Med Surg Final Review
Based upon Eleanor's manifestations, which finding supports a diagnosis of Pneumonia? A. Swelling the feet B. Not sleeping well C. Increased chest diameter D. HR 106
D
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. A client who sustained a head injury and is having periods of confusion B.A client who reports a severe migraine headache C. A client who has a suspected diagnosis of tuberculosis (TB) D. A client who has a history of atrial fibrillation and is on continuous ECG monitoring.
A
A client who is HIV-positive has had a tuberculin skin test (TST). The nurse notes a 7mm area of induration at the site of the skin test and interprets the result as which of the following? A. Positive B. Negative C. Inconclusive D. Need for repeat testing
A
A nurse is caring for a client who has the following ABGs: HCO3 = 18mEq, PaCO2 = 22mmHg and pH = 7.30. The nurse recognizes the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis
A
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the clients blood glucose to be 48mg/dL, he should give the client which of the following? A. 4 oz juice B. cheese slices C. 4 oz diet soda D. 2 oz skim milk
A
A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? A. Vitamin B12 injections B. Iron supplements C. Blood transfusions D. Vitamin B6 supplements
A
A nurse is planning care for a client who has thrombocytopenia. Which of the following interventions should the nurse include in the plan? A. Apply pressure to needle-stick sites for 10 min. B. Assess core temperatures using a rectal thermometer. C. Measure abdominal girth twice weekly. D. Monitor for the presence of WBCs in the urine.
A
A nurse is preparing a teaching plan for a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching? A. Bottled water is an appropriate choice to increase fluid intake. B.The salad bar is a healthy choice when dining out. C. Soft-boiled eggs are an appropriate source of protein. D. Eating at a buffet is a good choice to increase caloric intake.
A
A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include? A. "Place the tablet under your tongue" B. "The medication can take up to 15 minutes to take effect." C. "Avoid taking the medication prior to exercising." D. "Stop taking the medication and notify your provider if you develop a headache."
A
The nurse is taking the history of a client with occupational lung disease (silicosis). The nurse should assess whether the client wears which item during periods of exposure to silica particles? A. Mask B. Gown C. Gloves D. Eye protection
A
Which condition is essential that the nurse should monitor given Eleanor's rising blood glucose levels? A. HHNS B. DKA C. Somogyi D. Polyuria
A
While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first? A. Discontinue the existing IV line. B. Initiate a new IV line in the other extremity. C. Apply a hot pack to the irritated site. D. Determine if the client needs to continue IV therapy.
A
Eleanor is receiving Albuterol and Flovent via inhalers. Which patient statement requires further teaching by the nurse? Select all that apply A. "I will wait at least 5 minutes between each puff of my Flovent" B. "I will rinse my mouth after the Albuterol" C. "I should take the Flovent at the first sign of respiratory troubles" D. "I will call the doctor if I feel any chest discomfort with the medications"
A, B, C
A nurse has received a change of shift report on a group of clients and is preparing her assignment. Which of the following clients should the nurse assess first? A. A client who had a blood glucose reading at 0650 of 70 mg/dL after receiving 50% dextrose for a hypoglycemic episode B. A client who was admitted for chest pain and is reporting a new onset of indigestion C. A client who has pneumonia and was treated for a temperature of 38.9° C (102° F) at 0400 D. A client who has pulled out the peripheral IV catheter and is scheduled to receive a dose of famotidine at 0800
B
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect? A. Diarrhea B. Facial edema C. Tachycardia D. Heat intolerance
B
A nurse is caring for a client who develops a PE. Which of the following interventions should the nurse implement first? A.Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.
B
A nurse is caring for a client who has infective endocarditis. Which of the following manifestations is the priority for the nurse to monitor for? A. Anorexia B. Dyspnea C. Fever D. Malaise
B
A nurse is caring for a client who is 1 day post op following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? A. Check the pedal pulses. B. Verify the most recent calcium level. C. Request prescription for a relaxant. D. Administer an oral potassium supplement.
B
A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching? A. Limit intake of potassium-rich foods. B. Restrict sodium intake. C. Increase carbohydrate intake. D. Decrease protein intake
B
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension
C
A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include? A. Perform vigorous exercise when blood glucose is less than 100 mg/dL. B. Do not exercise if ketones are present in your urine. C. Avoid eating for 2 hr before exercise. D. Examine your feet weekly.
B
A nurse is working with an assistive personnel (AP) while caring for a client who is 1-day post op. Which task should the nurse take responsibility for completing? A. Measuring vital signs B. Removing the abdominal dressing C. Helping the client into the shower D. Ambulating the client in the hallway
B
Approximately 10 minutes after a client returns from surgery with a tracheostomy tube, the nurse assesses increased noisy respiratory rate, restlessness and increased pulse. What action should the nurse take immediately? A. Take the blood pressure B. Suction the tracheostomy tube C. Drain water from the O2 tube D. Change the tracheostomy tube
B
Eleanor's blood sugar is 340mg/dL. Which item most likely accounts for this blood sugar level? A. The slice of cake the night prior B. Developing Pneumonia C. Missing one dose of oral diabetic medication D. Lack of recent activity
B
A nurse is assessing a client who has hyperthyroidism. The nurse should expect which of the following manifestations? A.Sensitivity to cold B. Constipation C. Frequent mood changes D. Weight gain of 4.5 kg (10 lb) in 3 weeks
C
The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which items when performing this care? A. Surgical mask and gloves B. Particulate respirator, gown, and gloves C. Particulate respirator and protective eyewear D. Surgical mask, gown and protective eyewear
B
Which assessment is essential for the nurse to check while Eleanor is receiving Albuterol? A. temperature B. apical pulse C. weight D. intake and output
B
Which nursing diagnosis is priority in the caring for Eleanor? A. Activity Intolerance B. Ineffective Airway Clearance C. Altered nutrition D. Anxiety
B
Which outcome indicates to the nurse that the diagnosis of Ineffective Airway Clearance is resolving and Eleanor is improving? A. Pulse ox 95% B. Lungs clear to auscultation C. Tolerates walking down the hall D. Reports less pain when taking deep breaths
B
Eleanor is transferred to the ICU and her vital signs are slowing improving but her a blood sugar is now 500mg/dL. What interventions can the nurse expect will be ordered for Eleanor? Select all that apply. A. Administer D51/2 NSS at 100 mL/hr B. IV regular Insulin in NSS C. Place on a cardiac monitor D. Administer bicarbonate
B, C
The nurse is caring for a client hospitalized with acute exacerbation of COPD. Which findings would the nurse expect to note on an assessment of this client? Select all that apply A. A low arterial PCO2 level B. A hyperinflated chest noted on the chest x-ray C. Decreased O2 sat with mild exercise D. A widened diaphragm noted on the chest x-ray E. PFT that demonstrate increased vital capacity
B, C
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? Select all that apply. A. Polyuria B. Blurred vision C. Polydipsia D. Tachycardia E. Moist, clammy skin
B, D, E
The nurse is monitoring a client with heart failure who is taking digoxin. Which findings are a characteristic of digoxin toxicity? Select all that apply A. Tremors B. Diarrhea C. Irritability D. Blurred vision E. Nausea and vomiting
B, D, E
A new graduate nurse is caring for a patient with a pulse ox of 89% who is experiencing dyspnea due to heart failure and COPD. Which nursing action requires intervention by the charge nurse? Select all that apply. A. Elevate the bed 30 degrees B. Turn and reposition the client every 1-2 hours C. Teach the client purse-lip breathing D. Weigh the client daily in the morning E. Apply oxygen at 3 liters/min
B, E
A client has experienced a PE. The nurse should assess for which symptom, which is most commonly reported? A. Hot, flushed feeling B. Sudden chills and fever C. Chest pain that occurs suddenly D. Dyspnea when deep breaths are taken
C
A client is being treated with procainadmide for a cardiac dysrhythmia. Following IV administration of the medication, the client complaints of dizziness. What intervention should the nurse take first? A. Obtain a 12-lead electrocardiogram B. Check the client's fingerstick blood glucose level C. Auscultate the client's apical pulse and BP D. Measure the QRS interval duration on the rhythm strip
C
A client is diagnosed with an ST segment elevation MI (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? A. Monitor for kidney failure B. Monitor psychosocial status C. Monitor for signs of bleeding D. Have heparin available
C
A client with AIDS has histoplasmosis. The nurse should assess the client for which expected finding? A. Dyspnea B. Headache C. Weight gain D. Hypothermia
