Med Surg Final - SG

A client is receiving total parenteral nutrition (TPN). What action by the nurse is most important?

Performing appropriate hand hygiene

A nurse cares for a client with infective endocarditis. Which infection control precautions should the nurse use?

Standard Precautions

A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding should alert the nurse to immediately contact the health care provider?

Periorbital edema

A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the second postoperative day the client states, I feel numbness and tingling around my mouth. What action should the nurse take?

Assess for Chvosteks sign.

A cardiac nurse wants to know about the best practices to prevent pneumonia after open-heart surgery. In what order do the steps of the evidence-based practice (EBP) process take place?

1. Asking burning clinical questions 4. Finding the very best evidence to try to answer those questions 6. Critically appraising and synthesizing the relevant evidence 2. Making recommendations for practice improvement 3. Implementing accepted recommendations 5. Evaluating outcomes

While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?

Assess for symptoms of left-sided heart failure.

A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?

Assess medication records for steroid use

A nursing student caring for a client removes the clients oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air?

21%

What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago?

Administering morphine for pain at a 4 on a 0-to-10 scale

The nurse is teaching a transgender client about the medication goserelin (Zoladex). What action by the client indicates good understanding?

Administers a subcutaneous injection

A nurse is triaging clients in the emergency department (ED). Which client should the nurse prioritize to receive care first?

A 45-year-old reporting chest pain and diaphoresis

A client has been given hydroxyzine (Atarax) in the preoperative holding area. What action by the nurse is most important for this client?

Raise the siderails on the bed.

An emergency room nurse is triaging victims of a multi-casualty event. Which client should receive care first?

A 26-year-old male who has pale, cool, clammy skin

A nurse assesses clients on a cardiac unit. Which client should the nurse identify as being at greatest risk for the development of left-sided heart failure?

A 36-year-old woman with aortic stenosis

A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism?

A 41-year-old male receiving dialysis for end-stage kidney disease

A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone?

A 42-year-old male who experienced head trauma 3 years ago

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer?

A 50-year-old who has the BRCA2 gene mutation

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?

A 55-year-old woman who is 50 pounds overweight

A nurse is triaging clients in the emergency department. Which client should the nurse classify as nonurgent?

A 62-year-old with a simple fracture of the left arm

A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer?

A 66-year-old who smokes cigarettes

A nurse is triaging clients in the emergency department. Which client should be considered urgent?

A 75-year-old female with a cough and a temperature of 102 F

A student is caring for clients in the preoperative area. The nurse contacts the surgeon about a client whose heart rate is 120 beats/min. After consulting with the surgeon, the nurse administers a beta blocker to the client. The student asks why this was needed. What response by the nurse is best?

A rapid heart rate requires more effort by the heart.

A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best?

A risk factor for lymphedema is infection, so wear gloves when gardening outside.

A 19-year-old college student seeks information from the schools nurse about how to avoid sexually transmitted diseases (STDs) without abstinence as a choice. Which statement by the nurse is best?

A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV).

The perioperative nurse manager and the postoperative unit manager are concerned about the increasing number of surgical infections in their hospital. What action by the managers is best?

Audit charts to see if the Surgical Care Improvement Project (SCIP) outcomes were met.

A nursing manager is concerned about the number of infections on the hospital unit. What action by the manager would best help prevent these infections?

Auditing staff members hand hygiene practices

A postoperative client vomited. After cleaning and comforting the client, which action by the nurse is most important?

Auscultate lung sounds.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service?

African-American churches

After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional instruction?

After surgery, I wont need to take thyroid medication.

A client is taking prednisone to prevent transplant rejection. What instruction by the nurse is most important?

Avoid large crowds and people who are ill.

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)?

Angiotensin-converting enzyme (ACE) inhibitor

The nurse on the postoperative inpatient unit assesses a client after a total hip replacement. The clients 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 best?

Assess neurovascular status in both legs.

A postoperative nurse is caring for a client whose oxygen saturation dropped from 98% to 95%. What action by the nurse is most appropriate?

Assess other indicators of oxygenation

A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best?

Assess physiologic indicators and vital signs.

A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the clients pulse is 128 beats/min, blood pressure is 98/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?

Assess the 24-hour fluid balance.

A client in the operating room has developed malignant hyperthermia. The clients potassium is 6.5 mEq/L. What action by the nurse takes priority?

Administer 10 units of regular insulin.

A nurse assesses a client after administering isosorbide mononitrate (Imdur). The client reports a headache. Which action should the nurse take?

Administer PRN acetaminophen.

While at a public park, a nurse encounters a person immediately after a bee sting. The persons lips are swollen, and wheezes are audible. Which action should the nurse take first?

Administer an EpiPen from the first aid kit and call 911.

An emergency department nurse cares for a middle-aged mountain climber who is confused and exhibits bizarre behaviors. After administering oxygen, which priority intervention should the nurse implement?

Administer dexamethasone (Decadron).

A nurse is caring for a client receiving enteral feedings through a Dobhoff tube. What action by the nurse is best to prevent hyperosmolarity?

Administer free-water boluses.

A provider prescribes a rewarming bath for a client who presents with partial-thickness frostbite. Which action should the nurse take prior to starting this treatment?

Administer intravenous morphine..

What action by the perioperative nursing staff is most important to prevent surgical wound infection in a client having a total joint replacement?

Administer preoperative antibiotic as ordered.

A client presents to the emergency department after prolonged exposure to the cold. The client is difficult to arouse and speech is incoherent. Which action should the nurse take first?

Administer warmed intravenous fluids to the client.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe?

Administering intravenous fluids through the AV fistula

A nurse teaches a client recovering from a heart transplant who is prescribed cyclosporine (Sandimmune). Which statement should the nurse include in this clients discharge teaching?

Avoid large crowds and people who are sick.

A nurse in the family clinic is teaching a client newly diagnosed with osteoarthritis (OA) about drugs used to treat the disease. For which medication does the nurse plan primary teaching?

Acetaminophen (Tylenol)

A rehabilitation nurse cares for a client who has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement?

Active range of motion

A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately?

Alanine aminotransferase (ALT): 180 U/L

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern?

Albumin level of 2.5 g/dL

A client is receiving norepinephrine (Levophed) for shock. What assessment finding best indicates a therapeutic effect from this drug?

Alert and oriented, answering questions

The nurse is administering sulfamethoxazole-trimethoprim (Bactrim) to a client diagnosed with bacterial prostatitis. Which finding causes the nurse to question this medication for this client?

Allergy to sulfa medications

A circulating nurse has transferred an older client to the operating room. What action by the nurse is most important for this client?

Allow the client to keep hearing aids in until anesthesia begins.

A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse?

Allowing a very tired client to skip oral hygiene and sleep

A 34-year-old client comes to the clinic with concerns about an enlarged left testicle and heaviness in his lower abdomen. Which diagnostic test would the nurse expect to be ordered to confirm testicular cancer?

Alpha-fetoprotein (AFP)

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond?

Ambulating in the hallway twice a day will help.

After teaching a client about advance directives, a nurse assesses the clients understanding. Which statement indicates the client correctly understands the teaching?

An advance directive will specify what I want done when I can no longer make decisions about health care.

A nurse cares for a client newly diagnosed with Graves disease. The clients mother asks, I have diabetes mellitus. Am I responsible for my daughters disease? How should the nurse respond?

An association has been noted between Graves disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves disease.

A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?

Assess the client for anxiety.

A nurse is assessing an older client for the presence of infection. The clients temperature is 97.6 F (36.4 C). What response by the nurse is best?

Assess the client for more specific signs.

A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate?

Assess the client for pain when swallowing.

A client in the orthopedic clinic has a self-reported history of osteoarthritis. The client reports a low-grade fever that started when the weather changed and several joints started acting up, especially both hips and knees. What action by the nurse is best?

Assess the client for the presence of subcutaneous nodules or Bakers cysts.

A client has been admitted to the hospital for a virulent infection and is started on antibiotics. The client has laboratory work pending to determine if the diagnosis is meningitis. After starting the antibiotics, what action by the nurse is best?

Assess the client frequently for worsening of his or her condition.

Emergency medical technicians arrive at the emergency department with an unresponsive client who has an oxygen mask in place. Which action should the nurse take first?

Assess the client is breathing adequately

A nurse cares for a client who is recovering after a nephrostomy tube was placed 6 hours ago. The nurse notes drainage in the tube has decreased from 40 mL/hr to 12 mL over the last hour. Which action should the nurse take?

Assess the clients abdomen and vital signs.

A client is in the bariatric clinic 1 month after having gastric bypass surgery. The client is crying and says I didnt know it would be this hard to live like this. What response by the nurse is best?

Assess the clients coping and support systems.

A nurse is concerned that a preoperative client has a great deal of anxiety about the upcoming procedure. What action by the nurse is best?

Ask client to describe current feelings

A nurse is caring for a terminally ill client who has just died in a hospital setting with family members at the bedside. Which action should the nurse take first?

Ask family members if they would like to spend time alone with the client.

A nurse is working with a client who takes atorvastatin (Lipitor). The clients recent laboratory results include a blood urea nitrogen (BUN) of 33 mg/dL and creatinine of 2.8 mg/dL. What action by the nurse is best?

Ask if the client eats grapefruit.

A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best?

Ask the client about pain goals and if they are being met.

A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as George Smith. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?

Ask the client about preferred forms of address.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?

Ask the client if he or she has ever been evaluated for sleep apnea.

A client is in the family practice clinic. Today the client weighs 186.4 pounds (84.7 kg). Six months ago the client weighed 211.8 pounds (96.2 kg). What action by the nurse is best?

Ask the client if the weight loss was intentional.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?

Ask the client to gargle with mouthwash containing lidocaine.

The emergency department team is performing cardiopulmonary resuscitation on a client when the clients spouse arrives at the emergency department. Which action should the nurse take first?

Ask the spouse if he wishes to be present during the resuscitation.

A client has been hospitalized with tuberculosis (TB). The clients spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best?

Ask the spouse to explain the fear of visiting in further detail.

Which action by the nurse working with a client best demonstrates respect for autonomy?

Asks if the client has questions before signing a consent

A nurse provides health screening for a community health center with a large population of African-American clients. Which priority assessment should the nurse include when working with this population?

Assess blood pressure.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?

Assess clients lung sounds

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met?

Antibiotics started before admission

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate?

Antihistamines do not help poison ivy.

A client has a deep vein thrombosis (DVT). What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Apply a warm moist pack.

A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client?

Apply ice to the perineum

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?

Apply water-soluble ointment to nares and lips.

A client had a femoropopliteal bypass graft with a synthetic graft. What action by the nurse is most important to prevent wound infection?

Appropriate hand hygiene before giving care

A nurse assesses a client who has a history of heart failure. Which question should the nurse ask to assess the extent of the clients heart failure?

Are you able to walk upstairs without fatigue?

A male client is diagnosed with primary syphilis. Which question by the nurse is a priority at this time?

Are you allergic to penicillin?

A client is 4 hours postoperative after a femoropopliteal bypass. The client reports throbbing leg pain on the affected side, rated as 7/10. What action by the nurse takes priority?

Assess distal pulses and skin color.

A client has been diagnosed with rheumatoid arthritis. The client has experienced increased fatigue and worsening physical status and is finding it difficult to maintain the role of elder in his cultural community. The elder is expected to attend social events and make community decisions. Stress seems to exacerbate the condition. What action by the nurse is best?

Assess the clients culture more thoroughly.

A client is having surgery. The circulating nurse notes the clients oxygen saturation is 90% and the heart rate is 110 beats/min. What action by the nurse is best?

Assess the clients end-tidal carbon dioxide level.

A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first?

Assess the clients endotracheal tube with 40% FiO2.

A client with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important?

Assess the clients gait and balance.

A client with a history of heart failure and hypertension is in the clinic for a follow-up visit. The client is on lisinopril (Prinivil) and warfarin (Coumadin). The client reports new-onset cough. What action by the nurse is most appropriate?

Assess the clients lung sounds and oxygenation.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the clients face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the clients oxygen saturation.

A nurse is caring for a client after surgery. The clients respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best?

Assess the clients tissue perfusion further.

A nurse assesses a client who is recovering from a radical nephrectomy for renal cell carcinoma. The nurse notes that the clients blood pressure has decreased from 134/90 to 100/56 mm Hg and urine output is 20 mL for this past hour. Which action should the nurse take?

Assess the rate and quality of the clients pulse.

A client has been diagnosed with a deep vein thrombosis and is to be discharged on warfarin (Coumadin). The client is adamant about refusing the drug because its dangerous. What action by the nurse is best?

Assess the reason behind the clients fear.

A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?

Assessing the IV site every hour

A clinic nurse is working with an older client. What assessment is most important for preventing infections in this client?

Assessing vaccination records for booster shot needs

A client has hypertension and high risk factors for cardiovascular disease. The client is overwhelmed with the recommended lifestyle changes. What action by the nurse is best?

Assist in finding one change the client can control.

A client has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important?

Assist the client in getting out of bed.

A nurse is caring for a postoperative client who reports discomfort, but denies serious pain and does not want medication. What action by the nurse is best to promote comfort?

Assist the client into a position of comfort.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Assist the client to choose a communication method.

A nurse working with clients who experience alopecia knows that which is the best method of helping clients manage the psychosocial impact of this problem?

Assisting the client to pre-plan for this event

A nurse assesses a client who has mitral valve regurgitation. For which cardiac dysrhythmia should the nurse assess?

Atrial fibrillation

The nurse is working with a client who has rheumatoid arthritis (RA). The nurse has identified the priority problem of poor body image for the client. What finding by the nurse indicates goals for this client problem are being met?

Attends meetings of a book club

A nurse is teaching a client with heart failure who has been prescribed enalapril (Vasotec). Which statement should the nurse include in this clients teaching?

Avoid using salt substitutes.

The nurse is caring for four hypertensive clients. Which druglaboratory value combination should the nurse report immediately to the health care provider?

Furosemide (Lasix)/potassium: 2.1 mEq/L

A nurse reads on a hospitalized clients chart that the client is receiving teletherapy. What action by the nurse is best?

Coordinate continuation of the therapy.

An African-American female with blisters on the vagina is being treated with acyclovir (Zovirax) for genital herpes. She is angry at her partner for transmitting the infection. Which action by the nurse is best?

Be sensitive to the clients feelings and refer her to a support group.

A nurse is providing health teaching to a middle-aged male-to-female (MtF) client who has undergone gender reassignment surgery. What information is most important to this client?

Be sure to have an annual prostate examination.

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important?

Beginning venous thromboembolism prophylaxis

A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best?

Being able to sleep doesnt mean pain doesnt exist.

A client is in stage 2 of general anesthesia. What action by the nurse is most important?

Being prepared to suction the airway

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond?

Bile salts accumulate in the skin and cause the itching.

A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, Why will I need to take anticoagulants for the rest of my life? How should the nurse respond?

Blood clots form more easily in artificial replacement valves.

A client is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority?

Blood pressure

A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding is the cause of immediate action by the nurse?

Blood pressure of 76/58 mm Hg

A nursing student learning about antibody-mediated immunity learns that the cell with the most direct role in this process begins development in which tissue or organ?

Bone marrow

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying I have been drinking tons of water. How am I dehydrated? What response by the nurse is best?

Breathing so quickly can be dehydrating.

A nurse is caring for a client with a nonhealing arterial lower leg ulcer. What action by the nurse is best?

Consult with the Wound Ostomy Care Nurse.

A client takes celecoxib (Celebrex) for chronic osteoarthritis in multiple joints. After a knee replacement, the health care provider has prescribed morphine sulfate for postoperative pain relief. The client also requests the celecoxib in addition to the morphine. What action by the nurse is best?

Consult with the health care provider about administering both drugs to the client.

A client is hospitalized and on multiple antibiotics. The client develops frequent diarrhea. What action by the nurse is most important?

Consult with the provider about obtaining stool cultures.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Contact the provider and prepare for intubation

A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first?

Contact the provider and prepare for intubation.

A nurse in the oncology clinic is providing preoperative education to a client just diagnosed with cancer. The client has been scheduled for surgery in 3 days. What action by the nurse is best?

Call the client at home the next day to review teaching.

An older client is hospitalized after an operation. When assessing the client for postoperative infection, the nurse places priority on which assessment?

Change in behavior

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best?

Check the clients digoxin (Lanoxin) level.

A client is receiving bolus feedings through a Dobhoff tube. What action by the nurse is most important?

Check tube placement before each feeding.

A nurse works in an allergy clinic. What task performed by the nurse takes priority?

Checking emergency equipment each morning

A client with pelvic inflammatory disease is seen by the nurse 72 hours after starting oral antibiotics. Which finding leads the nurse to take immediate action?

Chills and a temperature of 101 F

A nurse is reviewing laboratory values for several clients. Which value causes the nurse to conduct nutritional assessments as a priority?

Cholesterol: 142 mg/dL

A nurse is caring for four clients. Which one should the nurse see first?

Client who had a first dose of captopril (Capoten) and needs to use the bathroom

A nurse is caring for four postoperative clients who each had a total abdominal hysterectomy. Which client should the nurse assess first upon initial rounding?

Client who has had two saturated perineal pads in the last 2 hours

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding?

Client with Kussmaul respirations

The nurse gets the hand-off report on four clients. Which client should the nurse assess first?

Client with a blood pressure change of 128/74 to 110/88 mm Hg

The nurse in the rheumatology clinic is assessing clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a fever and cough who is taking tofacitinib (Xeljanz)

A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?

Client with a potassium level of 2.6 mEq/L

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first?

Client with a red, hot, swollen right wrist

The postanesthesia care unit (PACU) charge nurse notes vital signs on four postoperative clients. Which client should the nurse assess first?

Client with a respiratory rate of 6 breaths/min

A nurse and a registered dietitian are assessing clients for partial parenteral nutrition (PPN). For which client would the nurse suggest another route of providing nutrition?

Client with congestive heart failure

The nurse is conducting a history on a male client to determine the severity of symptoms associated with prostate enlargement. Which finding is cause for prompt action by the nurse?

Cloudy urine

The charge nurse on a medical unit is preparing to admit several clients who have possible pandemic flu during a preparedness drill. What action by the nurse is best?

Cohort the clients in the same area of the unit.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next?

Collect the nasal drainage on a piece of filter paper.

An emergency department nurse is caring for a client who has died from a suspected homicide. Which action should the nurse take?

Communicate the clients death to the family in a simple and concrete manner.

Which action by the nurse is most helpful to prevent clients from acquiring infections while hospitalized?

Consistently using appropriate hand hygiene

A nurse assesses a client in the preoperative holding area and finds brittle nails and hair, dry skin turgor, and muscle wasting. What action by the nurse is best?

Consult the surgeon about a postoperative dietitian referral.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction?

Correctly identifying the client prior to a blood transfusion

A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information?

Could you walk further than that a few months ago?

The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is best?

Create an atmosphere of acceptance and discussion.

A nurse is assessing a client for acute rejection of a kidney transplant. What assessment finding requires the most rapid communication with the provider?

Creatinine of 3.9 mg/dL

A nurse suspects a client has serum sickness. What laboratory result would the nurse correlate with this condition?

Creatinine: 3.2 mg/dL

The nurse on an inpatient rheumatology unit receives a hand-off report on a client with an acute exacerbation of systemic lupus erythematosus (SLE). Which reported laboratory value requires the nurse to assess the client further?

Creatinine: 3.9 mg/dL

A 55-year-old post-menopausal woman is assessed by the nurse with a history of dyspareunia, backache, pelvis pressure, urinary tract infections, and a frequent urinary urgency. Which condition does the nurse suspect?

Cystocele

A woman diagnosed with breast cancer had these laboratory tests performed at an office visit: Alkaline phosphatase 125 U/L Total calcium 12 mg/dL Hematocrit 39% Hemoglobin 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed?

Elevated alkaline phosphatase and calcium suggests bone involvement.

A nurse teaches a client with heart failure about energy conservation. Which statement should the nurse include in this clients teaching?

Gather everything you need for a chore before you begin.

A client has a wound infection to the right arm. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?

Elevate the arm above the level of the heart.

The nurse working with oncology clients understands that which age-related change increases the older clients susceptibility to infection during chemotherapy?

Decreased immune function

A nurse assesses this PICOT question: In the adult hospitalized client, does a COX-2 inhibitor decrease the risk of gastrointestinal bleeding compared with other NSAIDs? What is the outcome component in this question?

Decreased risk of gastrointestinal bleeding

While on a camping trip, a nurse cares for an adult client who had a drowning incident in a lake and is experiencing agonal breathing with a palpable pulse. Which action should the nurse take first?

Deliver rescue breaths.

A client has a great deal of pain when coughing and deep breathing after abdominal surgery despite having pain medication. What action by the nurse is best?

Demonstrate how to splint the incision.

A nurse is caring for a client with systemic sclerosis. The clients facial skin is very taut, limiting the clients ability to open the mouth. After consulting with a registered dietitian for appropriate nutrition, what other consultation should the nurse facilitate?

Dentist

A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client?

Depression and withdrawal

. A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best?

Determine if the client can switch to a nasal cannula during the meal.

A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first?

Determine whether the client feels like talking about his or her feelings.

A client has been on dialysis for many years and now is receiving a kidney transplant. The client experiences hyperacute rejection. What treatment does the nurse prepare to facilitate?

Dialysis

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse?

Dialysis works by movement of wastes from lower to higher concentration.

A nurse cares for an adult client who has received genetic testing. The clients mother asks to receive the results of her daughters genetic tests. Which action should the nurse take?

Direct the mother to speak with the client and support the clients decision to share or not share the results.

A male 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?

Discuss what the treatment regimen means to him.

A client had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicates a priority outcome for this client has been met?

Distal pulse on affected extremity 2+/4+

A client tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate?

Do not expose the radiation area to direct sunlight.

An inpatient nurse brings an informed consent form to a client for an operation scheduled for tomorrow. The client asks about possible complications from the operation. What response by the nurse is best?

Do not have the client sign the consent and call the surgeon.

A nurse teaches a client who is prescribed digoxin (Lanoxin) therapy. Which statement should the nurse include in this clients teaching?

Do not take this medication within 1 hour of taking an antacid.

The nurse is examining a womans breast and notes multiple small mobile lumps. Which question would be the most appropriate for the nurse to ask?

Do the small lumps seem to change with your menstrual period?

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge?

Do you have a one- or two-story home?

A nurse plans care for a client who is nearing end of life. Which question should the nurse ask when developing this clients plan of care?

Do you want to be at home at the end of your life?

A client is having robotic surgery. The circulating nurse observes the instruments being inserted, then the surgeon appears to break scrub when going to the console and sitting down. What action by the nurse is best?

Document the time the robotic portion of the procedure begins.

A nurse is assessing a client who presents with a scaly rash over the palms and soles of the feet and the feeling of muscle aches and malaise. The nurse suspects syphilis. Which action by the nurse is appropriate?

Don gloves and further assess the clients lesions.

A trauma client with multiple open wounds is brought to the emergency department in cardiac arrest. Which action should the nurse take prior to providing advanced cardiac life support?

Don personal protective equipment.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider?

Drainage from a fistula

The nurse is caring for a postoperative client following an anterior colporrhaphy. What action can be delegated to the unlicensed assistive personnel (UAP)?

Drawing a shallow hot bath for comfort measures

The nurse is teaching a client with gout dietary strategies to prevent exacerbations or other problems. Which statement by the nurse is most appropriate?

Drink 1 to 2 liters of water each day.

A nurse works at a community center for older adults. What self-management measure can the nurse teach the clients to prevent shock?

Drink fluids on a regular schedule.

A nurse cares for a middle-aged female client with diabetes mellitus who is being treated for the third episode of acute pyelonephritis in the past year. The client asks, What can I do to help prevent these infections? How should the nurse respond?

Drink more water and empty your bladder more frequently during the day.

During dressing changes, the nurse assesses a client who has had breast reconstruction. Which finding would cause the nurse to take immediate action?

Dusky color of the flap

A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the clients stenosis has progressed?

Dyspnea on exertion

A nurse cares for a client with autosomal dominant polycystic kidney disease (ADPKD). The client asks, Will my children develop this disease? How should the nurse respond?

Each of your children has a 50% risk of having ADPKD.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

Educating the client on adherence to the treatment regimen

A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate?

Either Gardasil or Cervarix can provide protection.

An emergency department nurse assesses a client admitted after a lightning strike. Which assessment should the nurse complete first?

Electrocardiogram (ECG)

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 clients care?

Electrolyte and fluid imbalance

A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)?

Empty the urine from the urinary catheter bag.

A 23-year-old female has been diagnosed with genital warts. Which action by the nurse is best?

Encourage the client to have an annual Papanicolaou (Pap) test.

A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, When I wake up I am in pain. Which action should the nurse take?

Encourage the client to use the PCA pump upon awakening.

A client is in the hospital and receiving IV antibiotics. When the nurse answers the clients call light, the client presents an appearance as shown below:

Ensure a patent airway while calling the Rapid Response Team

A morbidly obese client is admitted to a community hospital that does not typically care for bariatric-sized clients. What action by the nurse is most appropriate?

Ensure adequate staff when moving the client.

A client just returned to the surgical unit after a gastric bypass. What action by the nurse is the priority?

Ensure an adequate airway.

A hospitalized client is placed on Contact Precautions. The client needs to have a computed tomography (CT) scan. What action by the nurse is most appropriate?

Ensure that the radiology department is aware of the isolation precautions.

A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this clients plan of care?

Ensure that working suction equipment is in the room.

A client is in the preoperative holding area prior to surgery. The nurse notes that the client has allergies to avocados and strawberries. What action by the nurse is best?

Ensure the information is relayed to the surgical team.

A nurse is caring for a morbidly obese client. What comfort measure is most important for the nurse to delegate to the unlicensed assistive personnel (UAP)?

Ensuring siderails are not causing excess pressure

A client hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer?

Epoetin alfa (Epogen)

A nurse identifies clinical practice problems on a cardiac unit. Which question is a background question?

How are a clients vital signs affected by anxiety?

A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurse is best?

Even being new, you can implement activities designed to improve care.

A client is on the phone when the nurse brings a preoperative antibiotic before scheduled surgery. The circulating nurse has requested the antibiotic be started. The client wants the nurse to wait before starting it. What response by the nurse is most appropriate?

Explain the rationale for giving the medicine now.

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best?

Explore the idea of a referral to a breast cancer support group.

A 25-year-old client has recently been diagnosed with testicular cancer and is scheduled for radiation therapy. Which intervention by the nurse is best?

Explore with the client the possibility of sperm collection.

A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate?

Facilitate polymerase chain reaction testing.

A nurse working in a geriatric clinic sees clients with cold symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms?

Fexofenadine (Allegra)

A nurse attempted to assist a morbidly obese client back to bed and had immediate pain in the lower back. What action by the nurse is most appropriate?

Fill out and file a variance report.

A postoperative client has respiratory depression after receiving midazolam (Versed) for sedation. Which IV-push medication and dose does the nurse prepare to administer?

Flumazenil (Romazicon) 0.2 to 1 mg

An emergency room nurse assesses a client who has been raped. With which health care team member should the nurse collaborate when planning this clients care?

Forensic nurse examiner

A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?

Friction rub at the left lower sternal border

A client waiting for surgery is very anxious. What intervention can the nurse delegate to the unlicensed assistive personnel (UAP)?

Give the client a back rub

A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?

Give the client a bedpan or urinal to use.

A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority?

Give the client a bottle of water immediately.

A client is started on etanercept (Enbrel). What teaching by the nurse is most appropriate?

Giving subcutaneous injections

A rehabilitation nurse cares for a client who is wheelchair bound. Which intervention should the nurse implement to prevent skin breakdown?

Have the client do wheelchair push-ups.

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history?

Have you been taking any aspirin, ibuprofen, or naproxen recently?

The clinic nurse assesses a client with diabetes during a checkup. The client also has osteoarthritis (OA). The nurse notes the clients blood glucose readings have been elevated. What question by the nurse is most appropriate?

Have you been taking glucosamine supplements?

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply?

Have you passed any flatus or moved your bowels?

A 55-year-old male client is admitted to the emergency department with symptoms of a myocardial infarction. Which question by the nurse is the most appropriate before administering nitroglycerin?

Have you taken any drugs like Viagra recently?

A nurse assesses a client who is prescribed levothyroxine (Synthroid) for hypothyroidism. Which assessment finding should alert the nurse that the medication therapy is effective?

Heart rate is 70 beats/min and regular.

A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting the family. What action by the nurse is best?

Help the client create backup plans to minimize disruption.

A client with cancer has anorexia and mucositis, and is losing weight. The clients family members continually bring favorite foods to the client and are distressed when the client wont eat them. What action by the nurse is best?

Help the family show other ways to demonstrate love and caring.

A nurse and an unlicensed assistive personnel (UAP) are caring for a client with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP?

Helping the client transfer from the bed to the chair

A client is in shock and the nurse prepares to administer insulin for a blood glucose reading of 208 mg/dL. The spouse asks why the client needs insulin as the client is not a diabetic. What response by the nurse is best?

High glucose is common in shock and needs to be treated.

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best?

Hold all medications since both cefazolin and vitamins are dialyzable.

A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?

Hold the feeding until the nausea subsides.

A nurse teaches a client who is considering being admitted to hospice. Which statement should the nurse include in this clients teaching?

Hospice care focuses on a holistic approach to health care. It is designed not to hasten death, but rather to relieve symptoms.

A client recently diagnosed with systemic lupus erythematosus (SLE) is in the clinic for a follow-up visit. The nurse evaluates that the client practices good self-care when the client makes which statement?

I always wear long sleeves, pants, and a hat when outdoors.

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism?

I am always tired, even with 12 hours of sleep.

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?

I am glad that these tubes will fall out at home when I finally shower.

With a history of breast cancer in the family, a 48-year-old female client is interested in learning about the modifiable risk factors for breast cancer. After the nurse explains this information, which statement made by the client indicates that more teaching is needed?

I am glad that we can still have wine with every evening meal.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed?

I am thrilled that I can continue to eat fast food.

A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities?

I can use a heating pad on my legs if its set on low.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, Why is this happening to me? How should the nurse respond?

I dont know. I wish I had an answer for you, but I dont.

The nurse is teaching a family member about various types of complementary therapies that might be effective for relieving the dying clients anxiety and restlessness. Which statement made by the family member indicates understanding of the nurses teaching?

I have some of her favorite hymns on a CD that I could bring for music therapy.

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The clients sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

I hope I can get my water turned back on when I get home.

After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

I hope I can go back to wearing size 8 shoes instead of size 12.

After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

I must increase my intake of dietary fiber and fluids.

A nurse assesses a client in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure?

I must stop halfway up the stairs to catch my breath.

The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which statement by the client indicates a lack of understanding?

I need to change my tampon every 8 hours during the day.

A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydia infection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection?

I never told my boyfriend about the infection.

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the client?

I only have to wash the outside of the catheter once a week.

A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?

Judaism, A person who is extremely ill and dying should not be left alone

An intensive care nurse discusses withdrawal of care with a clients family. The family expresses concerns related to discontinuation of therapy. How should the nurse respond?

I realize this is a difficult decision. Discontinuation of therapy will allow the client to die a natural death.

The nurse teaches a client with genital herpes about effective comfort measures. Which statement by the client indicates a need for further teaching by the nurse?

I really should try to limit urination due to the pain.

After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

I shall keep my appointment at the infusion center each week.

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?

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

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

I will decrease the amount of fatty foods in my diet.

A nurse is caring for a dying client. The clients spouse states, I think he is choking to death. How should the nurse respond?

I will have another nurse assist me to turn your husband on his side.

After teaching a client who is being discharged home after mitral valve replacement surgery, the nurse assesses the clients understanding. Which client statement indicates a need for additional teaching?

I will have my teeth cleaned by my dentist in 2 weeks.

After teaching a client with nephrotic syndrome and a normal glomerular filtration, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?

I will increase my intake of protein.

A nurse is discharging a client after a total hip replacement. What statement by the client indicates good potential for self-management?

I will not sit with my legs crossed.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective?

I will take this medication on an empty stomach.

A client with rheumatoid arthritis (RA) has an acutely swollen, red, and painful joint. What nonpharmacologic treatment does the nurse apply?

Ice packs

The nurse working in an organ transplantation program knows that which individual is typically the best donor of an organ?

Identical twin

After teaching a client with hypertension secondary to renal disease, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

If I have increased urination at night, I need to drink less fluid during the day.

A nurse teaches a client with a cortisol deficiency who is prescribed prednisone (Deltasone). Which statement should the nurse include in this clients instructions?

If you work outside in the heat, you may need another drug.

After teaching a client who is recovering from an endoscopic trans-nasal hypophysectomy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching?

Ill keep food on upper shelves so I do not have to bend over.

A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate?

Include support people, such as the male partner, in the decision making.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate?

Increase the dose of immunosuppression.

A client has been prescribed lorcaserin (Belviq). What teaching is most appropriate?

Increase the fiber and water in your diet

A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy?

Increased thirst and urination

A client seen in the emergency department reports fever, fatigue, and dry cough but no other upper respiratory symptoms. A chest x-ray reveals mediastinal widening. What action by the nurse is best?

Inform the client that antibiotics will be needed for 60 days.

The circulating nurse is in the operating room and sees the surgeon don gown and gloves using appropriate sterile procedure. The surgeon then folds the hands together and places them down below the hips. What action by the nurse is most appropriate?

Inform the surgeon that the sterile field has been broken.

A client has been placed on Contact Precautions. The clients family is very afraid to visit for fear of being contaminated by the client. What action by the nurse is best?

Inform them that the infection is the issue, not the client.

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Initiate Standard Precautions.

An emergency department nurse assesses a client with kidney trauma and notes that the clients abdomen is tender and distended and blood is visible at the urinary meatus. Which prescription should the nurse consult the provider about before implementation?

Inserting an indwelling urinary catheter

A client comes to the family medicine clinic and reports joint pain and stiffness. The nurse is asked to assess the client for Heberdens nodules. What assessment technique is correct?

Inspect the clients distal finger joints.

A client having severe allergy symptoms has received several doses of IV antihistamines. What action by the nurse is most important?

Instruct the client not to get up without help.

A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?

Instruct the client not to try to get out of bed unassisted.

After administering newly prescribed captopril (Capoten) to a client with heart failure, the nurse implements interventions to decrease complications. Which priority intervention should the nurse implement for this client?

Instruct the client to ask for assistance when rising from bed.

A client has a platelet count of 9800/mm3. What action by the nurse is most appropriate?

Instruct the client to call for help to get out of bed.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met?

Intact skin behind the ears

A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer?

It has reached the vagina or lymph nodes.

A nurse is giving a preoperative client a dose of ranitidine (Zantac). The client asks why the nurse is giving this drug when the client has no history of ulcers. What response by the nurse is best?

It helps prevent ulcers from the stress of the surgery.

A 68-year-old male client is embarrassed about having bilateral breast enlargement. Which statement by the nurse is the most appropriate?

It is good that you came to be carefully evaluated.

A student nurse asks what essential hypertension is. What response by the registered nurse is best?

It is hypertension with no specific cause.

A client in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate?

It is normal to be fatigued even for years afterward.

A student nurse asks why brushing clients teeth with a toothbrush in the intensive care unit is important to infection control. What response by the registered nurse is best?

It mechanically removes biofilm on teeth.

A client is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best?

It prevents the start of cell division in the cancer cells.

A client is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug?

It selectively blocks estrogen in the breast.

The nurse has taught a client with cancer ways to prevent infection. What statement by the client indicates that more teaching is needed?

Its alright for me to keep my pets and change the litter box.

A nurse is caring for several clients at risk for shock. Which laboratory value requires the nurse to communicate with the health care provider?

Lactate: 6 mmol/L

A nurse is caring for a client who is terminally ill. The clients spouse states, I am concerned because he does not want to eat. How should the nurse respond?

Let him know that food is available if he wants it, but do not insist that he eat.

A nurse is evaluating levels and functions of trauma centers. Which function is appropriately paired with the level of the trauma center?

Level II Located within community hospitals and provides care to most injured clients

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client?

Levothyroxine sodium (Synthroid)

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute?

Light-colored stools

An emergency department nurse is caring for a client who is homeless. Which action should the nurse take to gain the clients trust?

Listen to the clients concerns and needs.

A nurse is working with a community group promoting healthy aging. What recommendation is best to help prevent osteoarthritis (OA)?

Lose weight if needed

A student is caring for a client who suffered massive blood loss after trauma. How does the student correlate the blood loss with the clients mean arterial pressure (MAP)?

Lower blood volume lowers MAP.

A client had a surgical procedure with spinal anesthesia. The nurse raises the head of the clients bed. The clients blood pressure changes from 122/78 mm Hg to 102/50 mm Hg. What action by the nurse is best?

Lower the head of the bed

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort?

Maintain nothing by mouth (NPO) and administer intravenous fluids.

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema?

Maintaining a balanced intake and output

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first?

Make sure the string is taped to the clients cheek.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this clients teaching?

Make sure you clean the humidifier to prevent infection.

A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client?

Read the label before using salt substitutes.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

A nurse is caring for a client after surgery who is restless and apprehensive. The unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?

Measure urine output from the catheter.

A nurse is searching for evidence related to a qualitative PICOT question. Which type of evidence should the nurse search first?

Meta-syntheses

A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority for this client?

Metoclopramide (Reglan)

A nurse caring for a client notes the following assessments: white blood cell count 3800/mm3, blood glucose level 198 mg/dL, and temperature 96.2 F (35.6 C). What action by the nurse takes priority?

Notify the health care provider immediately.

A nurse receives report from the laboratory on a client who was admitted for fever. The laboratory technician states that the client has a shift to the left on the white blood cell count. What action by the nurse is most important?

Notify the provider and request antibiotics.

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like pins and needles and that the neck is very painful since returning from surgery. What action by the nurse is best?

Notify the provider immediately.

The nurse is taking the history of a client who is scheduled for breast augmentation surgery. The client reveals that she took two aspirin this morning for a headache. Which action by nurse is best?

Notify the surgeon about the aspirin ingestion by the client.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse?

Monitor the clients temperature.

A nurse is caring for a client who has lung cancer and is dying. Which prescription should the nurse question?

Morphine 10 mg sublingual every 6 hours PRN for pain level greater than 5

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?

Most people with hypertension do not have symptoms

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?

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

After teaching a client how to prevent altitude-related illnesses, a nurse assesses the clients understanding. Which statement indicates the client needs additional teaching?

My partner and I will plan to sleep at a higher elevation to acclimate more quickly.

A nurse assesses a client admitted to the cardiac unit. Which statement by the client alerts the nurse to the possibility of right-sided heart failure?

My shoes fit really tight lately.

A nurse answers a call light on the postoperative nursing unit. The client states there was a sudden gush of blood from the incision, and the nurse sees a blood spot on the sheet. What action should the nurse take first?

Perform hand hygiene and apply gloves.

Which risk factors would the nurse teach a 23-year-old client about to prevent pelvic inflammatory disease (PID)? (Select all that apply.)

NOT Drinking two alcoholic beverages per day

A primary care clinic sees some clients with sexually transmitted diseases. Which clients would the nurse be required to report to the local authority in every state, according to the Centers for Disease Control and Prevention? (Select all that apply.)

NOT Female with pelvic inflammatory disease

A client being treated for syphilis visits the office with a possible allergic reaction to benzathine penicillin G. Which abnormal findings would the nurse expect to document? (Select all that apply.)

NOT Heart irregularity

A client came to the clinic with erectile dysfunction. What are some possible causes of this condition that the nurse could discuss with the client during history taking? (Select all that apply.)

NOT Hour-long exercise sessions

A nurse assesses a client with anterior pituitary hyperfunction. Which clinical manifestations should the nurse expect? (Select all that apply.)

NOT high pitched voice but all the rest are correct

A nurse works with many transgender clients. What routine monitoring is important for the nurse to facilitate in this population? (Select all that apply.)

NOT renal profile

The nurse understands that which type of immunity is the longest acting?

Natural active

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time?

No adventitious sounds in the lungs

A client is diagnosed with benign prostatic hyperplasia and seems sad and irritable. After assessing the clients behavior, which statement by the nurse would be the most appropriate?

Nocturia could cause interruption of your sleep and cause changes in mood.

Which finding in a female client by the nurse would receive the highest priority of further diagnostics?

Nontender immobile mass in the upper outer quadrant of the breast

A nurse cares for a client after a pituitary gland stimulation test using insulin. The clients post-stimulation laboratory results indicate elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH). How should the nurse interpret these results?

Normal pituitary response to insulin

A client is receiving an infusion of alteplase (Activase) for an intra-arterial clot. The client begins to mumble and is disoriented. What action by the nurse takes priority?

Notify the Rapid Response Team.

After a total knee replacement, a client is on the postoperative nursing unit with a continuous femoral nerve blockade. On assessment, the nurse notes the clients pulses are 2+/4+ bilaterally; the skin is pale pink, warm, and dry; and the client is unable to dorsiflex or plantarflex the affected foot. What action does the nurse perform next?

Notify the surgeon or anesthesia provider immediately.

A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?

Notify your provider at once if you get a fever.

A nurse plans care for a client who is bedridden. Which assessment should the nurse complete to ensure to prevent pressure ulcer formation?

Nutritional intake and serum albumin levels

A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?

Obtain a STAT electrocardiogram (ECG).

A client is diagnosed with a fibrocystic breast condition while in the hospital and is experiencing breast discomfort. What comfort measure would the nurse delegate to the unlicensed assistive personnel (UAP)?

Obtain a cold pack to temporarily relieve the pain.

A client has a recurrent Bartholin cyst. What is the nurses priority action?

Obtain a fluid sample for laboratory analysis.

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best?

Obtain daily weights of the client.

An emergency nurse cares for a client who is experiencing an acute adrenal crisis. Which action should the nurse take first?

Obtain intravenous access.

A client is admitted with possible sepsis. Which action should the nurse perform first?

Obtain specified cultures.

A client in shock is apprehensive and slightly confused. What action by the nurse is best?

Offer to remain with the client for awhile.

A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?

Older adult who lives at home despite some memory loss

After receiving the hand-off report, which client should the oncology nurse see first?

Older client on chemotherapy with mental status changes

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best?

Older people often have vague symptoms, so an x-ray is essential.

A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The clients symptoms have now resolved and the client asks, When can I stop taking these medications? How should the nurse respond?

Once you start corticosteroids, you have to be weaned off them.

A client has the diagnosis of valley fever accompanied by myalgias and arthralgias. What treatment should the nurse educate the client on?

Oral fluconazole (Diflucan)

A nurse is caring for a client with a deep vein thrombosis (DVT). What nursing assessment indicates a priority outcome has been met?

Oxygen saturation of 98%

A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene?

Palpates the abdomen in four quadrants

A nurse wants to provide community service that helps meet the goals of Healthy People 2020 (HP2020) related to cardiovascular disease and stroke. What activity would best meet this goal?

Participate in blood pressure screenings at the mall.

A client has arrived in the postoperative unit. What action by the circulating nurse takes priority?

Participating in hand-off report

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse?

Place a heparin or heparin/saline dwell after hemodialysis.

A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take?

Place the client in semi-Fowlers position.

A client is admitted with fever, myalgia, and a papular rash on the face, palms, and soles of the feet. What action should the nurse take first?

Place the client on Airborne Precautions.

A client has received intravenous anesthesia during an operation. What action by the postanesthesia care nurse is most important?

Place the client on a cardiac monitor and pulse oximeter

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse?

Place the client on a cardiac monitor immediately.

A woman is admitted to the hospital for antibiotic therapy for pelvic inflammatory disease. She is in pain, with a rating of 7 on a scale of 0 to 10. What comfort measure can the nurse delegate to the unlicensed assistive personnel (UAP)?

Position the client in a semi-Fowlers position.

A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?

Potassium: 2.9 mEq/L

A client is receiving plasmapheresis as treatment for Goodpastures syndrome. When planning care, the nurse places highest priority on interventions for which client problem?

Potential for infection related to the site for organism invasion

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority?

Prepare protamine sulfate for administration.

An older client is scheduled to have hip replacement in 2 months and has the following laboratory values: white blood cell count: 8900/mm3, red blood cell count: 3.2/mm3, hemoglobin: 9 g/dL, hematocrit: 32%. What intervention by the nurse is most appropriate?

Prepare to administer epoetin alfa (Epogen).

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection cultured from the urine. What action by the nurse is most appropriate?

Prepare to administer vancomycin (Vancocin).

A 55-year-old African-American client is having a visit with his health care provider. What test should the nurse discuss with the client as an option to screen for prostate cancer, even though screening is not routinely recommended?

Prostate-specific antigen

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)?

Provide oral care every 4 hours.

An emergency department (ED) case manager is consulted for a client who is homeless. Which intervention should the case manager provide?

Provide referrals to subsidized community-based health clinics.

A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?

Providing a verbal hand-off report to the facility

The student nurse learns that the most important function of inflammation and immunity is which purpose?

Providing protection against invading organisms

A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, for what additional data should the nurse assess as the priority?

Psychosocial influences on weight

A client on the postoperative nursing unit has a blood pressure of 156/98 mm Hg, pulse 140 beats/min, and respirations of 24 breaths/min. The client denies pain, has normal hemoglobin, hematocrit, and oxygen saturation, and shows no signs of infection. What should the nurse assess next?

Psychosocial status

A client has a leg wound that is in the second stage of the inflammatory response. For what manifestation does the nurse assess?

Purulent drainage

A client has a continuous passive motion (CPM) device after a total knee replacement. What action does the nurse delegate to the unlicensed assistive personnel (UAP) after the affected leg is placed in the machine while the client is in bed?

Raise the lower siderail on the affected side.

A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?

Red, swollen calf

A nurse is assessing a female client who is taking progestins. What assessment finding requires the nurse to notify the provider immediately?

Red, warm, swollen calf

A client is preparing for gender reassignment surgery and will transition from male to female. The client is worried about the voice not sounding feminine enough. What action by the nurse is best?

Refer the client for vocal therapy with speech-language pathology.

The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub?

Registered nurse who was assigned the same client yesterday

A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety?

Remove the old patch when applying the new one.

A client is admitted to the emergency department with toxic shock syndrome. Which action by the nurse is the most important?

Remove the tampon as the source of infection.

A nurse cares for a client who is recovering from a hypophysectomy. Which action should the nurse take first?

Report clear or light yellow drainage from the nose.

A client in shock has been started on dopamine. What assessment finding requires the nurse to communicate with the provider immediately?

Report of chest heaviness

A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate?

Report the findings as per agency policy.

An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important?

Request a home safety assessment.

A nurse assesses a client who is dying. Which manifestation of a dying client should the nurse assess to determine whether the client is near death?

Respiratory rate

A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The clients serum sodium level is 114 mEq/L. Which action should the nurse take first?

Restrict the clients fluid intake to 600 mL/day.

After teaching a client who has a history of cholelithiasis, the nurse assesses the clients understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching?

Roasted chicken breast, baked potato with chives, and orange juice

An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority?

Role of work in the adults life

A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the clients care plan?

Round-the-clock analgesia with PRN analgesics

A nurse cares for a client who is recovering from a parathyroidectomy. When taking the clients blood pressure, the nurse notes that the clients hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?

Serum calcium: 6.9 mg/dL

The nurse working in the orthopedic clinic knows that a client with which factor has an absolute contraindication for having a total joint replacement?

Severe osteoporosis

A nurse is observing as an unlicensed assistive personnel (UAP) performs hygiene and changes a clients bed linens. What action by the UAP requires intervention by the nurse?

Shaking dirty linens and placing them on the floor

A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide (Cytoxan), and fluorouracil (5-FU) for breast cancer. Which side effect seen in the client should the nurse report to the provider immediately?

Shortness of breath

A nurse delegates the ambulation of an older adult client to an unlicensed nursing assistant (UAP). Which statement should the nurse include when delegating this task?

Sit the client on the edge of the bed with legs dangling before ambulating.

A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?

Sit the client up with a pillow to lean forward on.

The nursing instructor explaining infection tells students that which factor is the best and most important barrier to infection?

Skin and mucous membranes

A 70-year-old client returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium: 128 mEq/L Hemoglobin: 14 g/dL Hematocrit: 42% Red blood cell count: 4.5

Slow down the bladder irrigation if the urine is pink.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action?

Slow down the normal saline infusion.

An older adult has been transferred to the postoperative inpatient unit after surgery. The family is concerned that the client is not waking up quickly and states She needs to get back to her old self! What response by the nurse is best?

Sometimes older people take longer to wake up.

A nursing student is studying nutritional problems and learns that kwashiorkor is distinguished from marasmus with which finding?

Specific lack of protein

A hospital unit is participating in a bioterrorism drill. A client is admitted with inhalation anthrax. Under what type of precautions does the charge nurse admit the client?

Standard Precautions

On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 F (40.1 C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurse take?

Start an intravenous line and infuse 0.9% saline solution.

Several nurses have just helped a morbidly obese client get out of bed. One nurse accesses the clients record because I just have to know how much she weighs! What action by the clients nurse is most appropriate?

State That is a violation of client confidentiality

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the clients pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?

Stay with the client and have someone else call the provider immediately.

Before marriage, a female client has a blood test drawn for syphilis. The test reveals a positive Venereal Disease Research Laboratory (VDRL) serum test. What is the advice that the nurse should give the client?

Submit to a more specific treponemal test to confirm the infection.

The nurse working with clients who have autoimmune diseases understands that what component of cell-mediated immunity is the problem?

Suppressor T cells

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?

Take a sample of the effluent and send to the laboratory.

Which teaching point is most important for the client with bacterial pharyngitis?

Take all antibiotics as directed.

A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery?

Take vital signs and notify the surgeon immediately.

A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first?

Take vital signs, including temperature.

A nurse cares for a client who has pyelonephritis. The client states, I am embarrassed to talk about my symptoms. How should the nurse respond?

Take your time. It is okay to use words that are familiar to you.

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse?

Taking blood pressure

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe?

Taking the blood pressure on the right arm

A client has undergone a vaginal hysterectomy with a bilateral salpingo-oophorectomy. She is concerned about a loss of libido. What intervention by the nurse would be best?

Teach that estrogen cream inserted vaginally may help.

A client is in the family practice clinic reporting a severe cold that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best?

Teach the client to sneeze in the upper sleeve.

A nurse works with clients who have alopecia from chemotherapy. What action by the nurse takes priority?

Teaching measures to prevent scalp injury

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement?

Tell me more about your feelings regarding hemodialysis treatment.

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

The best time to take the enzymes is immediately after I have a meal or a snack.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

The client has joined a book club that meets at the library.

A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

The client has lost 11 pounds in the past 10 days.

A nurse discusses inpatient hospice with a client and the clients family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?

The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left.

A nurse instructor is teaching a student nurse about the factors that have increased the number of people with sexually transmitted diseases (STDs) seen in practice. Which statement by the student indicates a lack of understanding?

The organisms causing STDs are all becoming more virulent.

A client is diagnosed with metastatic prostate cancer. The client asks the nurse the purpose of his treatment with the luteinizing hormonereleasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate?

The treatment reduces testosterone and prevents bone fractures.

A client asks the nurse about drugs for weight loss. What response by the nurse is best?

There are three drugs currently approved for this.

A postoperative client has an abdominal drain. What assessment by the nurse indicates that goals for the priority client problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

The nurse is doing preoperative teaching for a client who is scheduled for removal of cervical polyps in the office. Which statement by the client indicates a correct understanding of the procedure?

There should be little or no discomfort during the procedure.

The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement indicates a lack of understanding by the client?

There should be no problem with a glass of wine with dinner each night.

The nurse is teaching a 45-year-old woman about her fibrocystic breast condition. Which statement by the client indicates a lack of understanding?

This condition will become malignant over time.

A client has fibromyalgia and is prescribed duloxetine hydrochloride (Cymbalta). The client calls the clinic and asks the nurse why an antidepressant drug has been prescribed. What response by the nurse is best?

This drug works in the brain to decrease pain.

A 26-year-old client with multiple sexual partners is being assessed for symptoms of dysuria and vaginal discharge. Because the results from the culture of the cervical cells are not available, the client will be treated for both Chlamydia and gonorrhea. Which explanation by the nurse is best?

This early treatment will prevent obstruction to the fallopian tubes.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?

This is normal after surgery. What types of food do you like to eat?

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, How will this medication help me? How should the nurse respond?

This medication will promote daytime wakefulness.

A 19-year-old female is asking the nurse about the vaccine for human papilloma virus (HPV). Which statement by the nurse is accurate?

This will lower your risk for cervical cancer.

A nurse assesses a client who is admitted with hip problems. The client asks, Why are you asking about my bowels and bladder? How should the nurse respond?

To plan your care based on your normal elimination routine.

Ten hours after surgery, a postoperative client reports that the antiembolism stockings and sequential compression devices itch and are too hot. The client asks the nurse to remove them. What response by the nurse is best?

To prevent blood clots you need them a few more hours.

While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?

Transfer the client to a negative-pressure room.

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate?

Visiting Nurses for directly observed therapy

An older adult has a mild temperature, night sweats, and productive cough. The clients tuberculin test comes back negative. What action by the nurse is best?

Treat the client as if he or she has tuberculosis (TB).

The nurse is reviewing the lipid panel of a male client who has atherosclerosis. Which finding is most concerning?

Triglycerides: 198 mg/dL

A client has rheumatoid arthritis that especially affects the hands. The client wants to finish quilting a baby blanket before the birth of her grandchild. What response by the nurse is best?

Try a paraffin wax dip 20 minutes before you quilt.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful?

Try warm, moist heat packs on your face.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?

Tuck the chin down when swallowing

While assessing a client with Graves disease, the nurse notes that the clients temperature has risen 1 F. Which action should the nurse take first?

Turn the lights down and shut the clients door.

A nurse is preparing to give a client ketorolac (Toradol) intravenously for pain. Which assessment findings would lead the nurse to consult with the provider?

Urine output of 20 mL/2 hr

A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this clients plan of care?

Use a lift sheet to assist the client with position changes.

A nurse plans care for a client with Cushings disease. Which action should the nurse include in this clients plan of care to prevent injury?

Use a lift sheet to change the clients position

A nurse plans care for a client with a growth hormone deficiency. Which action should the nurse include in this clients plan of care?

Use a lift sheet to re-position the client.

An older client has returned to the surgical unit after a total hip replacement. The client is confused and restless. What intervention by the nurse is most important to prevent injury?

Use an abduction pillow.

A nurse is caring for a client after joint replacement surgery. What action by the nurse is most important to prevent wound infection?

Use aseptic technique for dressing changes.

A nurse is weighing and measuring a client with severe kyphosis. What is the best method to obtain this clients height?

Use knee-height calipers.

A preoperative nurse is assessing a client prior to surgery. Which information would be most important for the nurse to relay to the surgical team?

Use of multiple herbs and supplements

A nurse is caring for a client who has a spinal cord injury at level T3. Which intervention should the nurse implement to assist with bladder dysfunction?

Use the Cred maneuver every 3 hours.

A rehabilitation nurse prepares to move a client who has new bilateral leg amputations. Which is the best approach?

Utilize the facilitys mechanical lift to move the client.

A nurse teaches a client who has a flaccid bladder. Which bladder training technique should the nurse teach?

Valsalva maneuver

A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take?

Wash hands when entering the room

A nurse is preparing a client for discharge after surgery. The client needs to change a large dressing and manage a drain at home. What instruction by the nurse is most important?

Wash your hands before touching the drain or dressing.

Which action would the nurse teach to help the client prevent vulvovaginitis?

Wear loose cotton underwear.

A client with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the clients oral chemotherapy medications. What action by the nurse is most appropriate?

Wear personal protective equipment when handling the medications.

A nurse teaches a client who has a history of heart failure. Which statement should the nurse include in this clients discharge teaching?

Weigh yourself daily while wearing the same amount of clothing.

A nurse cares for a client with right-sided heart failure. The client asks, Why do I need to weigh myself every day? How should the nurse respond?

Weight is the best indication that you are gaining or losing fluid.

While evaluating a male client for treatment of gonorrhea, which question is the most important for the nurse to ask?

What are the names of your recent sexual partners?

A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important?

What is your occupation?

After teaching a client who is prescribed voice rest therapy for vocal cord polyps, a nurse assesses the clients understanding. Which statement indicates the client needs further teaching?

When I speak, I will whisper rather than use a normal tone of voice.

A nurse cares for a male client with hypopituitarism who is prescribed testosterone hormone replacement therapy. The client asks, How long will I need to take this medication? How should the nurse respond?

When your beard thickens and your voice deepens, the dose is decreased, but treatment will continue forever.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?

White rice

A nurse cares for a client with end-stage heart failure who is awaiting a transplant. The client appears depressed and states, I know a transplant is my last chance, but I dont want to become a vegetable. How should the nurse respond?

Would you like information about advance directives?

A nurse cares for an older adult client with heart failure. The client states, I dont know what to do. I dont want to be a burden to my daughter, but I cant do it alone. Maybe I should die. How should the nurse respond?

Would you like to talk more about this?

A client has scheduled brachytherapy sessions and states that she feels as though she is not safe around her family. What is the best response by the nurse?

You are only reactive when the radioactive implant is in place.

A nurse teaches a client about performing intermittent self-catheterization. The client states, I am not sure if I will be able to afford these catheters. How should the nurse respond?

You can reuse the catheters at home. Clean technique, rather than sterile technique, is acceptable.

A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, I feel like I am going crazy. How should the nurse respond?

You feel this way because of your hormone levels.

After a vaginoplasty, what instruction by the nurse is most important?

You must dilate the vagina several times a day for months.

A nurse teaches a client who is recovering from a nephrectomy secondary to kidney trauma. Which statement should the nurse include in this clients teaching?

You need to avoid participating in contact sports like football.

A nurse cares for a client who has hypothyroidism as a result of Hashimotos thyroiditis. The client asks, How long will I need to take this thyroid medication? How should the nurse respond?

Youll need thyroid pills for life because your thyroid wont start working again.

After teaching a client who is recovering from a heart transplant to change positions slowly, the client asks, Why is this important? How should the nurse respond?

Your new heart is not connected to the nervous system and is unable to respond to decreases in blood pressure caused by position changes.

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.)

a. 22-year-old client with asthma c. Client with well-controlled diabetes d. Healthy 72-year-old client e. Client who is taking medication for hypertension

A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for hypopituitarism? (Select all that apply.)

a. A 20-year-old female with benign pituitary tumors c. A 41-year-old female with anorexia nervosa d. A 55-year-old male with hypertension e. A 60-year-old female who is experiencing shock

A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency? (Select all that apply.)

a. A 22-year-old female with metastatic cancer b. A 43-year-old male with tuberculosis d. A 65-year-old male with gram-negative sepsis

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.)

a. A 24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

A nurse assesses clients on a cardiac unit. Which clients should the nurse identify as at greatest risk for the development of acute pericarditis? (Select all that apply.)

a. A 36-year-old woman with systemic lupus erythematosus (SLE) b. A 42-year-old man recovering from coronary artery bypass graft surgery d. An 80-year-old man with a bacterial infection of the respiratory tract

The circulating nurse reviews the days schedule and notes clients who are at higher risk of anesthetic overdose and other anesthesia-related complications. Which clients does this include?

a. A 75-year-old client scheduled for an elective procedure b. Client who drinks a 6-pack of beer each day c. Client with a serum creatinine of 3.8 mg/dL e. Young male client with a RYR1 gene mutation

A student nurse is caring for clients on the postoperative unit. The student asks the registered nurse why malnutrition can lead to poor surgical outcomes. What responses by the nurse are best? (Select all that apply.)

a. A malnourished client will have fragile skin. c. Many drugs are bound to protein in the body. d. Protein stores are needed for wound healing. e. Weakness and fatigue are common in malnutrition.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.)

a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity

A client has been diagnosed with fibromyalgia syndrome but does not want to take the prescribed medications. What nonpharmacologic measures can the nurse suggest to help manage this condition? (Select all that apply.)

a. Acupuncture b. Stretching d. Tai chi

A client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.)

a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. d. Administer a 250-mL bolus of normal saline.

The nurse is caring for a client with suspected severe sepsis. What does the nurse prepare to do within 3 hours of the client being identified as being at risk? (Select all that apply.)

a. Administer antibiotics. b. Draw serum lactate levels. e. Obtain blood cultures.

An emergency department nurse plans care for a client who is admitted with heat stroke. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

a. Administer oxygen via mask or nasal cannula. d. Infuse 0.9% sodium chloride via a large-bore intravenous cannula. e. Obtain baseline serum electrolytes and cardiac enzymes.

A client is being admitted with suspected tuberculosis (TB). What actions by the nurse are best? (Select all that apply.)

a. Admit the client to a negative-airflow room. c. Order specialized masks/respirators for caregiving.

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.)

a. Age greater than 65 years b. Increased breast density e. Genetic factors

A student nurse asks the nursing instructor why older adults are more prone to infection than other adults. What reasons does the nursing instructor give? (Select all that apply.)

a. Age-related decrease in immune function b. Decreased cough and gag reflexes c. Diminished acidity of gastric secretions e. Thinning skin that is less protective

A nurse is admitting an older client for surgery to the inpatient surgical unit. The client relates a prior history of acute confusion after a previous operation. What interventions does the nurse include on the clients plan of care to minimize the potential for this occurring? (Select all that apply.)

a. Allow family and friends to visit as the client desires. b. Ask the client about coping techniques frequently used. c. Instruct the nursing assistant to ensure the client is bathed. e. Provide the client with uninterrupted periods of sleep.

A client is clearly uncomfortable and anxious in the preoperative holding room waiting for emergent abdominal surgery. What actions can the nurse perform to increase comfort? (Select all that apply.)

a. Allow the client to assume a position of comfort. b. Allow the clients family to remain at the bedside. d. Provide warm blankets or cool washcloths as desired. e. Pull the curtains around the bed to provide privacy

A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)

a. Allow the client uninterrupted rest time. b. Assess the clients usual bedtime routine. c. Limit environmental noise as much as possible. d. Offer a massage or warm shower at night.

When working with older adults to promote good nutrition, what actions by the nurse are most appropriate? (Select all that apply.)

a. Allow uninterrupted time for eating. b. Assess dentures for appropriate fit. c. Ensure the client has glasses on when eating. e. Serve high-calorie, high-protein snacks.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.)

a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition

A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering? (Select all that apply.)

a. Amoxicillin (Amoxil) b. Ciprofloxacin (Cipro) c. Doxycycline (Vibramycin)

The student nurse studying shock understands that the common manifestations of this condition are directly related to which problems? (Select all that apply.)

a. Anaerobic metabolism c. Hypotension

The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.)

a. Annual mammogram d. Breast self-awareness e. Clinical breast examination

Which are steps in the process of making an antigen-specific antibody? (Select all that apply.)

a. Antibody-antigen binding b. Invasion d. Recognition e. Sensitization

For a person to be immunocompetent, which processes need to be functional and interact appropriately with each other? (Select all that apply.)

a. Antibody-mediated immunity b. Cell-mediated immunity c. Inflammation

An older client returning to the postoperative nursing unit after a hip replacement is disoriented and restless. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Apply an abduction pillow to the clients legs. c. Place pillows under the heels to keep them off the bed. e. Take and record vital signs per unit/facility policy.

The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.)

a. Infection of donor site b. Necrosis of the neopenis d. Urinary tract stenosis

A client has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep vein thrombosis (DVT) prevention? (Select all that apply.)

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

A client on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Apply moisturizers to dry skin. c. Bathe the client using mild soap.

A client is experiencing pain after leg surgery but cannot yet have more pain medication. What comfort interventions can the nurse provide? (Select all that apply.)

a. Apply stimulation to the contralateral leg. b. Assess the clients willingness to try meditation. c. Elevate the clients operative leg and apply ice. d. Reduce the noise level in the clients environment.

A client has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Apply the clients shoes before getting the client out of bed. b. Assist the client with ambulation. d. Use a lift sheet to move the client up in bed.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.)

a. Applying water-soluble lip balm to the clients lips d. Reminding the client to cough and deep breathe often

The student nurse learns that effective antimicrobial therapy requires which factors to be present? (Select all that apply.)

a. Appropriate drug b. Proper route of administration d. Sufficient dose e. Sufficient length of treatment

A nurse prepares to discharge a client who has heart failure. Which questions should the nurse ask to ensure this clients safety prior to discharging home? (Select all that apply.)

a. Are your bedroom and bathroom on the first floor? b. What social support do you have at home? d. What spiritual beliefs may impact your recovery?

A nurse is caring for a client with a nonhealing arterial ulcer. The physician has informed the client about possibly needing to amputate the clients leg. The client is crying and upset. What actions by the nurse are best? (Select all that apply.)

a. Ask the client to describe his or her current emotions. b. Assess the client for support systems and family. c. Offer to stay with the client if he or she desires.

A clients family members are concerned that telling the client about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the client. What actions by the nurse are most appropriate? (Select all that apply.)

a. Ask the family to describe their concerns more fully. b. Consult with a social worker, chaplain, or ethics committee. c. Explain the clients right to know and ask for their assistance.

A client receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.)

a. Assess all mucous membranes every 4 to 8 hours. c. Listen to lung sounds and monitor for cough. d. Monitor the venous access device appearance with vital signs. e. Take and record vital signs every 4 to 8 hours.

A nurse is caring for a client on IV infusion of heparin. What actions does this nurse include in the clients plan of care? (Select all that apply.)

a. Assess the client for bleeding. b. Monitor the daily activated partial thromboplastin time (aPTT) results. d. Use an IV pump for the infusion.

The nurse caring for hospitalized clients includes which actions on their care plans to reduce the possibility of the clients developing shock? (Select all that apply.)

a. Assessing and identifying clients at risk c. Performing proper hand hygiene d. Removing invasive lines as soon as possible e. