Med Surg 1

The 62 - year - old client diagnosed with type 2 diabetes who has a gangrenous right toe is being admitted for a below - the - knee amputation . Which nursing intervention should the nurse implement ? 1. Assess the client's nutritional status . 2. Refer the client to an occupational therapist 3. Determine if the client is allergic to IVP dye . 4. Start a 22 - gauge angiocatheter in the right arm

1. Assess the client's nutritional status .

The client with a right AKA is being taught how to toughen the residual limb . Which intervention should the nurse implement ? 1. Instruct the client to push the residual limb against a pillow . 2. Demonstrate how to apply an elastic bandage around the residual limb . 3. Encourage the client to apply vitamin B12 to the surgical incision . 4. Teach the client to elevate the residual limb at least three ( 3 ) times a day .

1. Instruct the client to push the residual limb against a pillow .

The nurse is administering a proton pump inhibitor to a client diagnosed with peptic ulcer disease . Which statement supports the rationale for administering this medication ? 1. It prevents the final transport of hydrogen ions into the gastric lumen . 2. It blocks receptors controlling hydrochloric acid secretion by the parietal cells . 3. It protects the ulcer from the destructive action of the digestive enzyme pepsin . 4. It neutralizes the hydrochloric acid secreted by the stomach .

1. It prevents the final transport of hydrogen ions into the gastric lumen .

The nurse is caring for a client diagnosed with a fracture of the right distal humerus . Which data indicate a complication ? Select all that apply . 1. Numbness and mottled cyanosis . 2. Paresthesia and paralysis . 3. Proximal pulses and point tenderness . 4. Coldness of the extremity and crepitus . 5. Palpable radial pulse and functional movement .

1. Numbness and mottled cyanosis 2. Paresthesia and paralysis . 4. Coldness of the extremity and crepitus .

The 32 - year - old male client with a traumatic left AKA is being discharged from the rehabilitation department . Which discharge instructions should be included in the teaching ? Select all that apply . 1. Report any pain not relieved with analgesics . 2. Eat a well - balanced diet and increase protein intake . 3. Be sure to attend all outpatient rehabilitation appointments . 4. Encourage the client to attend a support group for amputations . 5. Stay at home as much as possible for the first couple of months .

1. Report any pain not relieved with analgesics . 2. Eat a well - balanced diet and increase protein intake . 3. Be sure to attend all outpatient rehabilitation appointments . 4. Encourage the client to attend a support group for amputations .

The nurse instructs the client with a right BKA to lie on the stomach for at least 30 minutes a day . The client asks the nurse , " Why do I need to lie on my stomach ? " Which statement is the most appropriate statement by the nurse ? 1. " This position will help your lungs expand better . " 2. " Lying on your stomach will help prevent contractures . " 3. " Many times this will help decrease pain in the limb . " 4. " The position will take pressure off your backside . "

2. " Lying on your stomach will help prevent contractures . "

The recovery room nurse is caring for a client who has just had a left BKA . Which intervention should the nurse implement ? 1. Assess the client's surgical dressing every two ( 2 ) hours . 2. Allow the client to see the residual limb . 3. Keep a large tourniquet at the client's bedside . 4. Perform passive range - of - motion exercises to the right leg . 5. Wrap limb with a compression dressing

2. Allow the client to see the residual limb . 3. Keep a large tourniquet at the client's bedside .

The nurse is caring for a client with a right below - the - knee amputation . There is a large amount of bright red blood on the client's residual limb dressing . Which intervention should the nurse implement first ? 1. Notify the client's surgeon immediately . 2. Assess the client's blood pressure and pulse . 3. Reinforce the dressing with additional dressing . 4. Check the client's last hemoglobin and hematocrit level .

2. Assess the client's blood pressure and pulse .

The client admitted with a diagnosis of a fractured hip is in skin traction and reporting severe pain . Which intervention should the nurse implement ? 1. Adjust the patient - controlled analgesia ( PCA ) machine for a lower dose . 2. Ensure the weights of the traction are off the floor and hanging freely . 3. Raise the head of the bed to 45 degrees and the foot to 15 degrees . 4. Turn the client on the affected leg using pillows to support the other leg .

2. Ensure the weights of the traction are off the floor and hanging freely .

The nurse is caring for a client diagnosed with rule - out ARF . Which condition predisposes the client to developing prerenal failure 1. Diabetes mellitus . 2. Hypotension . 3. Aminoglycosides 4. Benign prostatic hypertrophy .

2. Hypotension .

The client is three ( 3 ) hours postoperative left AKA . The client tells the nurse , " My left foot is killing me . Please do something . " Which intervention should the nurse implement ? 1. Explain to the client his left leg has been amputated . 2. Medicate the client with a narcotic analgesic immediately . 3. Instruct the client on how to perform biofeedback exercises . 4. Place the client's residual limb in the dependent position .

2. Medicate the client with a narcotic analgesic immediately .

The nurse is providing discharge teaching to the 12 - year - old with a fractured humerus and the parents . Which information should the nurse include regarding cast care ? Select all that apply . 1. Keep the fractured arm at heart level . 2. Use a wire hanger to scratch inside the cast . 3. Apply an ice pack to any itching area . 4. Explain foul smells are expected occurrences . 5. Prevent cast from getting wet

3. Apply an ice pack to any itching area . 5. Prevent cast from getting wet

The nurse is caring for a client with a fractured left tibia and fibula . Which data should the nurse report to the health - care provider immediately ? 1. Localized edema and discoloration occurring hours after the injury . 2. Generalized weakness and increasing sensitivity to touch . 3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain . 4. Pain relieved after taking four ( 4 ) mg hydromorphone , a narcotic analgesic .

3. Dorsalis pedal pulse cannot be located with a Doppler and increasing pain .

The client is being evaluated for osteoporosis . Which diagnostic test is the most accurate when diagnosing osteoporosis ? 1. X - ray of the femur . 2. Serum alkaline phosphatase .. 3. Dual - energy x - ray absorptiometry ( DEXA ) . 4. Serum bone Gla - protein test .

3. Dual - energy x - ray absorptiometry ( DEXA ) .

The client diagnosed with ARF is experiencing hyperkalemia . Which medication should the nurse prepare to administer to help decrease the potassium level ? 1. Erythropoietin . 2. Calcium gluconate 3. Regular insulin . 4. Osmotic diuretic .

3. Regular insulin .

Which outcome should the nurse identify for the client diagnosed with fluid volume excess ? 1. The client will void a minimum of 30 mL per hour . 2. The client will have an elastic skin turgor . 3. The client will have no adventitious breath sounds . 4. The client will have a serum creatinine of 1.4 mg / dL

3. The client will have no adventitious breath sounds .

The nurse is caring for the client diagnosed with chronic kidney disease ( CKD ) who is experiencing metabolic acidosis . Which statement best describes the scientific rationale for metabolic acidosis in this client ? 1. There is an increased excretion of phosphates and organic acids , which leads to an increase in arterial blood pH . 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis . 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate . 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately .

3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate .

The nurse is caring for a client diagnosed with diabetic ketoacidosis ( DKA ) . Which statement best explains the scientific rationale for the client's Kussmaul's respirations ? 1. The kidneys produce excess urine and the lungs try to compensate . 2. The respirations increase the amount of carbon dioxide in the bloodstream . 3. The lungs speed up to release carbon dioxide and increase the pH . 4. The shallow and slow respirations will increase the HCO3 in the serum

3. The lungs speed up to release carbon dioxide and increase the pH .

Which assessment data support the nurse's diagnosis of gastric ulcer ? 1. Presence of blood in the client's stool for the past month . 2. Reports of a burning sensation moving like a wave . 3. Sharp pain in the upper abdomen after eating a heavy meal . 4. Complaints of epigastric pain 30 to 60 minutes after ingesting food .

4. Complaints of epigastric pain 30 to 60 minutes after ingesting food .

The client is admitted with a serum sodium level of 110 mEq / L . Which nursing intervention should be implemented ? 1. Encourage fluids orally . 2. Administer 10 % saline solution IVPB . 3. Administer antidiuretic hormone intranasally 4. Place on seizure precautions .

4. Place on seizure precautions .

The nurse is planning client teaching for a client with end - stage kidney disease who is scheduled for the creation of a fistula . The nurse should teach the client what information about the fistula ? A. " A vein and an artery in your arm will be attached surgically . " B. " The arm should be immobilized for 4 to 6 days . " C. " One needle will be inserted into the fistula for each dialysis treatment . " D. " The fistula can be used 5 to 7 days after the surgery for dialysis treatment . "

A. " A vein and an artery in your arm will be attached surgically . "

A client with diabetic nephropathy has end - stage renal disease and is starting dialysis . What should the nurse teach the client about hemodialysis ? A. " Hemodialysis is a treatment option that is usually required three times a week . " B. " Hemodialysis is a program that will require you to commit to daily treatment . " C. " This will require you to have surgery and a catheter will need to be inserted into your abdomen . " D. " Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again . "

A. " Hemodialysis is a treatment option that is usually required three times a week . "

The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure ( gastroduodenostomy ) . Which statement ( s ) by the client indicates effective knowledge of the procedure ? Select all that apply . A. " I will be at risk of developing diarrhea , nausea , and feeling light - headed after eating . " B. " It is likely that I will need to receive nutrition directly into my veins . " C. " One of my nerves , the vagus nerve , may be cut during the surgery . " D. " I can eat a normal diet again after 3 to 5 weeks . " E. " This surgery will remove part of my stomach and colon . "

A. " I will be at risk of developing diarrhea , nausea , and feeling light - headed after eating . " C. " One of my nerves , the vagus nerve , may be cut during the surgery . "

A nurse is conducting a class on how to self - manage insulin regimens . A client asks how long a vial of insulin can be stored at room temperature before it " goes bad . " What would be the nurse's best answer ? A. " If you are going to use up the vial within 1 month , it can be kept at room temperature . " B. " If a vial of insulin will be used up within 21 days , it may be kept at room temperature . " C. " If a vial of insulin will be used up within 2 weeks , it may be kept at room temperature . " D. " If a vial of insulin will be used up within 1 week , it may be kept at room temperature . "

A. " If you are going to use up the vial within 1 month , it can be kept at room temperature . "

The nurse is conducting client teaching about cholesterol levels . When discussing the client's elevated LDL and lowered HDL levels , the client shows an understanding of the significance of these levels by making what statement ? A. " Increased LDL and decreased HDL increase my risk of coronary artery disease . " B. " Increased LDL has the potential to decrease my risk of heart disease . " C. " The decreased HDL level will increase the amount of cholesterol moved away from the artery walls . " D. " The increased LDL will decrease the amount of cholesterol deposited on the artery walls . "

A. " Increased LDL and decreased HDL increase my risk of coronary artery disease . "

A client was brought to the emergency department after a fall . The client is taken to the operating room to receive a right hip prosthesis . In the immediate postoperative period , what health education should the nurse emphasize ? A. " Make sure you don't bring your knees close together . " B. " Try to lie as still as possible for the first few days . " C. " Try to avoid bending your knees until next week . " D. " Keep your legs higher than your chest whenever you can . "

A. " Make sure you don't bring your knees close together . "

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments . What client most likely faces the highest immediate risk of oral cancer ? A. A 65 - year - old man with alcoholism who smokes B. A 45 - year - old woman who has type 1 diabetes and who wears dentures C.A 32 - year - old man who is obese and uses smokeless tobacco D. A 57 - year - old man with GERD and dental caries

A. A 65 - year - old man with alcoholism who smokes

The surgical nurse is admitting a client from postanesthetic recovery following the client's below - the - knee amputation . The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside ? A. A tourniquet B. A syringe preloaded with vitamin K C. A unit of packed red blood cells placed on ice D. A dose of protamine sulfate

A. A tourniquet

A nurse is caring for a client who has an order to discontinue the administration of parenteral nutrition . What should the nurse do to prevent the occurrence of rebound hypoglycemia in the client ? A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN . B. Administer a hypertonic dextrose solution for 1 to 2 hours after discontinuing the PN . C. Administer 3 ampules of dextrose 50 % immediately prior to discontinuing the PN . D. Administer 3 ampules of dextrose 50 % 1 hour after discontinuing the PN .

A. Administer an isotonic dextrose solution for 1 to 2 hours after discontinuing the PN .

A client with end - stage liver disease has developed hypervolemia . What nursing interventions would be most appropriate when addressing the client's fluid volume excess ? Select all that apply . A. Administering diuretics B. Administering calcium channel blockers . C. Implementing fluid restrictions D. Implementing a 1500 kcal day restriction E. Enhancing client positioning

A. Administering diuretics C. Implementing fluid restrictions E. Enhancing client positioning

A nurse is working for the summer at a camp for adolescents with diabetes . When providing information on the prevention and management of hypoglycemia , what action should the nurse promote ? A. Always carry a form of fast - acting sugar . B. Perform exercise prior to eating whenever possible . C. Eat a meal or snack every 8 hours . D. Check blood sugar at least every 24 hours .

A. Always carry a form of fast - acting sugar .

A nurse is providing care for client whose pattern of laboratory testing reveals long - standing hypocalcemia . Which other laboratory result is most consistent with this finding ? A. An elevated parathyroid hormone level B. An increased calcitonin level C. An elevated potassium level D. A decreased vitamin D level

A. An elevated parathyroid hormone level

A nurse is caring for a client newly diagnosed with type 1 diabetes . The nurse is educating the client about self - administration of insulin in the home setting . The nurse should teach the client to do what action ? A. Avoid using the same injection site more than once in 2 to 3 weeks . B. Avoid mixing more than one type of insulin in a syringe . C. Cleanse the injection site thoroughly with alcohol prior to injecting . D. Inject at a 45 - degree angle .

