

d Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.

a patient is started on antihypertensive medications. which patient statement indicated effectiveness of teaching? a. i will be able to perform sit-ups in the morning b. i need to take the medication when i feel dizzy c. it helps reduce the incidence of a blood clot d. sudden changes in position may cause dizziness

d Many antihypertensive drugs cause postural hypotension with dizziness. Performing sit-ups is irrelevant to this medication. The medication should be taken every day, not just when feeling dizzy. An antihypertensive drug does not help prevent a blood clot.

which of the following foods would be appropriate to offer a child following a tonsillectomy? select all that apply a. low fat milk b. orange juice c. clear carbonated soft drink d. vanilla flavored ice pop e. yellow gelatin

d Offering a child post-tonsillectomy low fat milk will thicken the secretions in the throat and possibly cause coughing. Orange juice is acidic and could irritate the throat and carbonated soft drinks may cause burping/belching which can irritate the throat. Yellow gelatin provides calories and cannot be confused as blood tinged sputum. Vanilla flavored ice pops are soothing to the throat.

the nurse teaches a patient with diabetes to limit saturated fat and sodium intake because: a. all diabetic patients are at risk for obesity b. these foods contribute to higher glucose levels c. these nutrients are nonessential d. diabetic patients are at risk for cardiovascular disease

d Patients with diabetes are at a greater risk of developing cardiovascular disease, so it is recommended that they follow American Heart Association guidelines. However, some experts recommend reduction of cholesterol to an even greater extent for people with diabetes (200 mg/day).

a nurse is receiving a patient who had angioplasty and stenting of his right femoral artery. which nursing intervention would take priority in the immediate postoperative period? a. assessing the right femoral artery pulse b. monitoring for signs of fluid overload c. determining the range of motion d. checking right pedal pulses

d Pulse should be assessed distal to the procedure site, which would be the pedal pulse, not the femoral. Range of motion is not relevant to this surgery at this time. There is no increased risk of fluid overload for this procedure.

Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted? a. Ketone bodies in the urine have been absent for 3 hours. b. Blood osmolarity has decreased from 350 to 330 mOsm. c. Serum potassium level has increased from 2.8 to 3.2 mEq/L. d. The Glasgow Coma Scale is unchanged from 3 hours ago.

d Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement.

When caring for a patient on the neuro-trauma unit, the nurse should assess for which signs and symptoms of increased intracranial pressure? a. Dehydration b. Hunger c. Nausea d. Vomiting

d Symptoms of increased intracranial pressure include headache, decreased consciousness, and vomiting without nausea. Signs may include cranial nerve VI palsies, papilledema, periorbital bruising, and the late sign of Cushing's triad. Cerebral or brain parenchymal edema rather than dehydration occurs for many reasons. There may be chewing or swallowing problems, but hunger is not associated with increased intracranial pressure. One of the key signs of increasing intracranial pressure is vomiting occuring without nausea.

a nurse is reinforcing teaching with a client who is to have a shave biopsy for suspected cancer. which of the following statements by the client indicates understanding? a. this is a test to check my bone marrow b. this examination will require the removal of lymph nodes c. this procedure will include a needle insertion into the mass d. this test will involve removing a small skin sample

d a shave biopsy is taking the outer layer of skin. bone marrow is a needle biopsy, sentinel node biopsy involves excision of a lymph node, and needle biopsy involves aspiration of a tumor or fluid for tissue sampling

which assigned patient would take priority for immediate attention? a. a patient with infective endocarditis who has an antibiotic dose due b. a patient awaiting aortic stenosis surgery who is complaining of pain c. a patient with systolic HF whose weight is up 1.5 pounds today d. a patient with dysrhythmia whose heart rate has dropped to 42 bpm and is dizzy

d The patient is experiencing decreased cardiac output and should be attended to first. The patient with infective endocarditis should get the antibiotic within 30 minutes. This is the second priority, as antibiotic levels need to be maintained at a steady state in the blood. The patient with aortic stenosis who is awaiting surgery has been having chest pain for weeks and is scheduled for surgery. Assess him and medicate for pain after attending to patients 2 and 1. The weight gain needs to be addressed, but it is not a critical situation. Consult the doctor during rounds about the weight gain. Speak with the patient about whether there has been any extra sodium intake in the past 2 days.

your patient has undergone a thoracotomy with resection of the right lung. she is receiving oxygen by nasal cannula at 5L/min and has a chest tube in place attached to a disposable chest drainage system with suction. there is continuous bubbling in the suction chamber of the disposable water seal chest drainage unit, with120 mL of drainage in the last hour. what should you do? a. document the drainage and continue to monitor the patient b. check the suction tubes for air leaks c. check the patients vital signs d. call the primary care provider

d The primary care provider must be notified when the drainage is above 100 mL/hr. Continuous bubbling in the suction chamber is normal.

The patient presents to the emergency department after a soccer game. The patient reports that she made a sharp turn and heard and felt a large pop from her knee. The patient reports, "Now, when I'm walking, it feels like my knee just gives out, and I almost fall. Plus, it's twice the size of my other knee, and I can't straighten it all the way." The nurse recognizes that these symptoms correspond with which injury? a. Torn meniscus b. Dislocated patella c. Torn quadriceps muscle d. Torn anterior cruciate ligament injury

d The turning motion followed by a loud pop with the patient's complaint of severe swelling, joint instability, and decreased extension indicates a torn anterior cruciate ligament. A meniscal tear has less swelling and joint instability, although some exists. If the patient had dislocated her patella, the patella would be in a different spot than normal, and this would be part of the patient's chief complaint. The patient's complaint centers on the knee, not the quadriceps.

For the patient who needs the support of a crutch while walking, the type of crutch selected will depend on which assessment? a. The gait the patient will use b. What is most comfortable for the patient c. The availability of insurance reimbursement d. The extent of the patient's disability or paralysis

d The type of crutch to be used will depend on the extent of disability or paralysis and the patient's ability to bear weight and maintain balance. If the crutches are too short or too long, the patient will have problems with moving and shifting his or her weight. Reimbursement, the type of gait, and what is most comfortable for the patient are important considerations, but less so than the extent of the patient's disability.

The LPN/LVN is caring for a patient who has had a total hip replacement. Which intervention should be implemented for this patient to help prevent dislocation? a. Adjust the patient's chair so that the hips are flexed in a normal position. b. Ensure the surgical bone cement remains firmly bonded with the prosthesis. c. Assist the patient to bear weight on the operative side within the first 24 hours. d. Secure the abduction wedge between the legs until the surgeon requests removal.

d Use of an abduction wedge in the postoperative period is needed to prevent abduction. The pillow is applied immediately after surgery in the recovery area. It is to remain in place until removal is requested by the surgeon. Weight bearing is not necessarily indicated in the first 24-hour postoperative period. Normal sitting postures are to be avoided; they could potentially result in dislocation.

The nurse is assessing a patient for sleep patterns. The patient reports that he has trouble sleeping when lying flat. The best response from the nurse is a. open a window to let fresh air into the room. b. use nasal strips to assist with breathing. c. sleep in a side-lying position. d. use pillows to prop yourself up while sleeping.

d Using pillows to prop himself up during sleep allows the patient to breathe more easily and comfortably. Nasal strips will help with breathing, but they do not always bring relief when one is lying flat. Sleeping in a side position or opening a window does not help one to breathe more easily when one is lying flat.

the nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. the client has a leg fracture, and a plaster cast has been applied. in positioning the casted leg, the nurse should perform which intervention? a. keep the leg in a level position b. elevate the leg for 3 hours and put flat for 1 hour c. keep the leg level for 3 hours and elevate it for 1 hour d. elevate the legs continuously for 24-48 hours

d a casted extremity is elevated continuously fro the first 24-48 hours to minimize swelling and to promote venous drainage. therefore the other options are correct

a nurse is reinforcing teaching with a client who has stage 3 HIV. which of the following statements by the client should indicate an understanding? a. i will wear gloves while changing the litter box b. i will rinse raw fruits in water before eating them c. i will wear a mask around family members who are sick d. i will cook vegetables before eating them

d a client who has AIDS should cook vegetables before eating them to kill the bacteria. a client who has AIDS should avoid changing the litter box because of toxoplasmosis, avoid eating raw fruit due to the bacteria, and they should avoid all contact with any sick person in the family.

the nurse is monitoring the daily weight of an infant with heart failure. which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the RN? a. bradypnea b. diaphoresis c. decreased BP d. a weight gain of 1 lb in 1 day

d a gain of 1 lb in 1 day means an accumulation of fluid

a nurse is collecting data on a client who has chronic peripheral artery disease (PAD). which of the following findings should the nurse expect? a. edema around the ankles and feet b. ulceration around the medial malleoli c. brownish discoloration of the lower legs and ankles d. dependent rubor with pallor following limb elevation

d a person with chronic PAD, pallor is seen in the extremities during elevation and rubor after elevation

the nurse is assisting in administering immunizations at a health clinic. the nurse understands that immunizations provides which? a. protection from all diseases b. innate immunity from disease c. natural immunity from disease d. acquired immunity from disease

d acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. natural (innate) immunity is present at birth. no immunization to protect the client from all diseases

the client is recovering from a head injury is arousable and participating in care. the nurse determines that the client understands measures to prevent elevations in ICP if the nurse observes the client doing which activity? a. blowing the nose b. isometric exercises c. coughing vigorously d. exhaling during repositioning

d activities that increase intrathoracic and intraabdominal pressures causes indirect elevation of ICP

a nurse is contributing to the plan of care for a child following a surgical procedure. which of the following interventions should the nurse recommend? a. administer NSAIDS for pain greater than 7 on a 0-10 scale b. administer intranasal analgesics prn c. administer IM analgesics for pain d. administer analgesics on a schedule

d administering on a schedule helps to achieve optimal pain management. NSAIDS are used for mild to moderate pain. intranasal analgesics are used for someone over 18 years old. IM pain medications are not recommended for children

a nurse is reinforcing teaching with a client who is to have a bone scan. which of the following statements should the nurse include? a. you will receive an injection of a radioactive isotope when the scanning procedure begins b. you will be in a tube like structure during the procedure c. you will need to take radioactive precautions with your urine for the next 24 hours after the procedure d. you will have to urinate before the procedure

d an empty bladder helps visualization on the pelvic bones. the radioactive isotope is injected through IV prior to the procedure, it is not a tube like structure like an MRI, and radioactive precautions are not necessary for this procedure

a nurse is caring for a client who had an AKA. the client reports a sharp stabbing type of phantom pain. which of the following actions should the nurse take? a. remove the initial pressure dressing b. encourage the use of cold therapy c. question whether the pain is real d. administer an antiepileptic medication

d antiepileptic medication can help relieve pain. the other actions do not reduce phantom pain

a nurse is reinforcing teaching with a client who has MS and a new prescription for baclofen. which of the following statements should the nurse include in the teaching? a. this medication will help with your tremor b. this medication will help with your bladder function c. this medication may cause your skin to bruise easily d. this medication may cause your skin to appear yellow in color

d antispasmodics can cause the skin to turn yellow or jaundice. betablockers treat tremors. anticholingergic medications treats bladder dysfunction. steroids lead to easy bruising

the nurse is caring for a client with increased ICP. which change in vital signs would occur if ICP is rising? a. increased temp, pulse and respirations, and decreasing BP b. decreasing temp, pulse and BP and increasing respirations c. decreasing temp and respirations and increasing pulse and BP d. increasing temp and BP and decreasing respirations and pulse

d change in vital signs are a late sign of ICP, increasing temp and BP and decreasing pulse and respirations, respiratory irregularities may occur

a nurse is caring for a client who has a new diagnosis of fibromyalgia. which of the following medications should the nurse anticipate being prescribed for this client? a. colchicine b. hydroxychloroquine c. auranofin d. duloxetine

d duloxetine is a serotonin-norepinepherine reuptake inhibitor used to treat fibromyalgia. colchicine is to treat gout, auranofin treats RA, and hydroxychloroquine treats RA

the nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. the nurse determines that the client needs further teaching if the nurse observes the client doing which activity? a. pulling up on the trapeze b. flexing and extending the feet c. doing quadriceps-setting and gluteal-setting exercises d. performing active ROM to the right ankle and knee

d exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. the client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle setting exercises. the client may also flex and extend his or her feet. performing active ROM on the affected leg can be harmful

a nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type 1 DM. the nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? a. smear the blood onto the strip b. squeeze the blood onto the strip c. touch the puncture to stimulate the bleeding d. hold the strip next to the blood on the fingertip

d holding the pad of the strip next to the blood allows it to flow onto the strip til the amount is adequate

the nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (lanoxin). which statement by the parent indicated the need for further teaching? a. i will not mix medication with food b. if more than one dose is missed, i will call the HCP c. i will take my childs pulse before administering the medication d. if my child vomits after medication administration, i will repeat the dose

d if the child vomits after the first administration do not give anymore medicine

while a nurse is administering a cleansing enema, the client reports abdominal cramping. which of the following actions should the nurse take? a. have the client hold his breath briefly and bear down b. discontinue the fluid installation c. remind the client that cramping is normal at this time d. lower the enema fluid container

d lowering the fluid container slows the rate of flow and helps to relieve some of the cramping

a HCP has prescribed oxygen as needed for a 10 month old infant with heart failure. in which situation should the nurse administer the oxygen to the child? a. when the child is sleeping b. when changing the childs diaper c. when the mother is holding the child d. when drawing blood for electrolyte levels

d oxygen may be prescribed for stressful times like when crying or invasive procedures

a nurse is discussing the care of a group of clients with a newly licensed nurse. which of the following clients should the newly licensed nurse identify as experiencing chronic pain? a. a client who has a broken femur and reports hip pain b. a client who has incisional pain 72 hour following pacemaker insertion c. a client who has food poisoning and reports abdominal cramping d. a client who has episodic back pain following a fall two years ago

d pain lasting longer than 6 months is considered chronic. the other options are all pain from an acute problem

the client has clear fluid leaking from the nose after a basilar skull fracture. the nurse determines that this is cerebral spinal fluid (CSF).if the fluid meets which criteria? a. is grossly bloody in appearance and has a ph of 6 b. clumps together on the dressing and has a ph of 7 c. is clear in appearance and tests negative for glucose d. separates onto concenteric rings and tests positive for glucose

d the CSF will separate from blood to yellow concentric rings on dressing material

the nurse is preparing to ambulate a postoperative client after cardiac surgery. the nurse plans to do which to enable the client to best tolerate the ambulation? a. provide the client with a walker b. remove the telemetry equipment c. encourage the client to deep breathe and cough d. premedicate the client with an analgesic before ambulating

d the administration of pain medication will help the patient be able to do more with ambulating or deep breathing and coughing.

a nurse is reinforcing teaching with a client who has stage 2 HIV and is having difficulty maintaining a normal weight. which of the following statements indicates understanding? a. i will choose a diet high in fat to help gain weight b. i will be sure to eat 3 large meals a day c. i will drink up to 1 L of liquid a day d. i will add high protein foods to my diet

d the client should add high protein, high calorie to the diet to maintain health and gain weight

a nurse if reinforcing teaching with a school aged child who has diabetes mellitus about insulin administration. which of the following instructions should the nurse include? a. "you should inject the needle at a 30 degree angle" b. "you should combine glargine and regular insulin into the same syringe" c. "you should aspirate for blood before you inject the insulin" d. "you should give 4 to 5 injections in one site before switching sites"

d the client should administer 4 to 5 injections about 2.5 cm apart before switching to another site

the nurse is reinforcing instructions to a client receiving external radiation therapy. the nurse identifies that the client needs further teaching if the client states an intention to take which action? a. eat a high protein diet b. avoid exposure to sunlight c. wash the skin with mild soap and pat dry d. apply pressure on the radiated area to prevent bleeding

d the client should avoid pressure on the radiated area and should wear loose fitting clothing to prevent a disruption in the skin integrity.

the hcp provides laboratory studies for an infant of a woman positive for HIV to determine the presence of HIV antigen in the infant. the nurse anticipates that which laboratory study will be prescribed for the infant? a. chest x-ray b. western blot c. CD4+ cell count d. p24 antigen assay

d the detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of of HIV, or polymerase chain reaction. a chest x-ray evaluates the presence of other manifestations of HIV infection such as pneumonia. a western blot test confirms the presence of HIV antibodies. the CD4+ cell count indicates how well the immune system is working

a friend shares with a nurse about being engaged to be married. the nurse knows that the friend's fiance has tested positive for HIV. what is the nurse's legal obligation to do? a. inform the friend of the fiances HIV infectious status b. recommend the friend be tested for HIV c. advise the friend to postpone the marriage indefinitely d. safeguard information in the fiances history of health

d the nurse has a legal and ethical responsibility to protect the confidentiality of the person who tested positive for HIV

a nurse is caring for a child who is in a plaster shoulder spica cast. which of the following actions should the nurse take? a. use a heat lamp to facilitate drying b. avoid turning the child until the cast is dry c. position the cast below heart level during while it dries d. apple moleskin to the edges of the cast

d the nurse should apply moleskin to the edges of the cast to prevent cast from rubbing the childs skin. use a cool fan to dry. turn the child two hours to facilitate air drying. elevate the extremity above the heart to prevent swelling in the extremity

a nurse is reinforcing teaching with a client who has a new diagnosis of severe peripheral arterial disease. which of the following instructions should the nurse include? a. wear tightly fitting insulated socks with shoes when going outside b. elevate both legs above the heart when resting c. apply a heating pad to both legs for comfort d. place both legs in a dependent position while sleeping

d the nurse should instruct the client to place his legs in a dependent position, such as hanging off the bed while sleeping. this can alleviate swelling and discomfort of the legs

a nurse is caring for a client who will perform fecal occult blood testing at home. which of the following information should the nurse include when explaining the procedure to the client? a. eating more protein is optimal prior to testing b. one stool specimen is sufficient for testing c. a red color change indicates a positive test d. the specimen cannot be contaminated by urine

d the nurse should warn the client about contamination from the urine

a nurse is caring for a toddler who has dysplasia of the hip and a hip spica cast is in place. the childs mother asks the nurse why pavlik harness is not being used. which of the following responses should the nurse make? a. the pavlik harness is used for children with scoliosis, not hip dysplasia b. the pavlik harness is used for school age children c. the pavlik harness cannot be used for your childs condition because her condition is too severe d. the pavlik harness is used for infants less than 6 months of age

d the pavlik harness is only for children under 6 months with hip dysplasia

the client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. the nurse expect the cervical collar will remain in place until which time? a. the client is taken for spinal x-rays b. the client comes to visit after surgery c. the nurse needs to provide physical care d. the HCP reviews the x-ray results

d the spine stays in the collar until the HCP tells her different

a nurse is reviewing instructions with a client who has hearing loss and has just started wearing hearing aids. which of the following statements should the nurse identify as an indication that the client understands the instructions? a. i use a damp cloth to clean the outside part of the hearing aid b. i clean the ear molds of my hearing aid with alcohol c. i keep the volume of my hearing aids turned up so i can hear better d. i take the batteries out of my hearing aids when i take them off at night

d to conserve battery life batteries should be removed when not in use. hearing aids should be completely dry at all times, the ear molds should be cleaned with mild soap and water, and to avoid feedback the client should keep it on the lowest setting

the nurse is collecting data regarding a client after a thyroidectomy and notes the client a has developed hoarseness and a weak voice. which nursing action is appropriate? a. check for signs of bleeding b. administer calcium gluconate c. notify the registered nurse immediately d. reassure the client that this is usually a temporary condition

d weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve

the nurse is assigned to assist the health care provider with the removal of a chest tube. the nurse should reinforce instructing the client to do which during this process? a. stay very still b. exhale forcefully c. inhale and exhale quickly d. perform valsava's maneuver

d when a chest tube is removed they are asked to perform valsava's maneuver(take a deep breath, exhale and bear down), the tube is removed and airtight dressing is taped in place

the nurse answers the call light for a patient with diabetes. the patient states she feels shaky and weak. the nurse notes pallor and moist skin. list in priority order the actions of the nurse. a. give patient 6 oz of orange juice b. document interventions c. check finger stick glucose d. assess level of consciousness

d, c, a, b The level of consciousness determines the glucose intervention. If the patient is not able to swallow, injectable forms of glucose will be utilized. If the patient is unconscious, treatment should be initiated immediately, not taking time for checking the blood glucose level. For the conscious patient, fingerstick glucose should be done and treatment given and actions documented. Fifteen minutes after treatment, the glucose should be rechecked.

a nurse is reinforcing teaching with a client who has peptic ulcer disease about managing the disorder. which of the following instructions should the nurse include? select all that apply a. eat a bedtime snack b. drink decaf coffee c. avoid low dose aspirin therapy d. seek measures to reduce stress e. avoid drinking alcohol

d, e reducing stress helps heal an ulcer and avoiding drinking alcohol prevents developing peptic ulcers. the client should avoid a bedtime snack to reduce gastric secretions, the client should avoid coffee to reduce gastric secretions, and low dose aspirin therapy does not effect this scenario

Final Exam (Minus Test 1 Content)

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Chapter 4

Python Midterm IS4010

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Chapter 3 test

Biology Exam Pt. 4

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Exam 1 Concepts

3671 ch 7

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Math 110 Chapter 1 and 2 Review

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PrepU Maternity Chapter 22

ACCY 200 CQ 7 (Ch 13,14)