MED B

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults.

A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?

Place the client in a negative-pressure airflow room.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood.

For each potential nursing intervention, click to specify if the intervention is indicated or not indicated.

Request a chest x-ray - not indicated Place the client in reverse Trendelenburg position - indicated Assist with administering a 0.9% sodium chloride 200 mL IV bolus - indicated Apply oxygen at 2 L/min via nasal cannula - indicated Notify the charge nurse immediately - indicated Obtain the client's blood glucose level - not indicated

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

Withhold the dose.

Select the 3 findings that require follow-up by the nurse.

oxygen saturation pain level wound dressing

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen

A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?

Allow the weights to hang freely.

A nurse in a dermatology clinic is reviewing the medical records of a group of clients. Which of the following prescriptions for a client who has psoriasis should the nurse clarify with the provider?

Dermabrasion

A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?

Frequent colds

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosemide

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months.

Complete the following sentence by using the lists of options. The nurse should identify that the client is most likely experiencing _______, and the nurse should address the client's _________.

Migraine Pain

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime.

Drag words from the choices below to fill in each blank in the following sentence. The nurse should first address the client's ______, followed by the client's ________.

Oxygenation Blood pressure

A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?

Urine output is 50 mL/hr.

A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

Truncal Obesity

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client.

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin.

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

"Calcitonin will slow the breakdown of bone in your body."

The nurse is evaluating the client's understanding of the discharge instructions. click to highlight the client statements that indicate an understanding of the teaching. to deselect a statement, click on the statement again.

"Foods that contain tyramine might trigger my headaches" "I will keep a food headache diary" " I will place a cool cloth on my forehead when I experience a migraine"

A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make?

"Hospice care will provide support for you and your loved ones during the dying process."

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water."

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?

"I had a low fever this morning."

A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication?

"I have gained 3 pounds since my last appointment."

A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching?

1 cup of boiled broccoli

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?

Elevated troponin

A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

864 cal

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Administer Morphine IV Ensure the client is NPO Cholecystitis Jaundice Increasing temperature

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is assisting with the care of a client who has a migraine. Which of the following interventions should the nurse anticipate? Select all that apply.

Administer sumatriptan Dim the lights in the client's room

A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the cast using a blow dryer on a cool setting.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube.

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?

Cleanse the client's skin prior to electrode placement.

A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take?

Cleanse the drainage plug with alcohol swabs.

A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heat rate 120/min

Complete the following sentence by using the lists of options. The client is most likely experiencing a _______ as evidenced by the client's ________.

Hemothorax Respiratory findings

A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?

Household family members should be tested for TB.

A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress.

A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist

For each finding, click to specify if the finding is consistent with emphysema, asthma, or pneumonia. Each finding may support more than 1 disease process.

Temperature - pneumonia Breath sounds - emphysema, asthma, & pneumonia Respiratory rate - emphysema, asthma, & pneumonia Cough - emphysema, asthma, & pneumonia

For each potential provider prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Transfuse packed RBCs - anticipated Place the client in Trendelenburg position - contraindicated Prepare the client for chest tube insertion - anticipated Cover the client with a cooling blanket - contraindicated Initiate NPO status - anticipated

A nurse is reinforcing preoperative teaching with a client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.

" I will need to do the breathing exercises every 1 to 2 hrs after surgery." "I will use my PCA medication before my knee starts to hurt too bad." "I will probably be going home with a walker."

A nurse is reinforcing instructions with a client who has a new hearing aid. Which of the following instructions should the nurse include?

"Adjust the volume to a level where you can hear others speak at a distance of 3 feet."

A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?

Decrease in exertional dyspnea

A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes Mellitus

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath sounds

For each finding below, click to specify if the finding is consistent with migraine, stroke, or meningitis. Each finding may support more than 1 disease process.

Family history - migraine, stroke Pain - migraine, stroke, meningitis Nausea - migraine, meningitis Visual changes - migraine, stroke, meningitis

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamphlet?

Females have a higher risk for contracting STIs than males.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off of the affected areas

Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a finding, clink on the finding again.

Perineal pad is saturated with blood, and large clots are present Blood pressure 98/56 mm Hg Heart rate 102/min

A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?

Prednisone

A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?

"Add oily fish to your diet twice weekly."

Select the 3 findings that require follow-up by the nurse.

Visual disturbances headache Nausea

A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter."

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet."

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?

"My food tastes bland even after I add seasoning."

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

"Perform testicular self-examination after taking a warm shower."

A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.)

"Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution."

A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"Pursed-lip breathing works best for activities like walking up stairs."

A nurse is reinforcing teaching with a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

"Take calcium supplements with meals."

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?

"The virus can be transmitted without lesions being present."

A home health nurse is caring for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?

"Use a bronchodilator 30 minutes before your meal."

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide."

A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.)

"Your knee is flexed and extended as prescribed by your provider" "The machine is padded with sheep skin"

A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night

A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?

Assist the client to change positions at least every 2 hrs.

A nurse is caring for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first?

Check the incisional dressing

The nurse is assisting with the care of the client 1 hr following chest tube insertion. Click to highlight the findings that indicate the client's condition is improving. To deselect a finding, click on the finding again.

Client reports pain as a 3 on a scale of 0 to 10 Client reports shortness of breath has decreased Wound dressing is dry and intact Respiratory rate 24/min Blood pressure 108/74 mm Hg Oxygen saturation 95% on oxygen 2L/min via nasal cannula

A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow between the client's legs.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride.

A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?

Obtain the client's blood pressure.

A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light

Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is experiencing manifestations of (Condition) due to the client's (Client Finding).

Peritonitis Abdominal x-ray results

The nurse is assisting with the care of the client following the placement of a chest tube for a hemothorax. Which of the following actions should the nurse take? Select all that apply.

Place the client in high-fowler's position Place two rubber-tipped hemostats in client's room Palpate the chest tube insertion site for subcutaneous Ensure that all chest tube connections are securely attached

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client.

A nurse is repositioning a client who has low back pain. Which of the following positions is should the nurse place the client in?

Semi-Fowler's with knees flexed

A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent pacemaker. Which of the following findings should the nurse report to the provider?

The client experiences hiccups when sitting.

A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first?

Verify the client has given informed consent.

A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?

Upright, leaning forward

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3

A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will limit my coffee intake."

A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure."

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning."

Complete the following sentence by using the list of options. Following the administration of sumatriptan, the nurse should monitor for ________ due to the risk for ________.

Chest pain Myocardial ischemia

A nurse is caring for a client who is postoperative following an above-the-knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take?

Collaborate with the physical therapist to initiate alternative pain therapies

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough

A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?

Encourage reminiscence of past experiences.