A. Avoid using the same injection site more than once in 2 to 3 weeks .

A client has symptoms of osteoporosis and is being assessed during an annual physical examination . The assessment shows that the client will require further testing related to a possible exacerbation of osteoporosis . The nurse should anticipate which diagnostic test ? A. Bone densitometry B. Hip bone radiography C. Computed tomography ( CT ) D. Magnetic resonance imaging ( MRI )

A. Bone densitometry

An older , female client with osteoporosis has been hospitalized . Prior to discharge , when teaching the client , the nurse should include information about which major complication of osteoporosis ? A. Bone fracture B. Loss of estrogen C. Negative calcium balance D. Dowager hump

A. Bone fracture

The nurse is caring for a client whose acute kidney injury ( AKI ) resulted from a prerenal cause . Which condition most likely caused this client's health problem ? A. Burns B. Glomerulonephritis C. Ureterolithiasis D. Pregnancy

A. Burns

The nurse is administering total parenteral nutrition ( TPN ) to a client who underwent surgery for gastric cancer . Which of the nurse's assessments most directly addresses a major complication of TPN ? A. Checking the client's capillary blood glucose levels regularly B. Having the client frequently rate his or her hunger on a 10 - point scale C. Measuring the client's heart rhythm at least every 6 hours D. Monitoring the client's level of consciousness each shift

A. Checking the client's capillary blood glucose levels regularly

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain . The client is scheduled for diagnostic testing in the morning . Which of the following are appropriate diagnostic tests for assessing low back pain ? Select all that apply . A. Computed tomography ( CT ) B. Angiography C. Magnetic resonance imaging ( MRI ) D. Ultrasound E. X - ray

A. Computed tomography ( CT ) C. Magnetic resonance imaging ( MRI ) D. Ultrasound E. X - ray

A client with end - stage kidney disease is scheduled to begin hemodialysis . The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications . The client's diet should include which of the following modifications ? Select all that apply . A. Decreased protein intake B. Decreased sodium intake C. Increased potassium intake D. Fluid restriction E. Vitamin D supplementation

A. Decreased protein intake B. Decreased sodium intake D. Fluid restriction

The nurse is evaluating a client's diagnosis of arterial insufficiency with reference to the adequacy of the client's blood flow . On what physiologic variables does adequate blood flow depend ? Select all that apply . A. Efficiency of heart as a pump B. Adequacy of circulating blood volume C. Ratio of platelets to red blood cells D. Size of red blood cells E. Patency and responsiveness of the blood vessels

A. Efficiency of heart as a pump B. Adequacy of circulating blood volume E. Patency and responsiveness of the blood vessels

A nurse is caring for a client who had a right below - the - knee amputation ( BKA ) . The nurse recognizes the importance of implementing measures that focus on preventing flexion contracture of the hip and maintaining proper positioning . What nursing action will best achieve these goals ? A. Encouraging the client to turn from side to side and to assume a prone position B. Initiating ROM exercises of the hip and knee 10 to 12 weeks after the amputation C. Minimizing movement of the flexor muscles of the hip D. Encouraging the client to sit in a chair for at least 8 hours a day

A. Encouraging the client to turn from side to side and to assume a prone position

A. Enhancement of verbal communication B. Enhancement of immune function C. Maintenance of adequate social support D. Maintenance of fluid balance

A. Enhancement of verbal communication

A nurse is caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home . The nurse should teach the client to monitor closely for what post procedure complication ? A. Fever B. Crepitus C. Fasciculations D. Synovial fluid leakage

A. Fever

An oncology nurse is caring for a client with multiple myeloma who is experiencing bone destruction . When reviewing the client's most recent blood tests , the nurse should anticipate which imbalance ? A. Hypercalcemia B. Hyperproteinemia C. Elevated serum viscosity D. Elevated red blood count ( RBC )

A. Hypercalcemia

A client in the emergent / resuscitative phase of a burn injury has had blood work and arterial blood gases drawn . Upon analysis of the client's laboratory studies , the nurse will expect the results to indicate what findings ? A. Hyperkalemia , hyponatremia , elevated hematocrit B. Hypokalemia , hypernatremia , decreased hematocrit C. Hyperkalemia , hypernatremia , decreased hematocrit D. Hypokalemia , hyponatremia , elevated hematocrit

A. Hyperkalemia , hyponatremia , elevated hematocrit

A client has been brought to the emergency department by paramedics after being found unconscious . The client's MedicAlert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg / dL ( 1.2 mmol / L ) . The nurse should anticipate what intervention ? A. IV administration of 50 % dextrose in water B. Subcutaneous administration of 10 units of Humalog C. Subcutaneous administration of 12 to 15 units of regular insulin D. IV bolus of 5 % dextrose in 0.45 % NaCl

A. IV administration of 50 % dextrose in water

An older adult woman's current medication regimen includes alendronate . What outcome would indicate successful therapy ? A. Increased bone mass B. Resolution of infection C. Relief of bone pain D. Absence of tumor spread

A. Increased bone mass

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism ( VTE ) . When assessing a client's lower limbs , what sign or symptom is suggestive of deep vein thrombosis ( DVT ) ? A. Increased warmth of the calf B. Decreased circumference of the calf C. Loss of sensation to the calf D. Pale - appearing calf

A. Increased warmth of the calf

A client presents to the clinic reporting vomiting and burning in the mid - epigastrium . The nurse knows that in the process of confirming peptic ulcer disease , the health care provider is likely to order a diagnostic test to detect the presence of what ? A. Infection with Helicobacter pylori B. Excessive stomach acid secretion C. An incompetent pyloric sphincter D. A metabolic acid - base imbalance

A. Infection with Helicobacter pylori

A client with end - stage renal disease receives continuous ambulatory peritoneal dialysis . The nurse observes that the dialysate drainage fluid is cloudy . What is the nurse's most appropriate action A. Inform the health care provider and assess the client for signs of infection . B. Flush the peritoneal catheter with normal saline . C. Remove the catheter promptly and have the catheter tip cultured D. Administer a bolus of IV normal saline as prescribed .

A. Inform the health care provider and assess the client for signs of infection .

A client has been experiencing an unexplained decline in knee function and has consequently been scheduled for arthrography . The nurse should teach the client about what process ? A. Injection of a contrast agent into the knee joint prior to ROM exercises B. Aspiration of synovial fluid for serologic testing C. Injection of corticosteroids into the client's knee joint to facilitate ROM D. Replacement of the client's synovial fluid with a synthetic substitute

A. Injection of a contrast agent into the knee joint prior to ROM exercises

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates . What principle should the educator promote ? A. Knots in the rope should not be resting against pulleys . B. Weights should rest against the bed rails . C. The end of the limb in traction should be braced by the footboard of the bed . D. Skeletal traction may be removed for brief periods to facilitate the client's independence .

A. Knots in the rope should not be resting against pulleys .

The nurse is caring for a client who is exhibiting signs and symptoms of hypovolemic shock following injuries from a motor vehicle accident . In addition to normal saline , which crystalloid fluid should the nurse prepare to administer ? A. Lactated Ringer B. Albumin C. Dextran D. 3 % NaCl

A. Lactated Ringer

The nurse has identified the nursing diagnosis of " Risk for Infection " in a client who undergoes peritoneal dialysis . What nursing action best addresses this risk ? A. Maintain aseptic technique when administering dialysate . B. Wash the skin surrounding the catheter site with soap and water prior to each exchange . C. Add antibiotics to the dialysate as prescribed . D. Administer prophylactic antibiotics by mouth or IV as prescribed .

A. Maintain aseptic technique when administering dialysate .

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction . What is the nurse's priority during this aspect of the client's care A. Measure and record drainage . B. Monitor drainage for change in color . C. Titrate the suction every hour D. Feed the client via the G tube as prescribed

A. Measure and record drainage .

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms . The nurse should anticipate that the client may be prescribed what drug ? A. Metoclopramide B. Omeprazole C. Lansoprazole D. Calcium carbonate

A. Metoclopramide

A client in the critical care unit is prescribed crystalloid intravenous fluids . The nurse anticipates administering which fluid ? Select all that apply . A. Normal saline B. Lactated Ringer C. Dextrose 5 % in water D. Albumin E. Hetastarch ( TM )

A. Normal saline B. Lactated Ringer C. Dextrose 5 % in water

An 80 - year - old man in a long - term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days . The nurse notes that the site is now swollen and warm to the touch . The client should undergo diagnostic testing for what health problem ? A. Osteomyelitis B. Osteoporosis C. Osteomalacia D. Septic arthritis

A. Osteomyelitis

A. Peritonitis B. Gastritis C. Gastroesophageal reflux D. Acute pancreatitis

A. Peritonitis

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip . How should the nurse position the client ? A. Place a pillow between the legs . B. Turn the client on the surgical side . C. Avoid flexion of the right hip . D. Keep the right hip adducted at all times ..

A. Place a pillow between the legs .

A client was fitted with an arm cast after fracturing the humerus . Twelve hours after the application of the cast , the client tells the nurse that the injured arm hurts . Analgesics do not relieve the pain . What would be the most appropriate nursing action ? A. Prepare the client for opening or bivalving of the cast B. Obtain a prescription for a different analgesic . C. Encourage the client to wiggle and move the fingers . D petal the edges of the clients cast.

A. Prepare the client for opening or bivalving of the cast . Acute compartment syndrome involves a sudden and severe decrease in blood flow to the tissues distal to an area of injury that results in ischemic necrosis if prompt, decisive intervention does not occur. Removing or bivalving the cast is necessary to relieve pressure.

A client with cardiovascular disease is being treated with amlodipine , which is intended to cause what therapeutic effect ? A. Reducing the heart's workload by decreasing heart rate and myocardial contraction B. Preventing platelet aggregation and subsequent thrombosis C. Reducing myocardial oxygen consumption by blocking adrenergic stimulation to the heart D. Increasing the efficiency of myocardial oxygen consumption , thus decreasing ischemia and relieving pain

A. Reducing the heart's workload by decreasing heart rate and myocardial contraction

A client who is being treated for pneumonia reports sudden shortness of breath . An arterial blood gas ( ABG ) is drawn . The ABG has the following values : pH 7.21 , PaCO2 64 mm Hg , HCO3 24 mm Hg . Which condition does the ABG reflect ? A. Respiratory acidosis B. Metabolic alkalosis . C. Respiratory alkalosis D. Metabolic acidosis

A. Respiratory acidosis

A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha - adrenergic blocker . When teaching this client , what should the nurse emphasize ? A. Rising slowly from a lying or sitting position B. Increasing fluids to maintain BP C. Stopping medication if dizziness persists D. Taking medication first thing in the morning

A. Rising slowly from a lying or sitting position

A client is receiving a blood transfusion and reports a new onset of slight dyspnea . The nurse's rapid assessment reveals bilateral lung crackles and elevated BP . What is the nurse's most appropriate action ? A. Slow the infusion rate and monitor the client closely . B. Discontinue the transfusion and begin resuscitation . C. Pause the transfusion and administer a 250 mL bolus of normal saline . D. Discontinue the transfusion and administer a beta - blocker , as prescribed .

A. Slow the infusion rate and monitor the client closely .

A client presents to a clinic reporting a leg ulcer that isn't healing ; subsequent diagnostic testing suggests osteomyelitis . The nurse is aware that the most common pathogen to cause osteomyelitis is : A. Staphylococcus aureus . B. Proteus . C. Pseudomonas . D. Escherichia coli .

A. Staphylococcus aureus .

A nurse is collaborating with the physical therapist to plan the care of a client with osteomyelitis . What principle should guide the management of activity and mobility in this client ? A. Stress on the weakened bone must be avoided . B. Increased heart rate enhances perfusion and bone healing . C. Bed rest results in improved outcomes in clients with osteomyelitis . D. Maintenance of baseline ADLs is the primary goal during osteomyelitis treatment

A. Stress on the weakened bone must be avoided .

A 32 - year - old client comes to the clinic reporting shoulder tenderness , pain , and limited movement . Upon assessment the nurse finds edema . An MRI shows hemorrhage of the rotator cuff tendons and the client is diagnosed with impingement syndrome . What action should the nurse recommend in order to promote healing ? A. Support the affected arm on pillows at night . B. Take prescribed corticosteroids as prescribed . C. Put the shoulder through its full range of motion three times daily D. Keep the affected arm in a sling for 2 to 4 weeks .

A. Support the affected arm on pillows at night .

A client who experienced a large upper gastrointestinal ( GI ) bleed due to gastritis has had the bleeding controlled and is now stable . For the next several hours , the nurse caring for this client should assess for what signs and symptoms of recurrence ? A. Tachycardia , hypotension , and tachypnea B. Tarry , foul - smelling stools C. Diaphoresis and sudden onset of abdominal pain D. Sudden thirst , unrelieved by oral fluid administration

A. Tachycardia , hypotension , and tachypnea

A client with gastroesophageal reflux disease ( GERD ) has a diagnosis of Barrett esophagus . with minor cell changes . What principle should be integrated into the client's subsequent care ? A. The client will be monitored closely to detect malignant changes . B. Liver enzymes must be checked regularly , as H2 receptor antagonists may cause hepatic damage . C. Small amounts of blood are likely to be present the stools and are not cause for concern D. Antacids may be discontinued when symptoms of heartburn subside .

A. The client will be monitored closely to detect malignant changes .

The nurse is caring for an older adult client who has been admitted 5 times for hypertension since the death of a spouse 2 years ago . The client does not understand why the blood pressure returns to normal after a day or two in the hospital when taking the same . outpatient prescribed medications . What should the nurse know about the probable cause of this client's hypertension ? A. The emotional stress of losing a spouse and a perceived role in life could contribute to physical illness . B. Physical illness is caused by prolonged and unrelenting stress and anxiety . C. Older adults are at increased risk for hypertension due to stress and prolonged disability . D. Stress exacerbates the physiologic processes of older adults .

A. The emotional stress of losing a spouse and a perceived role in life could contribute to physical illness .

A nurse is preparing a client diagnosed with benign prostatic hyperplasia ( BPH ) for a lower urinary tract cystoscopic examination . The nurse should caution the client about what common temporary complication of this procedure ? A. Urinary retention B. Bladder perforation C. Hemorrhage D. Nausea

A. Urinary retention

A client has just had an arthroscopy performed to assess a knee injury . What nursing intervention should the nurse perform following this procedure ? A. Wrap the joint in a compression dressing . B. Perform passive range of motion exercises . C. Maintain the knee in flexion for up to 30 minutes D. Apply heat to the knee .

A. Wrap the joint in a compression dressing .

A client with diabetes is asking the nurse what causes diabetic ketoacidosis ( DKA ) . Which of the following is a correct statement by the nurse ? A. " DKA can be caused by taking too much insulin . " B. " DKA can be caused by taking too little insulin . " C. " DKA can happen without a cause . " D. " DKA will not happen with type 1 diabetes . "

B. " DKA can be caused by taking too little insulin . "

A client with a right tibial fracture is being discharged home after having a cast applied . What instruction should the nurse provide in relation to the client's cast care ? A. " Cover the cast with a blanket until the cast dries . " B. " Keep your right leg elevated above heart level . " C. " Use a clean object to scratch itches inside the cast . " D. " A foul smell from the cast is normal after the first few days . "

B. " Keep your right leg elevated above heart level . "

A nurse is caring for a client with type 1 diabetes . Ine client's medication administration record includes the administration of regular insulin three times daily . Knowing that the client's lunch tray will arrive at 11:45 AM , when should the nurse administer the client's insulin ? A. 10:45 AM B. 11:30 AM C. 11:45 AM D. 11:50 AM

B. 11:30 AM

A client has just been diagnosed with type 2 diabetes . The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose . What type of oral antidiabetic agent did the health care provider prescribe for this client ? A. A sulfonylurea B. A biguanide C. A thiazolidinedione D. An alpha - glucosidase inhibitor

B. A biguanide

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction . Which assessment findings are most consistent with this diagnosis ? A. Hot skin and a capillary refill of 1 to 2 seconds B. Absence of feeling , capillary refill of 4 to 5 seconds , and cool skin C. Pain , diaphoresis , and erythema D. Jaundiced skin , weakness , and capillary refill of 3 seconds

B. Absence of feeling , capillary refill of 4 to 5 seconds , and cool skin

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis ? A. A middle - aged adult who takes ibuprofen daily for rheumatoid arthritis B. An older adult client with an infected pressure ulcer in the sacral area C. A 17 - year - old football player who had orthopedic surgery 6 weeks prior D. An infant diagnosed with jaundice

B. An older adult client with an infected pressure ulcer in the sacral area

A client has suffered a muscle strain and is reporting pain at 6 on a 10 - point scale . The nurse should recommend what action ? M A. Taking an opioid analgesic as prescribed B. Applying a cold pack to the injured site C. Performing passive ROM exercises D. Applying a heating pad to the affected muscle

B. Applying a cold pack to the injured site

A nurse in a busy emergency department provides care for many clients who present with contusions , strains , sprains . What are treatment modalities that are common to all of these musculoskeletal injuries ? Select all that apply . A. Massage B. Applying C. Compression dressings D. Resting the affected extremity F. Elevating the injured limb

B. Applying ice C. Compression dressings D. Resting the affected extremity F. Elevating the injured limb

B. Aspiration C. Abdominal distention D. Diarrhea

B. Aspiration

A client with hypokalemia is to receive intravenous ( IV ) potassium replacement . Which action should the nurse take when administering potassium intravenously ? Select all that apply . A. Administer potassium by IV push . B. Assess blood urea nitrogen ( BUN ) and serum creatinine prior to potassium administration C. Monitor complete blood count during potassium infusion D. Follow the facility policy for infusion of potassium . E. Report a reduced urinary output to the health care provider .

B. Assess blood urea nitrogen ( BUN ) and serum creatinine prior to potassium administration . D. Follow the facility policy for infusion of potassium . E. Report a reduced urinary output to the health care provider .

A client's NG tube has become clogged after the nurse instilled a medication that was insufficiently crushed . The nurse has attempted to aspirate with a large - bore syringe , with no success . What should the nurse do next ? A. Withdraw the NG tube 2 inches ( 5 cm ) and reattempt aspiration . B. Attach a syringe filled with warm water and attempt an in - and - out motion of instilling and aspirating . C. Withdraw the NG tube slightly and attempt to dislodge by flicking the tube with the fingers . D. Remove the NG tube promptly and obtain an order for reinsertion from the primary care provider .

B. Attach a syringe filled with warm water and attempt an in - and - out motion of instilling and aspirating .

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis . What health practice should the nurse address when teaching the client to limit exacerbations of the disease ? A. Performing 15 minutes of physical activity at least three times per week B. Avoiding taking aspirin to treat pain or fever C. Taking multivitamins as prescribed and eating organic foods whenever possible D. Maintaining a healthy body weight

B. Avoiding taking aspirin to treat pain or fever

A nurse is caring for an older adult client who is preparing for discharge following recovery from a total hip replacement . What outcome must be met prior to discharge ? А. is able to perform ADLS independently . B. Client is able to perform transfers safely . C. Client is able to weight - bear equally on both legs . D. Client is able to demonstrate full ROM of the affected hip .

B. Client is able to perform transfers safely .

A nurse has taken on the care of a client who had a coronary artery stent placed yesterday . When reviewing the client's daily medication administration record , the nurse should anticipate administering what drug ? A. Ibuprofen B. Clopidogrel C. Dipyridamole D. Acetaminophen

B. Clopidogrel

A client has been admitted to the hospital with a spontaneous vertebral fracture related to osteoporosis . Which of the following nursing diagnoses must be addressed in the plan of care ? A. Risk for aspiration related to vertebral fracture B. Constipation related to vertebral fracture C. Impaired swallowing related to vertebral fracture D. Decreased cardiac output related to vertebral fracture

B. Constipation related to vertebral fracture Constipation is a problem related to immobility and medications used to treat vertebral fractures .

The nurse is reviewing the medication administration record of a client who takes a variety of medications for the treatment of hypertension . What potential therapeutic benefits of antihypertensives should the nurse identify ? Select all that apply . A. Increased venous return . B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions E. Decreased blood viscosity

B. Decreased peripheral resistance C. Decreased blood volume D. Decreased strength and rate of myocardial contractions

A nurse has written a plan of care for a client diagnosed with peripheral arterial insufficiency . One of the nursing diagnoses in the care plan is altered peripheral tissue perfusion related to compromised circulation . Which intervention is the most appropriate for this diagnosis ? A. Elevate the legs and arms above the heart when resting . B. Encourage the client to engage in a moderate amount of exercise . C. Encourage extended periods of sitting or standing . D. Discourage walking in order to limit pain .

B. Encourage the client to engage in a moderate amount of exercise .

A nurse is caring for a client who just has been diagnosed with a peptic ulcer . When teaching the client about his new diagnosis , how should the nurse best describe it ? A. Inflammation of the lining of the stomach B. Erosion of the lining of the stomach or intestine C. Bleeding from the mucosa in the stomach D. Viral invasion of the stomach wall

B. Erosion of the lining of the stomach or intestine

The nurse is providing care for a client who has had a below - the - knee amputation . The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow . What is the nurse's most appropriate action ? A. Inform the surgeon of this finding . B. Explain the risks of flexion contracture to the client . C. Transfer the client to a sitting position D. Encourage the client to perform active ROM exercises with the residual limb .

B. Explain the risks of flexion contracture to the client .

A client has just begun been receiving skeletal traction and the nurse is aware that muscles in the client's affected limb are spastic . How does this change in muscle tone affect the client's traction prescription ? A. Traction must temporarily be aligned in a slightly different direction . B. Extra weight is needed initially to keep the limb in proper alignment . C. A lighter weight should be initially used . D. Weight will temporarily alternate between heavier and lighter weights .

B. Extra weight is needed initially to keep the limb in proper alignment .

A client is brought to the emergency department . The client is a type 2 diabetic and is experiencing hyperglycemic hyperosmolar syndrome ( HHS ) . The nurse should identify what components of HHS ? Select all that apply . A. Leukocytosis B. Glycosuria C. Dehydration D. Hypernatremia E. Hyperglycemia

B. Glycosuria C. Dehydration E. Hyperglycemia

A patient has developed a duodenal ulcer . As the nurse , you know that which of the following plays a role in peptic ulcer formation . Select ALL that apply : A. Spicy foods B. Helicobacter pylori C. NSAIDs D. Milk E. Zollinger - Ellison Syndrome

B. Helicobacter pylori C. NSAIDs E. Zollinger - Ellison Syndrome

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy . The client reports tingling in the lips and fingers . The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone . Which electrolyte imbalance should the nurse first suspect ? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia

B. Hypocalcemia

A client's medication regimen for the treatment of hypertension includes hydrochlorothiazide . Following administration of this medication , the nurse should anticipate what effect ? A. Drowsiness or lethargy B. Increased urine output C. Decreased heart rate D. Mild agitation

B. Increased urine output

A client has been admitted to the hospital after diagnostic imaging revealed the presence of a gastric outlet obstruction ( GOO ) . What is the nurse's priority intervention ? A. Administration of antiemetics . B. Insertion of an NG tube for decompression C. Infusion of hypotonic IV solution D. Administration of proton pump inhibitors as prescribed

B. Insertion of an NG tube for decompression

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis . The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention ? A. Maintenance of high Fowler positioning whenever possible B. Intermittent application of heat to the client's back C. Use of a pressure - reducing mattress D. Passive range of motion exercises

B. Intermittent application of heat to the client's back

A client with diabetes is attending a class on the prevention of associated diseases . What action should the nurse teach the client to reduce the risk of osteomyelitis ? A. Increase calcium and vitamin intake . B. Monitor and control blood glucose levels . C. Exercise 3 to 4 times weekly for at least D. Take corticosteroids as prescribed .

B. Monitor and control blood glucose levels . Since poor glycemic control can exacerbate the spread of infection from other sources , the client with diabetes should maintain blood glucose levels within a desired range .

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow . What is the best way to assess the client's ability to prepare and self - administer insulin ? A. Ask the client to describe the process in detail . B. Observe the client drawing up and administering the insulin . C. Provide a health education session reviewing the main points of insulin delivery . D. Review the client's first hemoglobin A1C result after discharge .

B. Observe the client drawing up and administering the insulin .

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure . This solution will increase the number of dissolved particles in the client's blood , creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume . This process is best described with which of the following terms ? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport

B. Osmosis and osmolality

The nurse caring for a client post colon resection is assessing the client on the second postoperative day . The nasogastric tube remains patent and is draining moderate amounts of greenish fluid . Which assessment finding would suggest that the client's potassium level is too low ? A. Diarrhea . B. Paresthesias C. Increased muscle tone D. Joint pain

B. Paresthesias

The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta - blocker . Which item should the nurse integrate into the management of this client's hypertension ? A. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption . B. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion . C. Recognize that an older adult is less likely to adhere to the medication regimen than a younger client . D. Carefully assess for weight loss because of impaired kidney function resulting from normal aging .

B. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion .

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture ? A. Administer analgesics as required . B. Place a pillow between the client's legs when turning . C. Maintain prone positioning at all times .d encourage internal and external rotation of the hip.

B. Place a pillow between the client's legs when turning .

A client with chronic kidney disease is completing an exchange during peritoneal dialysis . The nurse observes that the peritoneal fluid is draining slowly and that the client's abdomen is increasing in girth . What is the nurse's most appropriate action ? A. Advance the catheter 2 to 4 cm further into the peritoneal cavity . B. Reposition the client to facilitate drainage . C. Aspirate from the catheter using a 60 - mL syringe D. Infuse 50 mL of additional dialysate .

B. Reposition the client to facilitate drainage .

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room . The triage nurse notes upon assessment that the client is hyperventilating . The triage nurse is aware that hyperventilation is the most common Icause of which acid - base imbalance ? A. Respiratory acidosis B. Respiratory alkalosis C. Increased PaCO2 D. Metabolic acidosis

B. Respiratory alkalosis

A client with a diagnosis of respiratory acidosis is experiencing renal compensation . What function does the kidney perform to assist in restoring acid - base balance ? A. Sequestering free hydrogen ions in the nephrons B. Returning bicarbonate to the body's circulation C. Retaining ammonium chloride D. Excreting bicarbonate in the urine

B. Returning bicarbonate to the body's circulation

A client with a history of peptic ulcer disease has presented to the emergency department ( ED ) in distress . What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer ? A. The client has abdominal bloating that developed rapidly . B. The client has a rigid , " board - like " abdomen that is tender . C. The client is experiencing intense lower right quadrant pain . D. The client is experiencing dizziness and confusion with no apparent hemodynamic changes .