C
A client with Afib is receiving a continuous heparin infusion at 1000units/hour. The nurse determines that the client is receiving the therapeutic effect based on which results? A. Prothrombin time of 12.5 seconds B. aPTT of 28 seconds C. aPTT of 60 seconds D. aPTT longer than 120 seconds
C
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A. Cyanosis B. Hypotension C. Paradoxical chest movement D. Dyspnea, especially on exhalation
C
A nurse in monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
C
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting and diarrhea. Which of the following should the nurse expect? A. Hyperactive reflexes B. Extreme thirst C. Weak, irregular pulse D. Hyperactive bowel sounds
C
A nurse is assessing a client who has hypothyroidism. The nurse could expect which of the following findings? A. Exophthalmos B. Palpitations C. Weight gain D. Diaphoresis
C
A nurse is caring for a client who has just developed a PE. Which of the following medications should the nurse anticipate administering? A. Furosemide B. Dexamethasone C. Heparin D. Atropine
C
A nurse is providing discharge instructions for a client who has CHF. Which of the following client statements indicates to the nurse that teaching was effective? A. "I will read food labels and limit my sodium to 4 grams per day." B. "I should use naproxen to manage discomfort." C. "I plan to slow down if I am tired the day after exercising." D. "I will take my diuretic before sleep and drink fluids during the day."
C
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted i the client, should be reported immediately to the PHCP? A. Dry cough B. Hematuria C. Bronchospasm D. Blood-streaked sputum
C
The nurse should report which assessment finding to the PHCP before initiating thrombolytic therapy in a client with a PE? A. Adventitious breath sounds B. Temperature of 99.4 degrees F C. BP of 198/110 D. RR of 28 breaths per minute
C
What action should the nurse take prior to administering ampicillin? A. Assess the BP B. Obtain a pulse ox reading C. Obtain the sputum culture D. Monitor the intake and output
C
What action will most help a client obtain maximum benefits after postural drainage? A. Administer PRN Oxygen B. Place the client in a sitting position C. Encourage the client to cough deeply D. Encourage the client to rest for 30 minutes
C
Which blood level is essential that the nurse monitor when Eleanor is taking Solumedrol? A. white blood cells B. potassium level C. glucose level D. sodium level
C
A nurse in the ED is assessing a client who is having a suspected MI. Which common manifestations should the nurse expect to find for a client experiencing an acute MI? Select all that apply. A. Orthopnea B. Paroxysmal nocturnal dyspnea (PND) C. Nausea D. Tachycardia E. Diaphoresis
C, D, E
A client who is receving digoxin daily has a serum potassium level of 3mEq/L and reports anorexia. The HCP prescribes a serum digoxin level to be done. The nurse checks the results and should recognize which level that is outside of the therapeutic range? A. 05.ng/mL B. 0.8ng/mL C. 0.9ng/mL D. 2.2ng/mL
D
A client with asthma has pronounced wheezing upon auscultation. Which action should the nurse take? A. Have the client cough and deep breathe B. Prepare to intubate the client C. Notify the health care provider D. Administer a nebulized beta 2 agonist (albuterol) * Pronounced wheezing is better
D
A nurse in an ED is caring for a client who has DKA and a blood glucose level of 925mg/dL. The nurse should anticipate which of the following prescriptions from the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45% sodium chloride C. Oral hypoglycemic medications D. 0.9% sodium chloride IV bolus
D
A nurse in the ED is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. Hypertension C. Tympany upon chest percussion D. Confusion
D
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Jugular venous distention B. Abdominal distension C. Dependent edema D. Hacking cough
D
A nurse is performing a respiratory assessment on a patient being treated with an asthma attack. Which assessment warrants immediate action by the nurse? A. Loud Wheezing B. Increased productive cough C. Wheezing on Expiration D. Diminished breath sounds
D
In addition to the serum fasting glucose level of 340mg/dL, Eleanor's Hgb A1c is 9.1% and her urine is positive for glucose. She is wondering if her pre-diabetes is getting worse. Which response by the nurse is most appropriate? A. "You are at risk for developing type 2 diabetes within 10 years from the initial signs of pre diabetes." B. "Your risk is higher given your increased weight, blood pressure and cholesterol levels." C. "Since your blood sugar is impacted by the Pneumonia, you are still considered pre-diabetic." D. "The laboratory test results suggests type 2 diabetes which can be controlled with diet and exercise."
D
Prior to administering a client's daily dose of digoxin to treat heart failure, the nurse reviews the client's lab data and notes the following results: serum calcium = 9.8mg/dL, serum magnesium = 1.0mEq/L, serum potassium = 4.1mEq/L and serum creatinine = 0.9mg/dL. Which result should alert the nurse that the client is at risk for digoxin toxicity? A. Serum calcium level B. Serum potassium level C. Serum creatinine level D. Serum magnesium level
D
A nurse is assessing a client who is receiving one packed unit of RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's BP is 80/64. Which of the following actions should the nurse take first? A. Stop the infusion of blood. B. Inform the provider. C. Obtain a urine specimen. D. Notify the laboratory.
A
A nurse in a provider's office is examining a client. The nurse should identify that which of the following findings are manifestations of pulmonary TB? A. Night sweats B. Low-grade fever C. Weight gain D. Flushed cheeks E. Blood in the sputum
A, B, E
A nurse is caring for a college athlete who develops epistaxis during a football game. Which actions should the nurse take? Select all that apply. A. Apply pressure to the nares. B. Place ice to the bridge of the client's nose. C. Instruct the client to blow his nose. D. Tilt the client's head backward E. Instruct athlete to sit down
A, B, E
Based upon the ABG results and Eleanor's manifestations, which action should the nurse implement? Select all that apply A. Increase the head of the bed B. Increase the oxygen to keep pulse ox >95% C. Bedrest D. Encourage fluids at least 3L /day
A, C
The community health nurse is conducting an educational session with community members regarding signs and symptoms associated with TB. The nurse informs the participants that TB is considered as a diagnosis if which signs and symptoms are present? Select all that apply A. Dyspnea B. Headache C. Night sweats D. A bloody, productive cough E. A cough with the expectoration of mucoid sputum
A, C, D, E
A client with valvular heart disease who has a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hr and warfarin sodium 7.5 mg at 5:00 p.m. daily. The morning laboratory results are as follows: activated partial thromboplastin time (aPTT), 32 seconds; international normalized ratio (INR), 1.3. The nurse should take which action based on the client's laboratory results? A. Collaborate with the PHCP to discontinue the heparin infusion and administer the warfarin as prescribed B. Collaborate with the PHCP to obtain a prescription to increase the heparin infusion and continue the warfarin as prescribed C. Collaborate with the PHCP to withhold the warfarin since the client is receiving a heparin infusion and the aPTT is within the therapeutic range D. Collaborate with the PHCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin
B
A nurse is assessing a client who has chronic venous insufficiency. Which of the following should the nurse expect? A. Dependent rubor B. Edema C. Hair loss D. Thick, deformed toenails
B
The Unlicensed Assistive Personnel (UAP) assisted Eleanor back to bed after urinating in the bedside commode. The register nurse (RN) enters Eleanor's room to find that the oxygen cannula lying on the bed and the pulse ox reading 82%. Eleanor mentions that the UAP took off the cannula since it did reach the commode. Which action should the RN take first? A. Locate the UAP and discuss the incident B. Restart the oxygen via cannula on the patient and check pulse ox C. Reassign care of Eleanor to an licensed practical nurse (LPN) D. Contact respiratory therapy to recheck the equipment and replace the cannula
B
The nurse administered IV bumetanide to a client being treated for heart failure. Which outcome indicates that the medication has achieved the expected effect? A. Cough becomes productive of frothy pink sputum B. Urine output increases from 10mL/hr to greater than 50mL hourly C. The serum potassium level changes from a 3.8 to 3.1mEq/L D. B-type natriuretic peptide (BNP) factor increases from 200 to 262ng/mL
B
The nurse is monitoring a client with HTN who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? A. Report infrequent insomnia B. Development of expiratory wheezes C. A baseline BP of 150/80 followed by a BP of 138/72 after 2 doses D. A baseline resting HR of 88bpm followed by a resting HR of 72 BPM after 2 doses
B
A nurse in the ED is caring for a client who collapsed after playing football on a hot day. After reviewing the admission lab findings, the nurse recognizes that these findings are consistent with which of the following conditions? Sodium: 152mEq/L Glucose: 102mg/dL Potassium: 3.6mEq/L BUN: 18mg/dL Chloride: 105mEq/L Creatinine: 0.7mg/dL A. Renal failure B. Low-protein diet C. Dehydration D. Syndrome of inappropriate antidiuretic hormone (SIADH)
C
A nurse in the ED is caring for a client who presents with manifestations that indicate a MI. Which of the following prescriptions should the nurse take first? A. Attach the leads for a 12-lead ECG. B. Obtain a blood sample. C. Initiate oxygen therapy. D. Insert the IV catheter.
C
A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? A. Restrict the client's fluid intake to less than 2 L/day. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Instruct the client to use pursed-lip breathing.
D
A nurse is instructing a client who has a new diagnosis of Raynaud's disease about preventing the onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching? A. "I will wear gloves when removing food from the freezer." B. "I will try to anticipate and avoid stressful situations when possible." C. "I will complete the smoking cessation program I started." D. "I will take my medications at the first sign of an attack."
D
A nurse is providing teaching for a client who has a new diagnosis of angina pectoris. The nurse should give the client which of the following information about anginal pain? A. The pain usually lasts longer than 20 min. B. The pain often radiates to the jaw or the back. C. The pain persists with rest and nitrates. D. Exertion and anxiety can trigger the pain.
D
The nurse is assessing a client with multiple traumas who is at risk for developing ARDS. The nurse should assess for which earliest sign? A. Bilateral wheezing B. Inspiratory crackles C. Intercostal retractions D. Increased RR
D
A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following lab results? A. Decreased thyroid-stimulating hormone (TSH) level B. Decreased triiodothyronine (T3) level C. Decreased thyroxine (T4) level D. Decreased thyroid-stimulating immunoglobulins (TSI) percentage
A
A nurse is assessing a client who has diabetes insipidus. Which of the following should the nurse expect? A. Dehydration B. Polyphagia C. Hyperglycemia D. Bradycardia
A
A nurse is assessing a client who has type 1 diabetes mellitus and finds the client laying in bed, sweating, and reporting feeling anxious. Which of the following complications should be nurse expect? A. Hypoglycemia B. Nephropathy C. Hyperglycemia D. Ketoacidosis
A
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to the assistive personnel (AP)? Select all that apply. A. Bathe a client who had an amputation 2 days ago. B. Assist a client to ambulate using a gait belt. C. Review a low-sodium diet for a client who has hypertension. D. Explain oral hygiene to a client receiving chemotherapy. E. Feed a client who had a stroke 3 months ago.
A, B, E
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for TB. Which instructions should the nurse include on the list? Select all that apply A. Activities should be resumed gradually B. Avoid contact with other individuals, except family members, for at least 6 months C. A sputum culture is needed every 2-4 weeks once medication therapy is initiated. D. Respiratory isolation is not necessary, because family members already have been exposed E. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags F. When 1 sputum culture comes back negative, the client is no longer considered infectious and usually can return to former employment
A, C, D, E
The nurse is monitoring a client for adverse effects of medications. Which findings are characteristic of adverse effects of hydrochlorothiazide? Select all that apply A. Sulfa allergy B. Osteoporosis C. Hypokalemia D. Hypouricemia E. Hyperglycemia F. Hypercalemia
A, C, E, F
A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and reports itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which interventions should the nurse anticipate? Select all that apply A. Stop the infusion B. Raise the head of the bed C. Administer protamine sulfate D. Administer diphenhydramine E. Call for the rapid response team
A, D, E
IV heparin therapy is prescribed for a client with Afib. While implementing this prescription, which medication is available on the nursing unit? A. Vitamin K B. Protamine sulfate C. Potassium chloride D. Aminocaproic acid
B
Later in the evening, Debbie calls the nurse into the room because she thinks her mother is getting worse. Upon assessment, the nurse notes, pulse ox is 75%, pulse is 120 weak and thready and BP is 79/56. In addition to initiating rapid response., which action should the nurse take next? A. Ask Debbie to leave the room and Initiate CPR B. Request the UAP gather the resuscitation cart and bring to the room C. Assess the vital signs and be prepared to administer a pericordial thump. D. Administer an albuterol treatment and recheck the pulse ox
B
The ED nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A. A low RR B. Diminished breath sounds C. The presence of a barrel chest D. A sucking sound at the site of injury
B
A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to take first? A. Ask the provider about advancing a client's diet. B. Reinsert an intravenous catheter that was removed due to infiltration. C. Suction the tracheostomy of a client who has copious secretions. D. Check the laboratory findings of a preoperative client scheduled for surgery later in the shift.
C
Based upon Eleanor's condition, an ABG is obtained with the following results.. 7.28/55/80/28/89%. Which acid base imbalance is she experiencing? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis
C
A nurse is caring for a client who had a total arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take? A. Insert a nasogastric tube. B. Administer an antiemetic. C. Encourage use of the incentive spirometer. D. Auscultate bowel sounds.
D
A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the ED confused, flushed, and with an acetone odor on the breath. DKA is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin B. Insulin glargine C. Insulin detemir D. Regular insulin
D
A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."
D
The home heath nurse is visiting a client with CAD with elevated triglyceride levels and a serum cholesterol of 398mg/dL. The client is taking cholestyramine, and the nurse teaches the client about the medication. Which statement by the client indicates the need for further teaching? A. "Constipation and bloating might be a problem." B. "I'll continue to watch my diet and reduce my fats." C. "Walking a mile each day will help the whole process." D. "I'll continue my nicotinic acid from the health food store."
D
The nurse has conducted discharge teaching with a client diagnosed with TB who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? A. "I need to continue medication therapy for 1 month." B. "I can't shop at the mall for the next 6 months." C. "I can return to work if a sputum culture comes back negative." D. "I should not be contagious after 2-3 weeks of medication therapy."
D
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? A. Slow, deep respirations B. Rapid, deep respirations C. Paradoxical respirations D. Pain, especially with inspiration
D
The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? A. Sitting up in bed B. Side-lying in bed C. Sitting in a recliner chair D. Sitting up and leaning on an overbed table
D
The nurse performs an admission assessment on a client with a diagnosis of TB. The nurse should check the result of which diagnostic test that will confirm this diagnosis? A. Chest x-ray B. Broncoscopy C. Sputum culture D. Tuberculin skin test
D
The nurse provides discharge instructions to a client with Afib who is taking Warfarin. Which statement by the client reflects the need for further teaching? A. "I will avoid alcohol consumption." B. "I will take my pills every day at the same time." C. "I have already called my family to pick up a MedicAlert bracelet." D. "I will take coated aspirin for my headaches because it will coat my stomach."
D
The nurse provides discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client indicates to report which early sign of excacerbation? A. Fever B. Fatigue C. Weight loss D. SOB
D
The nurse provides instructions to the client about nicotinic acid prescriped for hyperlipidemia. Which statement by the client indicates an understanding of the instructions? A. "The medication should be taken with meals to decrease flushing." B. "It's not necessary to avoid the use of alcohol when taking nicotinic acid C. "Clay colored stools are a common side effect and should not be of concern." D. "Ibuprofen taken 30 minutes before the nicotinic acid may decrease the flushing."
D
