Med surg exam 1

Emergent glaucoma

angle-closure

#1 cause PAD

atherosclerosis

Digoxin and beta blockers (ols)

improve heart contractility

Most common glaucoma

open angle

Heparin antidote

protamine sulfate

Right sided HF

systemic venous congestion, pedal edema

Mechanical debridement

wet to dry dressing

Increased heart hypertrophy better or worse contractility

worse

An older adult is admied to the hospital. The client's height is 5 feet, 6 inches (1.68 m), and weight is 250 lb (113.3 kg). The nurse calculates the client's current body mass index (BMI) as _______. Fill in the blank. Round your answer to the nearest whole number.

40.0

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lipogenesis F. Lipolysis

A, C

A client who had the Stretta procedure to treat severe GERD is being discharged. Which client statement requires further nursing teaching? Select all that apply. A. "Dysphagia after this procedure is normal." B. "It's important to stop my proton pump inhibitor." C. "I will not take NSAIDs and aspirin for at least 10 days." D. "I might cough up some blood following this procedure." E. "Today I will drink clear liquids and tomorrow I can eat soft food."

A. "Dysphagia after this procedure is normal." B. "It's important to stop my proton pump inhibitor." D. "I might cough up some blood following this procedure."

A client with obesity tells the nurse, "My genes are the only thing that have made me obese." What is the appropriate nursing response? Select all that apply. A. "Genes can contribute to obesity." B. "Tell me about your family history." C. "Let's talk about your nutrition intake." D. "Have you considered bariatric surgery?" E. "How do you feel about physical activity?" F. "What lifestyle modifications have you tried?"

A. "Genes can contribute to obesity." B. "Tell me about your family history." C. "Let's talk about your nutrition intake." E. "How do you feel about physical activity?" F. "What lifestyle modifications have you tried?"

Which client statement regarding a new diagnosis of tinnitus requires nursing teaching? Select all that apply. A. "I am so glad this condition will go away permanently." B. "It is important that I do not drive when I have tinnitus." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus." E. "I have found a couple of support groups that I like to aend."

A. "I am so glad this condition will go away permanently." C. "Watching my diet will make a difference in my condition." D. "Surgery is the only treatment that is available for tinnitus."

The nurse is teaching a class regarding reduction of risk factors for cardiovascular disease. Which teaching statement will the nurse include? Select all that apply. A. "If you tend to get angry easily, then your risk for heart disease is higher." B. "To reduce your overall risk, it is important to keep your BMI greater than 30." C. "Do not eat more calories on a daily basis that you are able to burn." D. "Decreasing the amount that you smoke will decrease your overall cardiovascular risk." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

A. "If you tend to get angry easily, then your risk for heart disease is higher." C. "Do not eat more calories on a daily basis that you are able to burn." E. "Secondhand smoke creates a significant risk to others for cardiovascular disease." F. "Exercise moderately at least 2 days per week for a total of 150 minutes."

The nurse is admiing a client with an ulcer on the right foot. Which client statement indicates venous insufficiency to the nurse? Select all that apply. A. "My ankles swell up all the time." B. "My leg hurts after I walk about a block." C. "My feet are always really cold." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

A. "My ankles swell up all the time." D. "My veins really stick out in my legs." E. "My ankles have been discolored for years."

The nurse is assessing the client's heart sounds. Which instruction will the nurse provide if there is difficulty in hearing heart sounds? A. "Please roll onto your left side." B. "Lay all the way down on your back." C. "Please hold your breath while I use my stethoscope." D. "I will just take your pulse instead."

A. "Please roll onto your left side."

The nurse is teaching a client with heart failure about a newly prescribed medication, ivabradine. What teaching will the nurse include? Select all that apply. A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A. "Visual changes with exposure to light are expected initially." B. "Be sure to take this medication with food." C. "Call your health care provider if your pulse rate is low or irregular." D. "Use caution when driving in the sunlight." E. "Check your BP regularly and notify the health care provider if elevated."

A nurse is caring for four clients. Which individual does the nurse identify as being at the highest risk for development of oral cancer? A. 28-year-old with human papillomavirus (HPV) infection B. 30-year-old with recurrent aphthous stomatitis (RAS) C. 55-year-old who quit chewing tobacco 5 years ago D. 76-year-old who is sometimes negligent in denture care

A. 28-year-old with human papillomavirus (HPV) infection

The nurse is caring for an older client who is experiencing acute confusion and agitation following a fractured hip repair this morning. Which risk factors may be contributing to the client's delirium? Select all that apply. A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

A. Anesthesia used during surgery B. Surgical pain C. Unfamiliar environment D. Noisy hospital unit E. Medications used to manage pain

The nurse is caring for four clients who have been recommended to consider bariatric surgery. Which assessment data require immediate nursing intervention? A. BMI of 23 with gastrointestinal reflux B. BMI of 36 with hypertension C. BMI of 40 with type II diabetes D. BMI of 43 with sleep apnea

A. BMI of 23 with gastrointestinal reflux

The nurse is conducting an admission assessment on a male client. Which assessment data does the nurse identify as a risk factor for cardiovascular disease? Select all that apply. A. BMI of 26 B. BP of 120/66 mm Hg C. Triglycerides 140 mg/dL D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cigaree smoke F. History of repeated streptococcal tonsillitis G. Family history of cardiovascular disease

A. BMI of 26 D. Moderate exercise for 20 to 30 minutes weekly E. Exposure to secondhand cig smoke G. Family history of cardiovascular disease

What discharge teaching will the nurse provide to a client who had gastric bypass surgery? Select all that apply. A. Be certain to stay hydrated by drinking water. B. Solid food can be introduced back into the diet in a week. C. Report any back, shoulder, or abdominal pain to the surgeon. D. You are likely to have lile urine output for the first few weeks. E. Each of your meals should initially contain about 5 tablespoons of food.

A. Be certain to stay hydrated by drinking water. C. Report any back, shoulder, or abdominal pain to the surgeon. E. Each of your meals should initially contain about 5 tablespoons of food.

Which assessment finding will the nurse anticipate in a client with severe atherosclerotic disease? A. Carotid artery bruit B. HDL 60 mg/dL C. Palpable peripheral pulses D. BP 120/58 mm Hg

A. Carotid artery bruit

While assessing functional ability, which activities will the nurse document as instrumental activities of daily living (IADLs)? Select all that apply. A. Cooking a meal B. Walking down the hallway C. Getting dressed for the day D. Answering the telephone E. Taking a shower before bed F. Shopping at the local market

A. Cooking a meal D. Answering the telephone F. Shopping at the local market

The nurse is admitting an 84-year-old client with heart failure to the emergency department with confusion, blurry vision, and an upset stomach. Which assessment data are most concerning? A. Digoxin therapy daily B. Daily metoprolol C. Furosemide twice daily D. Currently taking an antacid for upset stomach

A. Digoxin therapy daily

The rehabilitation nurse is teaching a client with multiple sclerosis who is wheelchair bound strategies to protect skin integrity. Which teaching will the nurse include? Select all that apply. A. Dry the skin carefully after bathing. B. Do not use pillows to support the body. C. Apply a moisture barrier on the perineum. D. Rub reddened areas of skin to help improve circulation. E. Perform pressure-relief strategies at least once an hour. F. Use an air mattress to decrease the need for repositioning.

A. Dry the skin carefully after bathing. C. Apply a moisture barrier on the perineum. E. Perform pressure-relief strategies at least once an hour.

When teaching a community group of older adults, what information will the nurse include regarding normal hearing changes associated with aging? Select all that apply. A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults C. Cerumen dries and becomes impacted more easily D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

A. Hair in the ear thins and falls out B. Hearing acuity changes in all older adults D. The ability to hear low-frequency pitches diminishes first E. Sounds such as f, s, sh, and pa may be more difficult to discern

The nurse performs an initial health assessment of an older adult. Which assessment findings indicate that the client may be at risk for falls? Select all that apply. A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts F. Has thin papery skin

A. Has presbyopia B. Has peripheral neuropathy C. Uses a cane D. Takes multiple medications E. Has bilateral cataracts

A nurse is caring for a 34-year-old client newly diagnosed with GERD. Which lifestyle change will the nurse suggest? Select all that apply. A. Lose weight if needed. B. Do not eat before bed. C. Elevate the foot of your bed by 6 to 12 inches. D. Avoid pants with a tight waistband or belt. E. Eat fat foods to minimize ongoing hunger.

A. Lose weight if needed. B. Do not eat before bed. D. Avoid pants with a tight waistband or belt.

Which supplement will the nurse recommend to a client who wants to enhance eye health? A. Lutein B. Vitamin D C. Magnesium D. Saw palmetto

A. Lutein

When providing discharge teaching about mouth care, which substance will the nurse teach the client with oral cancer to avoid? Select all that apply. A. Mouthwash B. Lip lubricant C. Warm saline rinses D. Ultrasoft toothbrush E. Disposable foam brushes F. Bicarbonate mouth rinse

A. Mouthwash E. Disposable foam brushes

When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

A. Nits can be removed with a fine-tooth comb. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.

Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm? A. Only take this drug once weekly. B. Report any vision changes immediately. C. Do not mix in the same syringe with insulin. D. This drug can only be given by a health care professional.

A. Only take this drug once weekly

Which assessment data does the nurse anticipate when a client presents to the emergency department reporting the sensation of a foreign body in the eye? Select all that apply. A. Pain B. Fever C. Tearing D. Photophobia E. Blurred vision

A. Pain C. Tearing D. Photophobia E. Blurred vision

Which symptom will the nurse teach the client who just had surgery to correct a retinal detachment to immediately report to the eye care provider? Select all that apply. A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity D. Temperature of 99.0°F E. Pupil that constricts in response to light

A. Pain in the affected eye B. Pus in the affected eye C. Decreased visual acuity

What teaching will the nurse provide to a client who continues to experience more frequent episodes associated with Ménière disease? Select all that apply. A. Reducing activity can reduce frequency of episodes. B. Episodes will eventually decrease in severity and number. C. Reducing sodium, caffeine, and alcohol intake can be beneficial. D. The only treatment that is effective is to undergo labyrinthectomy. E. When moving from sitting to standing, be cautious and take your time.

A. Reducing activity can reduce frequency of episodes. C. Reducing sodium, caffeine, and alcohol intake can be beneficial. E. When moving from sitting to standing, be cautious and take your time.

Which communication method is appropriate when the nurse is interacting with a client who is deaf? A. Use pictures and writing B. Speak with enunciated words C. Ask client to read the nurse's lips D. Dialogue with the client's caregivers

A. Use pictures and writing

HTN Signs and symptoms to primary healthcare provider

Abdominal fullness or pain or back pain Chest or back pain SOB Difficulty swallowing or hoarseness

Glaucoma inc risk

Age African American, Latino

A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to limit your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

B

How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg)? A. Use a 6-mm needle and inject at a 90-degree angle. B. Use a 6-mm needle and inject at a 45-degree angle. C. Use a 12-mm needle and inject at a 90-degree angle. D. Use a 12-mm needle and inject at a 45-degree angle.

B

Total enteral nutrition (TEN) has been prescribed for a client with terminal cancer. When the nurse notes that no advanced directives are in place, yet a durable power of aorney exists, what is the appropriate action? A. Withhold TEN indefinitely B. Contact the durable power of aorney C. Begin administration of TEN immediately D. Turn over care to the interprofessional ethics committee

B

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT dose of glucagon. B. Immediately give the client 30 g of glucose orally. C. Start an IV and administer a small amount of a concentrated dextrose solution. D. Recheck the blood glucose level and call the Rapid Response Team.

B

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bole or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B, C

Which client statement affirms that nurse teaching about instillation of multiple different eyedrops has been effective? Select all that apply. A. "It will be very easy for me to instill all of the drops at one time." B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eyedrops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."

B. "A schedule will help me remember when to instill the eyedrops." C. "If I have trouble instilling the drops, there are devices that can be helpful." D. "I can label the eyedrops by color to help me easily distinguish which one is which." E. "I will not touch the droppers to my eyes as this can cause contamination and infection."

The nurse is caring for a client with heart failure who is prescribed spironolactone. Which client statement requires further nursing education? A. "I may need to take this drug every other day according to lab values." B. "I need to take potassium supplements with this medication." C. "I will try my best not to use table salt on my food." D. "This medication will cause me to urinate more often."

B. "I need to take potassium supplements with this medication."

Which statement made by the client on the way to the catheterization laboratory requires an immediate action by the nurse? A. "My allergies are bothering me, so I took some Benadryl last night before bed." B. "I was nervous last night, but I still remembered to take my warfarin." C. "I sure am hungry. I haven't had anything to eat since I went to bed last night." D. "I don't know what I will do if they find a blockage in my heart."

B. "I was nervous last night, but I still remembered to take my warfarin."

Which client statement about GERD triggers requires further nursing teaching? Select all that apply. A. "I will decrease my alcohol intake." B. "Smoking one or two cigarees a day won't hurt." C. "My plan is to eat six small meals daily." D. "Tomato-based foods should be avoided."' E. "I love soda but I'm going to stop drinking it." F. "Our family eats tacos and burritos several times weekly."

B. "Smoking one or two cigarees a day won't hurt." F. "Our family eats tacos and burritos several times weekly."

A public health nurse is assessing community clients for oral health disorders. Which client is identified at highest risk? A. 23-year-old with three dental fillings B. 34-year-old with schizophrenia C. 55-year-old with stable angina D. 62-year-old with irritable bowel syndrome

B. 34-year-old with schizophrenia

A community health nurse is screening clients for esophageal cancer. Which client is identified as being at highest risk? A. 22-year-old who drinks a glass of beer weekly B. 44-year-old who smokes a pack of cigarees daily C. 50-year-old who takes over-the-counter omeprazole D. 63-year-old who uses protein supplements regularly

B. 44-year-old who smokes a pack of cigarees daily

A nurse is caring for a client with recurrent aphthous stomatitis (RAS) who asks about food choices while healing. Which food will the nurse suggest? A. Half of an orange B. Chocolate pudding C. Chips with hummus D. Glass of tomato juice

B. Chocolate pudding

Which hormones help prevent hypoglycemia? Select all that apply A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin

B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon G. Norepinephrine

A client is diagnosed with left-sided heart failure. Which client assessment findings will the nurse anticipate? Select all that apply. A. Peripheral edema B. Crackles in both lungs C. Tachycardia D. Ascites E. Tachypnea F. S3 gallop

B. Crackles in both lungs C. Tachycardia E. Tachypnea F. S3 gallop

The nurse is caring for a client immediately following a cardiac catheterization. Which assessment data require immediate nursing intervention? A. Blood pressure 146/70 mm Hg B. Hematoma developing at insertion site C. Client reports headache pain D. Client reports extreme thirst

B. Hematoma developing at insertion site

The nurse is caring for a hospitalized client with infective endocarditis who has been receiving antibiotics for 2 days. The client is now experiencing flank pain with hematuria. What complication will the nurse suspect? A. Pulmonary embolus B. Renal infarction C. Transient ischemic aack D. Splenic infarction

B. Renal infarction

The nurse is caring for a client receiving intravenous heparin for treatment of DVT who begins to begins to vomit blood. What action should the nurse be prepared to take? A. Administer vitamin K B. Stop the infusion of heparin C. Administer an antiemetic D. Insert a nasogastric tube

B. Stop the infusion of heparin

A client is admied to the hospital with an abdominal aortic aneurysm. Which assessment data would cause the nurse to suspect that the aneurysm has ruptured? A. Shortness of breath and hemoptysis B. Sudden, severe low back pain and bruising along the flank C. Gradually increasing substernal chest pain and diaphoresis D. Rapid development of patchy blue moling on feet and toes

B. Sudden, severe low back pain and bruising along the flank

An older adult's furosemide dosage was increased 2 days ago to 40 mg daily. This morning the nurse observes that the client has become confused and very weak. What is the nurse's best action? A. Encourage fluid intake. B. Withhold this morning's dose of furosemide. C. Review the most recent serum electrolyte levels. D. Place the patient on strict intake and output.

B. Withhold this morning's dose of furosemide.

FVO labs

BNP

Metoprolol HTN

Beta blocker Lowers HR HR >60 good Can affect glucose control

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

C

A client who recently had a heart valve replacement is preparing for discharge. Which client statement indicates that the nurse will need to do additional health teaching? A. "I need to brush my teeth at least twice daily and rinse with water." B. "I will eat foods that are low in vitamin K, such as potatoes and iceberg leuce." C. "I need to take a full course of antibiotics prior to my colonoscopy." D. "I will take my blood pressure every day and call if it is too high or low."

C. "I need to take a full course of antibiotics prior to my colonoscopy."

The nurse is caring for a client with a complete spinal cord injury resulting in paraplegia. Which client statement indicates understanding of a bowel retraining program? A. "I'll use a suppository to help empty my rectum." B. "I will avoid stool softeners so I don't experience diarrhea." C. "I'll eat high-fiber foods each day to help prevent constipation." D. "Digital stimulation for 1 full minute may be needed in order to produce stool."

C. "I'll eat high-fiber foods each day to help prevent constipation."

Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."

C. "It is important to keep my skin very moist, so I will use lotion."

A client who is receiving heparin therapy is started on warfarin. Which nursing explanation is appropriate? A. "You will need both drugs long-term to provide long-term anticoagulation." B. "Warfarin is easier on your stomach so you can take it long-term." y y g C. "It takes several days for warfarin to begin working, so both drugs are required for a shorime." D. "These drugs work the same, but one is taken by mouth, so it is easier to take at home."

C. "It takes several days for warfarin to begin working, so both drugs are required for a shorime."

The nurse is caring for a diabetic client who will be discharged on hydrochlorothiazide (HCTZ). What information will the nurse include in the discharge teaching? Select all that apply. A. "This drug may cause a dry, nagging cough." B. "Take this drug with a snack, right before bed." C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.

C. "Try to increase your intake of potassium in your diet." D. "This drug can affect your glucose control." E. "Increased urination is expected with this drug.

Which patient does the nurse identify at highest risk for development of dry age-related macular degeneration (AMD)? A. 55-year-old client who recently began wearing glasses B. 59-year-old client who has controlled hypertension C. 62-year-old client with hypothyroidism D. 65-year-old client with diabetes

C. 62-year-old client with hypothyroidism

The nurse is caring for a 25-year old client with a new spinal cord injury resulting in tetraplegia. The client states, "I won't be able to do any activities that I enjoy now." What is the priority nursing intervention? A. Encourage the client to explore new activities that they can do. B. Teach the client about reasonable goals for activities. C. Allow the client time to discuss feelings of loss related to the injury. D. Consult pastoral care to provide encouragement to the client.

C. Allow the client time to discuss feelings of loss related to the injury.

The assistive personnel (AP) is preparing to transfer a client with limited weight bearing from the bed to the chair. Which action by the AP would require intervention from the nurse? A. Places the bed at hip level B. Applies a gait belt to the client C. Extends arms to reach out to client D. Creates a wide base with the feet

C. Extends arms to reach out to client

What finding does the nurse anticipate when assessing a client with a new diagnosis of glaucoma? A. Seeing "shooting stars" B. Decrease in central vision C. Gradual loss of visual fields D. Abrupt onset of excruciating pain

C. Gradual loss of visual fields

A nurse conducts an assessment of an older adult's medications, including both prescription and over-the-counter drugs. Which drug would the nurse identify as being potentially inappropriate for older adults? A. Vitamin D B. Losartan C. Nortriptyline D. Hydrochlorothiazide (HCTZ)

C. Nortriptyline

A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.

C. Perform a head-to-toe skin assessment and document the findings.

The nurse is caring for a client with heart failure who is on oxygen at 2 L per nasal cannula with an oxygen saturation of 90%. The client states, "I feel short of breath." Which action will the nurse take first? A. Contact respiratory therapy. B. Increase the oxygen to 4 L. C. Place the client in a high-Fowler position. D. Draw arterial blood for arterial blood gas analysis.

C. Place the client in a high-Fowler position.

The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image

C. Presence of new plaques on leg

A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.

C. The lesion borders have expanded and are shaped differently in the second picture.

The nurse is assessing a client with heart failure. Which assessment data are the best indicator of fluid balance? A. Blood pressure 144/79 mm Hg B. Urine output 200 mL in the last 4 hours C. Weight increase of 9 lb in the past week D. Generalized edema in the lower extremities

C. Weight increase of 9 lb in the past week

Chemical debridement

Cream applied

Sharp or surgical debridement

Cut out dead tissue

The nurse reviewing the preadmission testing laboratory values for a 62- year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal. B. The client has type 1 diabetes mellitus. C. The client has type 2 diabetes mellitus. D. The client has prediabetes mellitus.

D

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

D

What is the appropriate nursing response when a 66-year-old healthy client asks how often a visit to the eye care provider is recommended? A. "Annually." B. "Every 6 months." C. "Only if you have vision problems." D. "Every 3 to 5 years if you have no eye problems."

D. "Every 3 to 5 years if you have no eye problems."

The nurse is teaching a client with stage 1 hypertension. Which client statement indicates understanding of dietary modifications? A. "I will reduce my sodium intake to 2500 mg per day." B. "I will restrict my intake of daily dietary lean protein." C. "I am only going to drink one cup of coffee to start my day." D. "I will drink a glass of low-fat milk with my breakfast."

D. "I will drink a glass of low-fat milk with my breakfast."

The nurse is caring for a client with intermient claudication due to peripheral arterial disease. Which client statement indicates understanding of proper self-management? A. "I need to reduce the number of cigaretes that I smoke each day." B. "I'll elevate my legs above the level of my heart." C. "I'll use a heating pad to promote circulation." D. "I'll start to exercise gradually, stopping when I have pain."

D. "I'll start to exercise gradually, stopping when I have pain."

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

D. "Plan several ways of escape from the home in case the primary exit is blocked."

What teaching will the nurse provide when educating about carbon monoxide prevention? A. "Carbon monoxide is only dangerous if accompanied by fire." B. "Black smoke can be seen when carbon monoxide is in the air." C. "Your skin will turn a blue color if you have carbon monoxide poisoning." D. "Put carbon monoxide detectors in your home, because this is an odorless gas."

D. "Put carbon monoxide detectors in your home, because this is an odorless gas."

When caring for four clients, which client does the nurse report to the health care provider who should not receive an otoscopic examination? A. 25-year-old with throat and ear pain B. 39-year-old experiencing dizziness C. 46-year-old who has type 2 diabetes D. 60-year-old experiencing delirium

D. 60-year-old experiencing delirium

What teaching will the nurse provide to a client who has just been fitted for new hearing aids? A. Turn off the hearing aid when not using it. B. Immerse the ear mold in alcohol to fully clean it. C. Store the hearing aid in a warm, humid bathroom when not in use. D. Avoid using hair spray, makeup, and personal care products around the device.

D. Avoid using hair spray, makeup, and personal care products around the device.

The nurse is conducting an assessment of an older adult living in the community. Which assessment findings are considered usual physiologic changes of aging? Select all that apply. A. Dementia B. Relocation stress C. Urinary incontinence D. Presbyopia E. Obesity

D. Presbyopia

Medicare

Elderly

Left sided HF

Fluid in lungs, internal

Alpha and beta cells

Glucagon alpha Insulin beta

Where to check for bleeding

Gums, Stool, urine, nose

ACE inhibitors HTN

Lisinopril Nagging dry cough

ARB inhibitors HTN

Losartan

Angiography

Most definitive most invasive x-ray

Coumadin (warfarin) labs

PT/INR

Heparin labs

PTT

Echocardiogram

Shows Ejection fraction

Coumadin antidote

Vitamin K

Natural chemical debridement

Wound Vac