B. The client has a rigid , " board - like " abdomen that is tender .

The nurse is providing care for a client who has just been diagnosed with peripheral arterial occlusive disease ( PAD ) . What assessment finding is most consistent with this diagnosis ? A. Numbness and tingling in the distal extremities B. Unequal peripheral pulses between extremities C. Visible clubbing of the fingers and toes D. Reddened extremities with muscle atrophy

B. Unequal peripheral pulses between extremities

The client diagnosed with osteoporosis is prescribed alendronate . Which information should the nurse teach the client about this medication ? Select all that apply A. Take this medication at the same time every night B. drink 6 to 8 oz of water with each dose C. wait 30 minutes before taking other medications , fluids or foods D. notify the hcp if experiencing pain or difficulty swallowing E. lie down for 30 minutes after taking medication

B. drink 6 to 8 oz of water with each dose C. wait 30 minutes before taking other medications , fluids or foods D. notify the hcp if experiencing pain or difficulty swallowing

The critical care nurse is caring for a client with a central venous pressure ( CVP ) monitoring system . The nurse notes that the client's CVP is increasing . This may indicate : A. psychosocial stress . B. hypervolemia . C. dislodgment of the catheter D. hypomagnesemia .

B. hypervolemia .

A 56 - year - old client at a screening event has a blood pressure reading of 146/96 mm Hg . Upon hearing the reading , the client states , " My pressure has never been this high . Do you think my doctor will prescribe medication to reduce it ? " What is the nurse's best response ? A. " Yes . It is fortunate we caught this during your routine examination . " B. " We will need to reevaluate your blood pressure because your age places you at high risk . for hypertension . " C. " A single elevated blood pressure does not confirm hypertension . Diagnosis requires multiple elevated readings . " D. " You have no need to worry . Your pressure is probably elevated because you are being tested . "

C. " A single elevated blood pressure does not confirm hypertension . Diagnosis requires multiple elevated readings . "

The management of the client's gastrostomy is an assessment priority for the home care nurse . What statement would indicate that the client is managing the tube correctly ? A. " I clean my stoma twice a day with alcohol . " B. " The only time I flush my tube is when I'm putting in medications . " C. " I flush my tube with water before and after each of my medications . " D. " I try to stay still most of the time to avoid dislodging my tube . "

C. " I flush my tube with water before and after each of my medications . "

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur . Which explanation should the nurse give the client about skeletal traction ? A. " Skeletal traction temporarily stabilizes the fracture before surgery . " B. " Weights are attached to the leg using a boot . " C. " Traction involves passing a pin through the bone . " D. " Light weights must be used with skeletal traction . "

C. " Traction involves passing a pin through the bone . "

A nurse is caring for a client who has been scheduled for a bone scan . Which statement should the nurse include when educating the client about this diagnostic test ? A. " The test is brief and requires that you drink a calcium solution 2 hours before the test . " B. " You will not be allowed fluid for 2 hours before and 3 hours after the test . " C. " You will be encouraged to drink water after the administration of the radioisotope injection . " D. " This is a common test that can be safely performed on anyone . "

C. " You will be encouraged to drink water after the administration of the radioisotope injection . "

The nurse is administering medications to a client through a feeding tube . Which action should the nurse take ? A. Flush the tube with 5 mL of water before administering medication . B. Turn the tube feeding off for 1 hour before administering the medication . C. Administer each medication separately D. Flush with 50 mL of water between each medication

C. Administer each medication separately .

A lipid profile has been ordered for a client who has been experiencing cardiac symptoms . When should a lipid profile be drawn in order to maximize the accuracy of results ? A. As close to the end of the day as possible B. After a meal high in fat C. After a 12 - hour fast D. Thirty minutes after a normal meal

C. After a 12 - hour fast

An older adult client diagnosed with cancer is admitted to the oncology unit for surgical treatment . The client has been on chemotherapeutic agents to decrease tumor size prior to the planned surgery . The nurse caring for the client is aware that what precipitating factors in this client may contribute to acute kidney injury ( AKI ) ? Select all that apply . A. Anxiety and agitation B. Low body mass index ( BMI ) C. Age - related physiologic changes D. Chronic systemic disease E. Nothing by mouth ( NPO ) status

C. Age - related physiologic changes D. Chronic systemic disease E. Nothing by mouth ( NPO ) status

A 79 - year - old client is admitted to the medical unit with digital gangrene . The client reports that the problem first began when the client stubbed the toe going to the bathroom in the dark . In addition to this trauma , the nurse should suspect that the client has a history of which health problem ? A. Raynaud phenomenon B. Coronary artery disease ( CAD ) C. Arterial insufficiency D. Varicose veins

C. Arterial insufficiency

A client has been experiencing progressive increases in knee pain and diagnostic imaging reveals a worsening effusion in the synovial capsule . The nurse should anticipate what diagnostic procedure ? A. Arthrography B. Knee biopsy C. Arthrocentesis D. Electromyography

C. Arthrocentesis

The nurse is caring for an acutely ill client . What assessment finding should prompt the nurse to inform the health care provider that the client may be exhibiting signs of acute kidney injury ( AKI ) ? A. An inability to initiate voiding for 2 days . B. The urine is cloudy and has visible sediment with a foul odor . C. Average urine output has been 10 mL / hr for several hours . D. Client reports left - sided flank pain .

C. Average urine output has been 10 mL / hr for several hours .

The nurse is providing an educational workshop about coronary artery disease ( CAD ) and its risk factors . The nurse explains to participants that CAD has many risk factors , some that can be controlled and some that cannot . What risk factors should the nurse list that can be controlled or modified ? A. Gender , obesity , family history , and smoking B. Inactivity , stress , gender , and smoking C. Cholesterol levels , hypertension , and smoking D. Stress , family history , and obesity

C. Cholesterol levels , hypertension , and smoking

Which intervention should the nurse teach a client who is at risk for hypercalcemia ? A. Avoid the use of stool softeners . B. Take laxatives daily . C. Consume 2 to 4 L of fluid daily . D. Restrict calcium intake .

C. Consume 2 to 4 L of fluid daily .

A client is admitted to the ICU after a motor vehicle accident . On the second day of the hospital admission , the client develops acute kidney injury . The client is hemodynamically unstable , and renal replacement therapy is needed to manage the client's hypervolemia and hyperkalemia . Which of the following therapies will the client's hemodynamic status best tolerate ? A. Hemodialysis B. Peritoneal dialysis C. Continuous venovenous hemodialysis ( CVVHD ) D. Plasmapheresis

C. Continuous venovenous hemodialysis ( CVVHD )

The acute care nurse is providing care for an adult client who is in hypovolemic shock . The nurse recognizes that antidiuretic hormone ( ADH ) plays a significant role in this health problem . What assessment finding will the nurse likely observe related to the role of antidiuretic hormone during hypovolemic shock ? A. Increased hunger B. Decreased thirst C. Decreased urinary output D. Increased capillary perfusion

C. Decreased urinary output

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident . The client has been placed in traction until the femur can be rodded in surgery . For what early complication ( s ) should the nurse monitor this client ? Select all that apply . A. Systemic infection . B. Complex regional pain syndrome C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism

C. Deep vein thrombosis D. Compartment syndrome E. Fat embolism

A client with hypertension has been prescribed hydrochlorothiazide . What nursing action will best reduce the client's risk for electrolyte disturbances ? A. Maintain a low - sodium diet . B. Encourage the use of over - the - counter calcium supplements C. Ensure the client has sufficient potassium intake . D. Encourage fluid intake .

C. Ensure the client has sufficient potassium intake .

The nurse is caring for a client in acute kidney injury ( AKI ) . Which complication would most clearly warrant the administration of polystyrene sulfonate ( Kayexalate ) ? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypercalcemia

C. Hyperkalemia

The nurse is caring for a client in acute kidney injury ( AKI ) . Which complication would most clearly warrant the administration of polystyrene sulfonate ? A. Hypernatremia B. Hypomagnesemia C. Hyperkalemia D. Hypercalcemia

C. Hyperkalemia

A client has returned to the floor after having a thyroidectomy for thyroid cancer . What laboratory finding may be an early indication of parathyroid gland injury or removal ? A. Hyponatremia B. Hypophosphatemia C. Hypocalcemia D. Hypokalemia

C. Hypocalcemia

The nurse is assessing the client for the presence of a Chvostek sign . Which electrolyte imbalance would a positive Chvostek sign indicate ? A. Hypermagnesemia B. Hyponatremia C. Hypocalcemia D. Hyperkalemia

C. Hypocalcemia

The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis . A nasogastric tube was placed upon admission , and since that time the client has been on low intermittent suction . Upon review of the morning's blood work , the nurse notices that the client's potassium is below reference range . The nurse should assess for signs and symptoms of what imbalance ? A. Hypercalcemia B. Metabolic acidosis . C. Metabolic alkalosis D. Respiratory acidosis

C. Metabolic alkalosis

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis . Following the latest meal , the client reports dizziness and palpitations . Inspection reveals that the client is diaphoretic . What is the nurse's best action ? A. Insert a nasogastric tube promptly . B. Reposition the client supine . C. Monitor the client closely for further signs of dumping syndrome . D. Assess the client for signs and symptoms of aspiration .

C. Monitor the client closely for further signs of dumping syndrome .

A client has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery . What nursing action best promotes comfort and facilitates spontaneous breathing for this client ? A. Placing the client in a left lateral position B. Administering opioids as prescribed C. Placing the client in Fowler position D. Teaching the client to use the client - controlled analgesia ( PCA ) system

C. Placing the client in Fowler position

A nurse is caring for a client who has a leg cast . The nurse observes the client using a pencil to scratch the skin under the edge of the cast . How should the nurse respond to this observation ? A. Allow the client to gently scratch inside the cast with a pencil . B. Give the client a sterile tongue depressor to use for scratching instead of the pencil . C. Provide a fan to blow cool air into the cast to relieve itching D. Obtain a prescription for a sedative , such as lorazepam , to prevent the client from scratching .

C. Provide a fan to blow cool air into the cast to relieve itching

A nursing educator is reviewing the risk factors for osteoporosis with a group of recent graduates . What of the following risk factors should the educator describe ? A. Recurrent infections and prolonged use of NSAIDs B. High alcohol intake and low body mass index C. Small frame and female sex D. Male sex , diabetes , and high protein intake

C. Small frame and female sex

A nurse is completing a health history on a client whose diagnosis is chronic gastritis . Which of the data should the nurse consider most significantly related to the etiology of the client's health problem ? A. Consumes one or more protein drinks daily . B. Takes over - the - counter antacids frequently throughout the day . C. Smokes one pack of cigarettes daily . D. Reports a history of social drinking on a weekly basis .

C. Smokes one pack of cigarettes daily .

A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3

The nurse is caring for a client receiving hemodialysis three times weekly . The client has had surgery to form an arteriovenous fistula . What is most important for the nurse to be aware of when providing care for this client ? A. Using a stethoscope for auscultating the fistula is contraindicated B. The client feels best immediately after the dialysis treatment C. Taking a BP reading on the affected arm can damage the fistula D. The client should not feel pain during initiation of dialysis

C. Taking a BP reading on the affected arm can damage the fistula

the priority education for this client A. The lack of exercise , which is the main cause of PAD B. The likelihood that heavy alcohol intake is a significant risk factor for PAD C. The nicotine in cigarettes , which is a powerful vasoconstrictor and may cause or aggravate PAD D. Alcohol , which suppresses the immune system , creates high glucose levels , and may cause PAD

C. The nicotine in cigarettes , which is a powerful vasoconstrictor and may cause or aggravate PAD

An older adult is newly diagnosed with primary hypertension and has just been started on a beta - blocker . Which topic should the nurse include in health education ? A. Increasing fluids to avoid extracellular volume depletion from the diuretic effect of the beta - blocker B. Maintaining a diet high in dairy to increase protein necessary to prevent organ damage C. Use of strategies to prevent falls stemming from orthostatic hypotension D. Limiting exercise to avoid injury that can be caused by increased intracranial pressure

C. Use of strategies to prevent falls stemming from orthostatic hypotension

At a blood pressure screening , the nurse learns that a client has a family history of hypertension , high cholesterol , and elevated lipid levels . The client says reports smoking one pack of cigarettes daily and drinking " about a pack of beer " every day . The nurse notes which nonmodifiable risk factor for hypertension ? A. Hyperlipidemia B. Excessive alcohol intake C.A family history of hypertension D. Closer adherence to medical regimen

C.A family history of hypertension

A kidney biopsy has been scheduled for a client with a history of acute kidney injury . The client asks the nurse why this test has been scheduled . What is the nurse's best response ? A. " A biopsy is routinely ordered for all clients with renal disorders . " B. " A biopsy is generally ordered following abnormal x - ray findings of the renal pelvis . " C. " A biopsy is often ordered for clients before they have a kidney transplant . " D. " A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease . "

D. " A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease . "

A nurse is caring for a client who has had a total hip replacement . The nurse is reviewing health education prior to discharge . Which of the client's statements would indicate to the nurse that the client requires further teaching ? A. " I'll need to keep several pillows between my legs at night . " B. " I need to remember not to cross my legs . It's such a habit . " C. " The occupational therapist is showing me how to use a ' sock puller ' to help me get dressed . " D. " I will need my husband to assist me in getting off the low toilet seat at home . "

D. " I will need my husband to assist me in getting off the low toilet seat at home . "

A nurse is discussing health promotion strategies with a client with elevated lipid levels . Which client response best indicates to the nurse that the client is exhibiting self - responsibility ? A. " Teach my spouse about diet since I do not do the cooking . " B. " I do not need to exercise since I am on my feet all day at work . " C. " My father had high cholesterol levels , and he is in good health . " D. " I will need to learn to read food labels when food shopping . "

D. " I will need to learn to read food labels when food shopping . "

A nurse is teaching an educational class to a group of older adults at a community center . In an effort to prevent osteoporosis , the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients ? Select all that apply . A. Vitamin B12 B. Potassium C. Calcitonin D. Calcium E. Vitamin D

D. Calcium E. Vitamin D

A 20 - year - old client newly diagnosed with type 1 diabetes needs to learn how to self - administer insulin . When planning the appropriate educational interventions and considering variables that will affect the client's learning , the nurse should prioritize what factor ? A. Client's expected lifespan B. Client's gender C. Client's occupation D. Client's culture

D. Client's culture

A. Arrange for a STAT assessment of the client's serum calcium levels B. Perform active range of motion exercises . C. Assess the client's joint function symmetrically D. Contact the primary provider immediately .

D. Contact the primary provider immediately .

A client has presented with signs and symptoms that are characteristic of acute kidney injury , but preliminary assessment reveals no obvious risk factors for this health problem . The nurse should recognize the need to interview the client about what priority topic ? A. Typical diet B. Allergy status C. Psychosocial stressors D. Current medication

D. Current medication use

The client is experiencing painful oral lesions following radiation for oropharyngeal cancer . Which instruction should the nurse give this client ? A. Spicy foods stimulate salivation and are soothing . B. Eat food while it is hot to enhance flavor . C. Avoid brushing teeth while lesions are present . D. Eat soft or liquid foods .

D. Eat soft or liquid foods .

A nurse is caring for a client who has an MRI scheduled . What is the priority safety action prior to this diagnostic procedure ? A. Assessing the client for signs and symptoms of active infection B. Ensuring that the client can remain immobile for up to 3 hours C. Assessing the client for a history of nut allergies . D. Ensuring that there are no metal objects on or in the client

D. Ensuring that there are no metal objects on or in the client

An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter . The client is found to have a blood glucose level of 600 mg / dL ( 33-3 mmol / L ) . The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours . The diagnosis of hyperglycemic hyperosmolar syndrome ( HHS ) is made . What nursing action would be a priority ? A. Administration of antihypertensive medications B. Administering sodium bicarbonate intravenously C. Reversing acidosis by administering insulin D. Fluid and electrolyte replacement

D. Fluid and electrolyte replacement

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases . The client reports a new onset of weakness with abdominal pain , and further assessment suggests that the client likely has a fluid volume deficit . The nurse should recognize that this client may be experiencing which electrolyte imbalance ? A. Hypernatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalcemia

D. Hypercalcemia

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing . Based on this change in status , the nurse should expect the client to exhibit signs and symptoms of which imbalance ? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

D. Hypovolemia

A nurse is caring for a client who is acutely ill and has included vigilant oral care in the client's plan of care . What factor increases this client's risk for dental caries ? A. Hormonal changes brought on by the stress response cause an acidic oral environment B. Systemic infections frequently migrate to the teeth C. Hydration that is received intravenously lacks fluoride D. Inadequate nutrition and decreased saliva production can cause cavities

D. Inadequate nutrition and decreased saliva production can cause cavities

A client's burns are estimated at 36 % of total body surface area ; fluid resuscitation has been ordered in the emergency department . After establishing intravenous access , the nurse should anticipate the administration of what fluid ? A. 0.45 % NaCl with 20 mEq / L KCI B. 0.45 % NaCl with 40 mEq / L C. Normal saline D. Lactated Ringer

D. Lactated Ringer

The emergency - room nurse is caring for a trauma client who has the following arterial blood gas results : pH 7.26 , PaCO2 28 , HCO3 11 mEq / L . How should the nurse interpret these results ? A. Respiratory acidosis with no compensation B. Metabolic alkalosis with compensatory alkalosis C. Metabolic acidosis with no compensation D. Metabolic acidosis with compensatory respiratory alkalosis

D. Metabolic acidosis with compensatory respiratory alkalosis

A client has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment . The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies ? A. Radiation therapy often results in secondary brain tumors . B. Surgical complications are exceedingly common . C. Diagnosis rarely occurs until the cancer is end stage . D. Metastases are common and respond poorly to treatment .

D. Metastases are common and respond poorly to treatment .

A medical nurse is aware of the need to screen specific clients for their risk of hyperglycemic hyperosmolar syndrome ( HHS ) . In what client population does this syndrome most often occur ? A. Clients who are obese and who have no known history of diabetes B. Clients with type 1 diabetes and poor dietary control C. Adolescents with type 2 diabetes and sporadic use of antihyperglycemics D. Middle - aged or older people with either type 2 diabetes or no known history of diabetes

D. Middle - aged or older people with either type 2 diabetes or no known history of diabetes

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse . Which action should the nurse take ? A. Administer pain medication . B. Massage the client's calf . C. Apply antiembolic stockings . D. Notify the health care provider .

D. Notify the health care provider .

A nurse working in a long - term care facility is performing the admission assessment of a newly admitted 85 - year - old resident . During inspection of the resident's feet , the nurse notes early evidence of gangrene on one of the resident's great toes . The nurse should assess for further evidence of which health problem ? A. Chronic venous insufficiency B. Raynaud phenomenon C. Venous thromboembolism ( VTE ) D. Peripheral artery disease ( PAD )

D. Peripheral artery disease ( PAD )

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team . What is the primary goal of this multidisciplinary team ? A. Maximize the efficiency of care . B. Ensure that the client's health care is holistic . C. Facilitate the client's adjustment to a new body image . D. Promote the client's highest possible level of function .

D. Promote the client's highest possible level of function .

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied . The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale . What is the nurse's most appropriate action ? A. Warm the client's foot and determine whether circulation improves B. Reposition the client with the affected foot dependent . C. Reassess the client's neurovascular status in 15 minutes . D. Promptly inform the primary care provider .

D. Promptly inform the primary care provider .

A client has just been diagnosed with acute gastritis after presenting in distress to the emergency department with abdominal symptoms . What would be the nursing care most needed by the client at this time ? A. Teaching the client about necessary nutritional modification B. Helping the client weigh treatment options C. Teaching the client about the etiology of gastritis D. Providing the client with physical and emotional support

D. Providing the client with physical and emotional support

The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident . The client is reporting dyspnea because of abdominal pain . An arterial blood gas test reveals the following results : pH 7.28 , PaCO2 50 mm Hg , HCO3- 20 mEq / L . The nurse should recognize the likelihood of which acid - base disorder ( s ) ? A. Respiratory acidosis only B. Respiratory acidosis and metabolic alkalosis C. Respiratory alkalosis and metabolic acidosis D. Respiratory acidosis and metabolic acidosis

D. Respiratory acidosis and metabolic acidosis

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia . What assessment finding would be most consistent with this diagnosis ? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations

D. Shallow respirations

A. Strategies for maintaining an alkaline gastric environment B. Safe technique for self - suctioning C. Techniques for positioning correctly to promote gastric healing D. Strategies for avoiding irritating foods and beverages

D. Strategies for avoiding irritating foods and beverages

A client's recently elevated BP has prompted the primary care provider to prescribe furosemide . The nurse should closely monitor which of the following levels ? A. The client's oxygen saturation level B. The client's red blood cells , hematocrit , and hemoglobin C. The client's level of consciousness D. The client's potassium level

D. The client's potassium level

An orthopedic nurse is caring for a client who is postoperative day 1 following foot surgery . What nursing intervention should be included in the client's subsequent care ? A. Dressing changes should not be performed unless there are clear signs of infection . B. The surgical site can be soaked in warm bath water for up to 5 minutes . C. The surgical site should be cleansed with hydrogen peroxide once daily . D. The foot should be elevated in order to prevent edema .

D. The foot should be elevated in order to prevent edema .

A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding . When explaining this diagnostic test to the client , what advantage should the nurse describe ? A. The entire peritoneal cavity can be visualized . B. The test allows for painless biopsy collection . C. The capsule is endoscopically placed in the intestine . D. The test is noninvasive .

D. The test is noninvasive .

A nurse is providing a class on osteoporosis at the local center for older adults . Which statement related to osteoporosis is most accurate ? A. High levels of vitamin D can cause osteoporosis . B. A nonmodifiable risk factor for osteoporosis is a person's level of activity . C. Secondary osteoporosis occurs in women after menopause . D. The use of corticosteroids increases the risk of osteoporosis .

D. The use of corticosteroids increases the risk of osteoporosis .

A nurse is assessing a new client who is diagnosed with peripheral artery disease . The nurse cannot feel the pulse in the client's left foot . How should the nurse proceed with assessment ? A. Have the primary care provider prescribe a computed tomography ( CT ) scan . B. Apply a tourniquet for 3 to 5 minutes and then reassess . C. Elevate the extremity and attempt to palpate the pulses . D. Use Doppler ultrasound to identify the pulses .

D. Use Doppler ultrasound to identify the pulses .

A nurse is creating a care plan for a client receiving nasogastric tube feedings . Which intervention should the nurse include ? A. Check the gastric residual volume every 4 hours . B. Hold the tube feeding if the gastric residual volume is greater than 200 mL . C. Position client flat in bed during feedings D. Use client assessment findings to determine tolerance of feedings .

D. Use client assessment findings to determine tolerance of feedings .

A nurse is assessing a client with peripheral artery disease ( PAD ) . The client states that walking five blocks is possible without pain . What question asked next by the nurse will give the best information ? a . " Could you walk further than that a few months ago ? " b . " Do you walk mostly uphill , downhill , or on flat surfaces ? " c . " Have you ever considered swimming instead of walking ? " d . " How much pain medication do you take each day ? "

a . " Could you walk further than that a few months ago ? "

A client has peripheral arterial disease ( PAD ) . What statement by the client indicates misunderstanding about self - management activities ? a . " I can use a heating pad on my legs if it's set on low . " b . " I should not cross my legs when sitting or lying down . " c . " I will go out and buy some warm , heavy socks to wear . " d . " It's going to be really hard but I will stop smoking . "

a . " I can use a heating pad on my legs if it's set on low . " Clients with PAD should never use heating pads as skin sensitivity is diminished and burns can result .

A client is unsure of the decision to undergo peritoneal dialysis ( PD ) and wishes to discuss the advantages of this treatment with the nurse . Which statements by the nurse are correct regarding PD ? ( Select all that apply . ) a . " You will not need vascular access to perform PD . " b . " There is less restriction of protein and fluids . " c . " You will have no risk for infection with PD . " d . " You have flexible scheduling for the exchanges . " e . " It takes less time than hemodialysis treatments . "

a . " You will not need vascular access to perform PD . " b . " There is less restriction of protein and fluids . " d . " You have flexible scheduling for the exchanges . "

A nurse is assessing clients for fluid and electrolyte imbalances . Which client will the nurse assess first for potential hyponatremia ? a . A 34 year old who is NPO and receiving rapid intravenous D5W infusions . b . A 50 year old with an infection who is prescribed a sulfonamide antibiotic . c . A 67 year old who is experiencing pain and is prescribed ibuprofen . d . A 73 year old with tachycardia who is receiving digoxin

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

The nurse recalls that the risk factors for acute gastritis include which of the following ? ( Select all that apply . ) a . Alcohol b . Caffeine c . Corticosteroids d . Fruit juice e . Nonsteroidal anti - inflammatory drugs ( NSAIDs )

a . Alcohol b . Caffeine c . Corticosteroids e . Nonsteroidal anti - inflammatory drugs ( NSAIDs )

A nurse is assessing a community group for dietary factors that contribute to osteoporosis In addition to inquiring about calcium , the nurse also assesses for which other dietary components ? ( Select all that apply . ) a . Alcohol b . Caffeine c . Fat d . Carbonated beverages e .Vitamin d

a . Alcohol b . Caffeine d . Carbonated beverages e . Vitamin d

A client has been bedridden for several days after major abdominal surgery . What action does the nurse delegate to the assistive personnel ( AP ) for deep vein thrombosis ( DVT ) prevention ? ( Select all that apply . ) a . Apply compression stockings . b . Assist with ambulation . c . Encourage coughing and deep breathing . d . Offer fluids frequently . e . Teach leg exercises .

a . Apply compression stockings . b . Assist with ambulation . d . Offer fluids frequently .

A nurse is caring for a client with a history of renal insufficiency who is scheduled for a cardiac catheterization . What actions would the nurse take prior to the catheterization ? ( Select all that apply . ) a . Assess for allergies to iodine . b . Administer intravenous fluids . c . Assess blood urea nitrogen ( BUN ) and creatinine results . d . Insert a Foley catheter . e . Administer a prophylactic antibiotic . f . Insert a central venous catheter .

a . Assess for allergies to iodine . b . Administer intravenous fluids . c . Assess blood urea nitrogen ( BUN ) and creatinine results .

A client with a history of heart failure and hypertension is in the clinic for a follow - up visit . The client is on lisinopril and warfarin . The client reports a new - onset cough . What action by the nurse is most appropriate ? a . Assess the client's lung sounds and oxygenation . b . Instruct the client on another antihypertensive . c . Obtain a set of vital signs and document them . d . Remind the client that cough is a side effect of lisinopril .

a . Assess the client's lung sounds and oxygenation .

A nurse is assessing a client with hypokalemia , and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago . What action does the nurse take first ? a . Assess the client's respiratory rate , rhythm , and depth . b . Measure the client's pulse and blood pressure . c . Document findings and monitor the client d . Call the health care primary health care provider .

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

A client with chronic kidney disease ( CKD ) has an elevated serum phosphorus level . What drug would the nurse anticipate to be prescribed for this client ? a . Calcium acetate b . Doxycyline c . Magnesium sulfate d . Lisinopril

a . Calcium acetate

The nurse is caring for five clients on the medical - surgical unit . Which clients would the nurse consider to be at risk for postrenal acute kidney injury ( AKI ) ? ( Select all that apply . ) a . Client with prostate cancer b . Client with blood clots in the urinary tract c . Client with ureterolithiasis d . Client with severe burns e . Client with lupus

a . Client with prostate cancer b . Client with blood clots in the urinary tract c . Client with ureterolithiasis

A nurse assesses a client who is recovering from a myocardial infarction . The client's blood pressure is 140/88 mm Hg . What action would the nurse take first ? a . Compare the results with previous blood pressure readings . b . Increase the intravenous fluid rate because these readings are low . c . Immediately notify the primary health care provider of the elevated blood pressure . d . Document the finding in the client's chart as the only action .

a . Compare the results with previous blood pressure readings .

A nurse is caring for a client who has the following laboratory results : potassium 2.4 mEq / L ( 2.4 mmol / L ) , magnesium 1.8 mEq / L ( 0.74 mmol / L ) , calcium 8.5 mEq / L ( 2.13 mmol / L ) , and sodium 144 mEq / L ( 144 mmol / L ) . Which assessment does the nurse complete first ? a . Depth of respirations b . Bowel sounds c . Grip strength d . Electrocardiography

a . Depth of respirations

A client with chronic kidney disease ( CKD ) is refusing to take his medication and has missed two hemodialysis appointments . What is the best initial action for the nurse ? a . Discuss what the treatment regimen means to the client . b . Refer the client to a mental health nurse practitioner . c . Reschedule the appointments to another date and time . d . Discuss the option of peritoneal dialysis .

a . Discuss what the treatment regimen means to the client .

The nurse is caring for a client diagnosed with probable gastroesophageal reflux disease ( GERD ) . What assessment finding ( s ) would the nurse expect ? ( Select all that apply . ) a . Dyspepsia b . Regurgitation c . Belching d . Coughing e . Chest discomfort f . Dysphagia

a . Dyspepsia b . Regurgitation c . Belching d . Coughing e . Chest discomfort f . Dysphagia

The nurse is reviewing risk factors in a client who has atherosclerosis . Which findings are most concerning ? ( Select all that apply . ) a . Elevated low - density lipoprotein ( LDL - C ) b . Decreased levels of high - density lipoprotein cholesterol ( HDL - C ) c . Asian ethnicity d . History of smoking e . Blood pressure : 142/92 mm Hg on one occasion

a . Elevated low - density lipoprotein ( LDL - C ) b . Decreased levels of high - density lipoprotein cholesterol ( HDL - C ) d . History of smoking

The nurse is caring for four hypertensive clients . Which drug - laboratory value combination would the nurse report immediately to the health care provider ? a . Furosemide / potassium : 2.1 mEq / L b . Hydrochlorothiazide / potassium : 4.2 mEq / L c . Spironolactone / potassium : 5.1 mEq / L d . Torsemide / sodium : 142 mEq / L

a . Furosemide / potassium : 2.1 mEq / L

A nurse is caring for clients with electrolyte imbalances on a medical - surgical unit . Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance ? ( Select all that apply . ) a . Hypokalemia - muscle weakness with respiratory depression b . Hypermagnesemia - bradycardia and hypotension c . Hyponatremia - decreased level of consciousness d . Hypercalcemia - positive Trousseau and Chvostek signs e . Hypomagnesemia - hyperactive deep tendon reflexes f . Hypernatremia - weak peripheral pulses

a . Hypokalemia - muscle weakness with respiratory depression b . Hypermagnesemia - bradycardia and hypotension c . Hyponatremia - decreased level of consciousness e . Hypomagnesemia - hyperactive deep tendon reflexes f . Hypernatremia - weak peripheral pulses

A nurse assesses a client who is admitted for treatment of fluid overload . Which signs and symptoms does the nurse expect to find ? ( Select all that apply . ) a . Increased pulse rate b . Distended neck veins c . Decreased blood pressure d . Warm and pink skin e . Skeletal muscle weakness f . Visual disturbances

a . Increased pulse rate b . Distended neck veins e . Skeletal muscle weakness f . Visual disturbances

A client is taking furosemide 40 mg / day for management of early chronic kidney disease ( CKD ) . To assess the therapeutic effect of the medication , what action of the nurse is best ? a . Obtain daily weights of the client . b . Auscultate heart and breath sounds . c . Palpate the client's abdomen . d . Assess the client's diet history .

a . Obtain daily weights of the client .

A client has a serum potassium level of 6.5 mEq / L ( 6.5 mmol / L ) , a serum creatinine level of 2 mg / dL ( 176 mcmol / L ) , and a urine output of 350 mL / day . What is the best action by the nurse ? a . Place the client on a cardiac monitor immediately . b . Teach the client to limit high - potassium foods . c . Continue to monitor the client's intake and output . d . Ask to have the laboratory redraw the blood specimen .

a . Place the client on a cardiac monitor immediately .

A nurse reviews a client's laboratory results . Which findings would alert the nurse to the possibility of atherosclerosis ? ( Select all that apply . ) a . Total cholesterol : 280 mg / dL ( 7.3 mmol / L ) b . High - density lipoprotein cholesterol : 50 mg / dL ( 1.3 mmol / L c . Triglycerides : 200 mg / dL ( 2.3 mmol / L ) d . Serum albumin : 4 g / dL ( 5.8 mcmol / L ) e . Low - density lipoprotein cholesterol : 160 mg / dL ( 4.1 mmol / L )

a . Total cholesterol : 280 mg / dL ( 7.3 mmol / L ) c . Triglycerides : 200 mg / dL ( 2.3 mmol / L ) e . Low - density lipoprotein cholesterol : 160 mg / dL ( 4.1 mmol / L )

" Take the drug on an empty stomach . "

b . " Make appointments to come get your injection . " Denosumab ( treats osteoporosis caused by corticosteroids ) is given by subcutaneous injection twice a year .

A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms . What response by the nurse is best ? a . " Do you have trouble affording your medications ? " b . " Most people with hypertension do not have symptoms . " c . " You are lucky ; most people get severe morning headaches . " d . " You need to take your medicine or you will get kidney failure . "

b . " Most people with hypertension do not have symptoms . "

A nurse teaches a client with diabetes mellitus and a body mass index of 42 who is at high . risk for coronary artery disease . Which statement related to nutrition would the nurse include in this client's teaching ? a . " The best way to lose weight is a high - protein , low - carbohydrate diet . " b . " You should balance weight loss with consuming necessary nutrients . " c . " A nutritionist will provide you with information about your new diet . " d . " If you exercise more frequently , you won't need to change your diet . "

b . " You should balance weight loss with consuming necessary nutrients . "

A client has a deep vein thrombosis ( DVT ) . What comfort measure does the nurse delegate to the assistive personnel ( AP ) ? a . Ambulate the client . b . Apply a warm moist pack . c . Massage the client's leg . d . Provide an ice pack .

b . Apply a warm moist pack .

The nurse is caring for a client who has fluid overload . What action by the nurse takes priority ? a . Administer high - ceiling ( loop ) diuretics . b . Assess the client's lung sounds every 2 hours . c . Place a pressure - relieving overlay on the mattress . d . Weigh the client daily at the same time on the same scale .

b . Assess the client's lung sounds every 2 hours .

The nurse is evaluating a 3 - day diet history with a client who has an elevated lipid panel . What meal selection indicates that the client is managing this condition well with diet ? a . A 4 - ounce steak , French fries , iceberg lettuce b . Baked chicken breast , broccoli , tomatoes c . Fried catfish , cornbread , peas d . Spaghetti with meat sauce , garlic bread

b . Baked chicken breast , broccoli , tomatoes

A nurse is caring for four clients . Which one would the nurse see first ? a . Client who needs a beta blocker , and has a blood pressure of 98/58 mm Hg . b . Client who had a first dose of captopril and needs to use the bathroom . c . Hypertensive client with a blood pressure of 188/92 mm Hg . d . Client who needs pain medication prior to a dressing change of a surgical wound .

b . Client who had a first dose of captopril and needs to use the bathroom . Angiotensin - converting enzyme inhibitors such as captopril can cause hypotension , especially after the first dose . The nurse would see this client first to prevent falling if the client decides to get up without assistance

The nurse is caring for four clients with chronic kidney disease ( CKD ) . Which client would the nurse assess first upon initial rounding ? a . Client with a blood pressure of 158/90 mm Hg b . Client with Kussmaul respirations c. Client with skin itching from head to toe d . Client with halitosis and stomatitis

b . Client with Kussmaul respirations

A nurse is caring for a client who has a serum calcium level of 14 mg / dL ( 3-5 mmol / L ) . Which primary health care provider order does the nurse implement first ? a . Encourage oral fluid intake . b . Connect the client to a cardiac monitor c . Assess urinary output . d . Administer oral calcitonin .

b . Connect the client to a cardiac monitor .

The nurse is assessing a client with a diagnosis of prerenal acute kidney injury ( AKI ) . Which condition would the nurse expect to find in the patient's recent history ? a . Pyelonephritis b . Dehydration c . Bladder cancer d . Kidney stones

b . Dehydration

The nurse sees that the patient is scheduled for a MRI. The client's health history includes a previous myocardial infarction and pacemaker implantation . What action would the nurse take ? a . Schedule an electrocardiogram just before the MRI . b . Notify the primary health care provider before scheduling the MRI . c . Request lab for cardiac enzymes from the primary health care provider . d . Instruct the client to increase fluid intake the day before the MRI .

b . Notify the primary health care provider before scheduling the MRI .

A client is having a peritoneal dialysis treatment . The nurse notes an opaque color to the effluent . What is the priority action by the nurse ? a . Warm the dialysate solution in a microwave before instillation . b . Obtain a sample of the effluent and send to the laboratory . c . Flush the tubing with normal saline to maintain patency of the catheter . d . Check the peritoneal catheter for kinking and curling .

b . Obtain a sample of the effluent and send to the laboratory .

A nurse is caring for a client with a deep vein thrombosis ( DVT ) . What nursing assessment indicates that an important outcome has been met ? a . Ambulates with assistance b . Oxygen saturation of 98 % c . Pain of 2/10 after medication . d . Verbalizing risk factors

b . Oxygen saturation of 98 %

A client has a nasogastric ( NG ) tube as a result of an upper gastrointestinal ( GI ) hemorrhage . What comfort measure would the nurse remind assistive personnel ( AP ) to provide ? a . Lavaging the tube with ice water . Performing frequent oral care c . Re - positioning the tube every 4 hours d . Taking and recording vital signs

b . Performing frequent oral care

A nurse is caring for several clients at risk for fluid imbalances . Which laboratory results are paired with the correct potential imbalance ? ( Select all that apply . ) a . Sodium : 160 mEq / L ( mmol / L ) : Overhydration b . Potassium : 5.4 mEq / L ( mmol / L ) : Dehydration c . Osmolarity : 250 mOsm / L : Overhydration d . Hematocrit : 68 % : Dehydration e . BUN : 39 mg / dL : Overhydration f . Magnesium : 0.8 mg / dL : Dehydration

b . Potassium : 5.4 mEq / L ( mmol / L ) : Dehydration c . Osmolarity : 250 mOsm / L : Overhydration d . Hematocrit : 68 % : Dehydration f . Magnesium : 0.8 mg / dL : Dehydration

A nurse prepares a client for a pharmacologic stress echocardiogram . What actions would the nurse take when preparing this client for the procedure ? ( Select all that apply . ) a . Assist the primary health care provider to place a central venous access device . b . Prepare for continuous blood pressure and pulse monitoring . c . Administer the client's prescribed beta blocker . d . Give the client nothing by mouth 3 to 6 hours before the procedure . e . Explain to the client that dobutamine will simulate exercise for this examination .

b . Prepare for continuous blood pressure and pulse monitoring . d . Give the client nothing by mouth 3 to 6 hours before the procedure . e . Explain to the client that dobutamine will simulate exercise for this examination .

A nurse teaches a client who is at risk for hyponatremia . Which statement does the nurse include in this client's teaching ? a . " Have you spouse watch you for irritability and anxiety . " b . " Notify the clinic if you notice muscle twitching . " c . " Call your primary health care provider for diarrhea . " d . " Bake or grill your meat rather than frying it . "

c . " Call your primary health care provider for diarrhea . "

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis . Which statement by the client demonstrates a correct understanding of the teaching ? a . " I should leave the drainage bag above the level of my abdomen . " b . " I could flush the tubing with normal saline if the flow stops . " c . " I should take a stool softener every morning to avoid constipation . " d . " My diet should have low fiber in it to prevent any irritation . "

c . " I should take a stool softener every morning to avoid constipation . "

Which statements by the client indicate good understanding of foot care in peripheral vascular disease ? ( Select all that apply . ) a . " A good abrasive pumice stone will keep my feet soft . " b . " I'll always wear shoes if I can buy cheap flip - flops . " c . " I will keep my feet dry , especially between the toes . " d . " Lotion is important to keep my feet smooth and soft . " e . " Washing my feet in room - temperature water is best . " f . " I will inspect my feet daily . "

c . " I will keep my feet dry , especially between the toes . " d . " Lotion is important to keep my feet smooth and soft . " e . " Washing my feet in room - temperature water is best . " f . " I will inspect my feet daily . "

A client asks what " essential hypertension " is . What response by the registered nurse is best ? a . " It means it is caused by another disease . " b . " It means it is ' essential ' that it be treated . " c . " It is hypertension with no specific cause . " d . " It refers to severe and life - threatening hypertension . "

c . " It is hypertension with no specific cause . "

The charge nurse is orienting a new nurse about care for an assigned client with an arteriovenous ( AV ) fistula for hemodialysis in her left arm . Which action by the float nurse would be considered unsafe ? a . Palpating the access site for a bruit or thrill b . Using the right arm for a blood pressure reading c . Administering intravenous fluids through the AV fistula d . Checking distal pulses in the left arm

c . Administering intravenous fluids through the AV fistula

A client is started on continuous venovenous hemofiltration ( CVVH ) . Which finding would require immediate action by the nurse ? a . Potassium level of 5.5 mEq / L ( 5.5 mmol / L ) b . Sodium level of 138 mEq / L ( 138 mmol / L ) c . Blood pressure of 76/58 mm Hg d . Pulse rate of 88 beats / min

c . Blood pressure of 76/58 mm Hg

A client is admitted with acute kidney injury ( AKI ) and a urine output of 2000 mL / day . What is the major concern of the nurse regarding this patient's care ? a . Edema and pain b . Cardiac and respiratory c . Electrolyte and fluid imbalance d . Mental health status

c . Electrolyte and fluid imbalance

A nurse cares for a client who has a serum potassium of 6.5 mEq / L ( 6.5 mmol / L ) and is exhibiting cardiovascular changes . Which intervention will the nurse implement first ? a . Prepare to administer patiromer by mouth . b . Provide a heart - healthy , low - potassium diet . c . Prepare to administer dextrose 20 % and 10 units of regular insulin IV push . d . Prepare the client for hemodialysis treatment .

c . Prepare to administer dextrose 20 % and 10 units of regular insulin IV push

A client with diabetes mellitus type 2 has been well controlled with metformin . The client is scheduled for magnetic resonance imaging ( MRI ) scan with contrast . What priority would the nurse take at this time ? a . Teach the client about the purpose of the MRI . b . Assess the client's blood urea nitrogen and creatinine c . Tell the client to withhold metformin for 24 hours before the MRI . d . Ask the client if he or she is taking antibiotics .

c . Tell the client to withhold metformin for 24 hours before the MRI .

An older client with peripheral vascular disease ( PVD ) is explaining the daily foot care regimen to the family practice clinic nurse . What statement by the client may indicate a barrier to proper foot care ? a . " I nearly always wear comfy sweatpants and house shoes . " b . " I'm glad I get energy assistance so my house isn't so cold . " c . " My daughter makes sure I have plenty of lotion for my feet . " d . " My hands shake when I try to do things requiring coordination . "

d . " My hands shake when I try to do things requiring coordination . "

A nurse assesses a client after administering the first dose of a nitrate . The client reports a headache . What action would the nurse take ? a . Initiate oxygen therapy . b . Hold the next dose . c . Instruct the client to drink water . d . Administer PRN acetaminophen .

d . Administer PRN acetaminophen .

The nurse is caring for several clients with osteoporosis . For which client would bisphosphonates not be a good option ? a . Client with diabetes who has a serum creatinine of o.8 mg / dL ( 61 mcmol / L ) . b . Client who recently fell and has vertebral compression fractures . c . Hypertensive client who takes calcium channel blockers . d . Client with a spinal cord injury who cannot tolerate sitting up .

d . Client with a spinal cord injury who cannot tolerate sitting up .

A client with acute kidney injury ( AKI ) has a blood pressure of 76/55 mm Hg . The primary . health care provider prescribed 1000 mL of normal saline to be infused over 1 hour to maintain perfusion . The client starts to develop shortness of breath . What is the nurse's priority action ? a . Calculate the mean arterial pressure ( MAP ) . b . Ask for insertion of a pulmonary artery catheter . c . Take the client's pulse .. d . Decrease the rate of the IV infusion .

d . Decrease the rate of the IV infusion .

After teaching a client who is prescribed a restricted sodium diet , a nurse assesses the client's understanding . Which food choice for lunch indicates that the client correctly understood the teaching ? a . Slices of smoked ham with potato salad b . Bowl of tomato soup with a grilled cheese sandwich c . Salami and cheese on whole - wheat crackers d . Grilled chicken breast with glazed carrots

d . Grilled chicken breast with glazed carrots

A nurse assesses a client after administering a prescribed beta blocker . Which assessment would the nurse expect to find ? a . Blood pressure increased from 98/42 to 132/60 mm Hg . b . Respiratory rate decreased from 25 to 14 breaths / min . c . Oxygen saturation increased from 88 % to 96 % . d . Pulse decreased from 100 to 80 beats / min .

d . Pulse decreased from 100 to 80 beats / min .

The client is NPO and is receiving total parenteral nutrition ( TPN ) via a subclavian line . Which precautions should the nurse implement ? Select all that apply . 1. Place the solution on an IV pump at the prescribed rate . 2. Monitor blood glucose every six ( 6 ) hours . 3. Weigh the client weekly , first thing in the morning 4. Change the IV tubing every three ( 3 ) days . 5. Monitor intake and output every shift .

1. Place the solution on an IV pump at the prescribed rate . 2. Monitor blood glucose every six ( 6 ) hours 5. Monitor intake and output every shift .

1. Pyrosis , water brash , and flatulence . 2. Weight loss , dysarthria , and diarrhea . 3. Decreased abdominal fat , proteinuria , and constipation . 4. Midepigastric pain , positive H. pylori test , and melena

1. Pyrosis , water brash , and flatulence .

The client is admitted to the burn unit and prescribed pantoprazole ( Protonix ) , a proton pump inhibitor ( PPI ) . Which statement best supports the scientific rationale for administering this medication to a client with a severe burn ? ( MEDSURG 1. This medication will help prevent a stress ulcer . 2. This medication will help prevent systemic infections . 3. This medication will provide continuous vasoconstriction . 4. This medication will stimulate new skin growth .

1. This medication will help prevent a stress ulcer .

The nurse in a long - term care facility is planning the care for a client with a percutaneous endoscopic gastrostomy ( PEG ) feeding tube . Which intervention should the nurse include in the plan of care ? 1. Inspect the insertion line at the naris prior to instilling formula . 2. Elevate the head of the bed after feeding the client . 3. Place the client in the Sims position following each feeding . 4. Change the dressing on the feeding tube every three ( 3 ) days

2. Elevate the head of the bed after feeding the client .

The nurse has administered an antibiotic , a proton pump inhibitor , and Pepto - Bismol for peptic ulcer disease secondary to H. pylori . Which data would indicate to the nurse the medications are effective ? ( 1. A decrease in alcohol intake . 2. Maintaining a bland diet . 3. A return to previous activities . 4. A decrease in gastric distress .

4. A decrease in gastric distress .

A client comes to the clinic reporting pain in the epigastric region . What statement by the client is specific to the presence of a duodenal ulcer ? A. " My pain resolves when I have something to eat . " B. " The pain begins right after I eat . " C. " I know that my father and my grandfather both had ulcers . " D. " I seem to. have bowel movements more often than I usually do . "

A. " My pain resolves when I have something to eat . "

A client was treated in the emergency department and critical care unit after ingesting bleach . What possible complication of the resulting gastritis should the nurse recognize ? A. Esophageal or pyloric obstruction related to scarring B. Uncontrolled proliferation of H. pylori C. Gastric hyperacidity related to excessive gastrin secretion D. Chronic referred pain in the lower abdomen

A. Esophageal or pyloric obstruction related to scarring

A ) Patient's concern that this medication has cardiovascular side effects B ) Patient's chronic use of PPIs C ) Family's concern that this medication will cause more harm than benefits D ) Patient's history of gastroesophageal reflux disease ( GERD )

B ) Patient's chronic use of PPIs

A nurse is assessing a client who has peptic ulcer disease . The client requests more information about the typical causes of Helicobacter pylori infection . What would be appropriate for the nurse to instruct the client ? A. Most affected clients acquired the infection during international travel . B. Infection typically occurs due to ingestion of contaminated food and water . C. Many people possess genetic factors causing a predisposition to H. pylori infection . D. The H. pylori microorganism is endemic in warm , moist climates .

B. Infection typically occurs due to ingestion of contaminated food and water .

A client with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease . Following the completion of this diagnostic test , what nursing intervention should the nurse perform ? A. Keep client NPO until the results of test are known . B. Keep client NPO until the client's gag reflex returns . C. Administer analgesia until post - procedure tenderness is relieved . D. Give the client a cold beverage to promote swallowing ability .

B. Keep client NPO until the client's gag reflex returns .

A nurse in an oral surgery practice is working with a client scheduled for removal of an abscessed tooth . When providing discharge education , the nurse should recommend what action ? A. Rinse the mouth with alcohol before bedtime for the next 7 days . B. Use warm saline to rinse the mouth as needed . C. Brush around the area with a firm toothbrush to prevent infection . D. Use a toothpick to dislodge any debris that gets lodged in the socket .

B. Use warm saline to rinse the mouth as needed

A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop . What action should the nurse recommend as having the greatest potential to prevent esophageal cancer ? A. Promotion of a nutrient - dense , low - fat diet B. Annual screening endoscopy for clients over 50 with a family history of esophageal cancer C. Early diagnosis and treatment of gastroesophageal reflux disease D. Adequate fluid intake and avoidance of spicy food

C. Early diagnosis and treatment of gastroesophageal reflux disease

A school nurse is assessing a student who was kicked in the shin during a soccer game . The area of the injury has become swollen and discolored . The triage nurse should organize care for a : A. sprain . B. strain . C. contusion . D. dislocation .

C. contusion .

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen . What health education related to this medication should the nurse provide ? A. Take the medication on an empty stomach . B. Take up to one extra dose per day if stomach pain persists . C. Take at bedtime to mitigate the effects of drowsiness . D. Avoid drinking alcohol while taking the drug .

D. Avoid drinking alcohol while taking the drug .

A client has experienced symptoms of dumping syndrome following gastric surgery . To what physiologic phenomenon does the nurse attribute this syndrome ? A. Irritation of the phrenic nerve due to diaphragmatic pressure B. Chronic malabsorption of iron and vitamins A and C C. Reflux of bile into the distal esophagus D. Influx of extracellular fluid into the small intestine

D. Influx of extracellular fluid into the small intestine

Which of these client assessment findings is typically associated with oral cancer ? a . Dry sticky oral membranes b . Increased appetite c . Itchy rash in oral cavity d.painless red or raised lesion

D. Painless red or raised lesion

The nurse is teaching assistive personnel about postoperative care for an older adult who had a posterolateral total hip arthroplasty . What teaching will the nurse include ? ( Select all that apply . ) a . " Move the client slowly to prevent dizziness and a possible fall . " b . " Encourage the client to deep breathe and cough at least every 2 hours . " c . " Help the client use the incentive spirometer at least every 2 hours . " d . " Keep the abduction pillow in place at all times while the client is in bed . " e . " Let me know if the client has an elevated temperature or pulse . " f . " Keep in mind that the client may be a little confused after surgery . " g . " Please let me know if you see any reddened or open skin areas during bathing . "

a . " Move the client slowly to prevent dizziness and a possible fall . " b . " Encourage the client to deep breathe and cough at least every 2 hours . " c . " Help the client use the incentive spirometer at least every 2 hours . " d . " Keep the abduction pillow in place at all times while the client is in bed . " e . " Let me know if the client has an elevated temperature or pulse . " f . " Keep in mind that the client may be a little confused after surgery . "

What information does the nurse teach a women's group about osteoporosis ? a . " Primary osteoporosis occurs in postmenopausal women due to lack of estrogen . " b . " Men actually have higher rates of the disease but are underdiagnosed . " c . " There is no way to prevent or slow osteoporosis after menopause . " d . " Women and men have an equal chance of getting osteoporosis . "

a . " Primary osteoporosis occurs in postmenopausal women due to lack of estrogen . "

A nurse cares for a client placed in skeletal traction . The client asks , " What is the primary purpose of this type of traction ? " How would the nurse respond ? a . " Skeletal traction will assist in realigning your fractured bone . " b . " This treatment will prevent future complications and back pain . " c . " Traction decreases muscle spasms that occur with a fracture . " d . " This type of traction minimizes damage as a result of fracture treatment . "

a . " Skeletal traction will assist in realigning your fractured bone . "

A client with chronic osteomyelitis is being discharged from the hospital . What information is important for the nurse to teach this client and family ? ( Select all that apply . ) a . Adherence to the antibiotic regimen b . Correct intramuscular injection technique c . Eating high - protein and high - carbohydrate foods d . Keeping daily follow - up appointments e . Proper use of the intravenous equipment

a . Adherence to the antibiotic regimen c . Eating high - protein and high - carbohydrate foods e . Proper use of the intravenous equipment

A client has a metastatic bone tumor in the left leg . What action by the nurse is appropriate ? a . Administer pain medication as prescribed . b . Elevate the extremity and apply moist heat . c . Teach the client about amputation care . d . Place the client on protective precautions

a . Administer pain medication as prescribed .

A client has dumping syndrome . What menu selections indicate the client understands the correct diet to manage this condition ? ( Select all that apply . ) a . Apricots b . Coffee cake c . Milk shake d . Potato soup e . Steamed broccoli

a . Apricots d . Potato soup

A client has dumping syndrome after a partial gastrectomy . Which action by the nurse would be appropriate ? a . Arrange a dietary consult . b . Increase fluid intake . c . Limit the client's foods . d . Make the client NPO .

a . Arrange a dietary consult .

A female client is preparing to have open magnetic resonance imaging ( MRI ) of the spine . What action ( s ) by the nurse is ( are ) most important to assess before the test ? ( Select all that apply . ) a . Ask if the client has a history of kidney disease . b . Ask the client if she could possibly be pregnant . c . Ensure that the patient has no metal or electronic implants d . Assess the client for the ability to communicate . e . Assess the client for a history of claustrophobia

a . Ask if the client has a history of kidney disease . b . Ask the client if she could possibly be pregnant . c . Ensure that the patient has no metal or electronic implants . d . Assess the client for the ability to communicate .

The nurse assesses a client after a total hip arthroplasty . The client's surgical leg is visibly shorter than the other one and the client reports extreme pain . While a co - worker calls the surgeon , what action by the nurse is appropriate ? a . Assess neurovascular status in both legs . b . Elevate the surgical leg and apply ice . c . Prepare to administer pain medication . d . Try to place the surgical leg in abduction .

a . Assess neurovascular status in both legs .

a . Assess the neurovascular status of the right leg . b . Document the findings in the patient's chart . c . Elevate the left leg on at least two pillows . d . Notify the primary health care provider immediately .

a . Assess the neurovascular status of the right leg .

A nurse is visiting a client discharged home after a total hip arthroplasty . What safety precautions would the nurse recommend to the client and family ? ( Select all that apply . ) a . Buy and install an elevated toilet seat . b . Install grab bars in the shower and by the toilet . c . Step into the bathtub with the affected leg first . d . Remove all throw rugs throughout the house e . Use a shower chair while taking a shower

a . Buy and install an elevated toilet seat . b . Install grab bars in the shower and by the toilet . d . Remove all throw rugs throughout the house e . Use a shower chair while taking a shower

A nurse is planning postoperative care for a client following a total hip arthroplasty . What nursing interventions would help prevent venous thromboembolism for this client ? ( Select all that apply . ) a . Early ambulation b . Fluid restriction c . Quadriceps - setting exercises d . Compression stockings / devices e. Anticoagulant drug therapy

a . Early ambulation c . Quadriceps - setting exercises d . Compression stockings / devices e. Amticoagulant drug therapy

The nurse is caring for a client who has frequent gastric pain and dyspepsia ( indigestion ) . Which procedure would the nurse expect for the client to make an accurate diagnosis ? a . Esophagogastroduodenoscopy ( EGD ) b . Abdominal arteriogram c . Nuclear medicine scan d . Magnetic resonance imaging ( MRI )

a . Esophagogastroduodenoscopy ( EGD )

A client is getting out of bed into the chair for the first time after an uncemented total hip arthroplasty . What action by the nurse is appropriate ? a . Have adequate help to transfer the patient . b . Provide socks so the patient can slide easier . c . Tell the patient full weight bearing is allowed . d . Use a footstool to elevate the patient's leg .

a . Have adequate help to transfer the patient .

The nurse is caring for a client who recently sustained a sports injury to his right leg . What nursing interventions are appropriate for this client ? ( Select all that apply . ) a . Immobilize the right leg b . Apply heat immediately after the injury . c . Use compression to support the leg . d . Obtain an x - ray to detect possible fracture . e . Elevate the right leg to decrease swelling . f . Administer an opioid every 4 to 6 hours

a . Immobilize the right leg . c . Use compression to support the leg . d . Obtain an x - ray to detect possible fracture . e . Elevate the right leg to decrease swelling .

A nurse teaches a client with a fractured tibia about external fixation . Which advantages of external fixation for the immobilization of fractures would the nurse share with the client ? ( Select all that apply . ) a . It leads to minimal blood loss . b . It allows for early ambulation . c . It decreases the risk of infection d . It increases blood supply to tissues . e . It promotes healing .

a . It leads to minimal blood loss . b . It allows for early ambulation e . It promotes healing .

The nursing is teaching a client diagnosed with gastroesophageal reflux disease ( GERD ) who is planning to have an endoscopic radiofrequency ( Stretta ) procedure . What preprocedure health teaching would the nurse include ? ( Select all that apply . ) a . " You will need to be on a liquid diet for the first week after the procedure . " b . " Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure . " c . " Contact the primary health care provider after the procedure if you have increased pain . " d . " You will need a nasogastric tube for a few days after the procedure . " e . " You will have a small incision in your stomach area that will have a wound closure .

b . " Avoid taking any NSAIDs like ibuprofen for 10 days before the procedure . " c . " Contact the primary health care provider after the procedure if you have increased pain . "

A client who has peptic ulcer disease is prescribed quadruple drug therapy for Helicobacter pylori infection . What health teaching related to bismuth would the nurse include ? a . " Report stool changes to your primary health care provider immediately . " b . " Do not take aspirin or aspirin products of any kind while on bismuth . " c . " Take bismuth about 30 minutes before each meal and at bedtime . " d . " Be aware that bismuth can cause frequent vomiting and diarrhea . "

b . " Do not take aspirin or aspirin products of any kind while on bismuth . "

A client with osteoporosis is going home where the client lives alone . What action by the nurse is best ? a . Refer the client to Meals on Wheels b . Arrange a home safety evaluation . . Ensure that the client has a walker at home d . Help the client look into assisted living .

b . Arrange a home safety evaluation .

A nurse participates in a community screening event for oral cancer . What client is the highest priority for referral to a primary health care provider ? a . Client who has poor oral hygiene practices . b . Client who smokes and drinks daily . c . Client who tans for an upcoming vacation . d . Client who occasionally uses illicit drugs

b . Client who smokes and drinks daily .

a . Pyloric obstruction b . Dumping syndrome c . Delayed gastric emptying d . Pernicious anemia

b . Dumping syndrome

A nurse plans care for a client who is recovering from a below - the - knee amputation of the left leg . Which intervention would the nurse include in this client's plan of care a . Place pillows between the client's knees . b . Encourage range - of - motion exercises . c . Administer prophylactic antibiotics . d . Implement strict bedrest in a supine position .

b . Encourage range - of - motion exercises .

A nurse cares for a client with a recently fractured tibia . Which assessment would alert the nurse to take immediate action ? a . Pain of 4 on a scale of 0-10 b . Numbness in the extremity c . Swollen extremity at the injury site d . Feeling cold while lying in bed

b . Numbness in the extremity

The nurse is caring for a client diagnosed with oral cancer . What is the nurse's priority for client care ? a . Encourage fluids to liquefy the client's secretions . b . Place the client on Aspiration Precautions . c . Remind the client to use an incentive spirometer . d . Manage the client's pain and inflammation .

b . Place the client on Aspiration Precautions .

The nurse is caring for a client who had an open traditional esophagectomy . Which assessment findings would the nurse report immediately to the primary health care provider ? ( Select all that apply . ) a . Nausea b . Wound dehiscence c . Fever d . Tachycardia e . Moderate

b . Wound dehiscence c . Fever d . Tachycardia

A client is prescribed celecoxib for joint pain . What statement by the client indicates a need for further teaching ? a . " I'll report any signs of bleeding or bruising to my primary health care provider . b . " I'll take this drug only as prescribed by my primary health care provider . " c . " I'll be sure to take this drug three times a day only on an empty stomach . " d . " I'll monitor the amount of urine that I excrete every day and report any changes . "

c . " I'll be sure to take this drug three times a day only on an empty stomach . "

The nurse teaches assistive personnel ( AP ) about care of an older adult diagnosed with osteoporosis . What teaching would the nurse include ? a . " Teach the client to eat high - calcium foods in the diet . " b . " Assist the client with activities of daily living . " c . " Osteoporosis places the client is at risk for fractures . " d . " The client should stay in bed to prevent falling . "

c . " Osteoporosis places the client is at risk for fractures . "

A nurse is caring for an older client who is recovering from a leg amputation surgery . The client states , " I don't want to live with only one leg . I should have died during the surgery . " What is the nurse's best response ? a . " Your vital signs are good , and you are doing just fine right now . " b . " Your children are waiting outside . Do you want them to grow up without a father ? " c . " This is a big change for you . What support system do you have to help you cope ? " d . " You will be able to do some of the same things as before you became disabled . "

c . " This is a big change for you . What support system do you have to help you cope ? "

A nurse assesses clients in an osteoporosis clinic . Which client would the nurse assess first ? a . Client taking calcium with vitamin D who reports flank pain 2 weeks ago . b . Client taking ibandronate who cannot remember when the last dose was . c . Client taking raloxifene who reports unilateral calf swelling . d . Client taking risedronate who reports occasional dyspepsia .

c . Client taking raloxifene who reports unilateral calf swelling .

The nurse assesses a client who has possible gastritis . Which assessment finding ( s indicate ( s ) that the client has chronic gastritis ? ( Select all that apply . ) a . Anorexia b . Dyspepsia c . Intolerance of fatty foods d . Pernicious anemia e . Nausea and vomiting

c . Intolerance of fatty foods d . Pernicious anemia

A nurse is caring for a client recovering from an above - the - knee amputation of the right leg . The client reports pain in the right foot . Which prescribed medication would the nurse most likely administer ? a . Intravenous morphine b . Oral acetaminophen c . Intravenous calcitonin d . Oral ibuprofen

c . Intravenous calcitonin The client is experiencing phantom limb pain , which usually manifests as intense burning , crushing , or cramping . IV infusions of calcitonin during the week after amputation can reduce phantom limb pain .

During an interview , the client tells the nurse that the client has a duodenal ulcer . Which assessment finding would the nurse expect ? a . Hematemesis b . Pain when eating c . Melena ( dark stool ) d . Weight loss

c . Melena ( dark stool )

A nurse is caring for four clients . After the hand - off report , which client would the nurse see first ? a . Client with osteoporosis and a white blood cell count of 27,000 / mm3 ( 27 109 / L ) b . Client with osteoporosis and a bone fracture who requests pain medication c . Post - microvascular bone transfer client whose distal leg is cool and pale d . Client with suspected bone tumor who just returned from having a spinal CT

c . Post - microvascular bone transfer client whose distal leg is cool and pale

e . Walk for 30 minutes at least three times a week .

c . Strengthening exercises are important d Take recommended calcium and vitamin D. E. Wal for 30 minutes at least three times a week.

The nurse is caring for a client who has been diagnosed with peptic ulcer disease . For which complication would the nurse monitor ? a . Large bowel obstruction b . Dyspepsia c . Upper gastrointestinal ( Gl ) bleeding d . Gastric cancer .

c . Upper gastrointestinal ( Gl ) bleeding

The nurse is teaching a client about the use of viscous lidocaine for oral pain . What health teaching would the nurse include ? a . " Use the drug before every meal to prevent aspiration . " b . " Increase your intake of citrus foods to help with healing . " c . " Use the drug only at bedtime because you won't be eating . " d . " Be sure to check food temperatures before eating . "

d . " Be sure to check food temperatures before eating . "

A nurse is caring for a client who is recovering from an above - the - knee amputation and reports pain in the limb that was removed . How would the nurse respond ? a . " The pain you are feeling does not actually exist . " b . " This type of pain is common and will eventually go away . " c . " Would you like to learn how to use imagery o minimize your pain ? " d . " How would you describe the pain that you are feeling ? "

d . " How would you describe the pain that you are feeling ? "

The nurse is teaching a client who has been treated for acute gastritis . What statement by the client indicates a need for further teaching ? a . " I need to cut down on drinking martinis every night . " b . " I should decrease my intake of caffeinated drinks , especially coffee . " c . " I will only take ibuprofen once in a while when I really need it . " d . " I can continue smoking cigarettes which is better than chewing tobacco . "

d . " I can continue smoking cigarettes which is better than chewing tobacco . "

A nurse cares for a client who had a wrist cast applied 3 days ago . The client states , " The cast is loose enough to slide off . " How would the nurse respond ? a . " Keep your arm above the level of your heart . " b . " As your muscles atrophy , the cast is expected to loosen . " c . " I will wrap a bandage around the cast to prevent it from slipping . " d . " You need a new cast now that the swelling is decreased . "

d . " You need a new cast now that the swelling is decreased . "

A nurse is caring for several clients with fractures . Which client would the nurse identify as being at the highest risk for developing deep vein thrombosis ? a . An 18 - year - old male athlete with a fractured clavicle b . A 36 - year - old female with type 2 diabetes and fractured ribs c . A 55 - year - old female prescribed ibuprofen for osteoarthritis d . A 74 - year - old male who smokes and has a fractured pelvis

d . A 74 - year - old male who smokes and has a fractured pelvis

a . Assess the neurovascular status of the right leg . b . Document the findings in the patient's chart . c . Elevate the left leg on at least two pillows . d . Notify the primary health care provider immediately . The nurse is taking a history from an older client who reports having frequent falls . Which dietary habit could be contributing to the client's problem ? a . Consumes high - protein foods . b . Eats few concentrated sweets . c . Limits fatty or greasy foods . d . Avoids dairy products .

d . Avoids dairy products .

The nurse caring for clients with gastrointestinal disorders would recall that omeprazole is a drug in which classification ? a . Gastric acid inhibitor b . Histamine receptor blocker c . Mucosal barrier fortifier d . Proton pump inhibitor

d . Proton pump inhibitor

A nurse plans care for a client who has an external fixator on the lower leg . Which intervention would the nurse include in the plan of care to decrease the client's risk for infection ? a . Washing the frame of the fixator once a day b . Releasing fixator tension for 30 minutes twice a day c . Avoiding moving the extremity by holding the fixator d . Scheduling for pin care to be provided every shift

d . Scheduling for pin care to be provided every shift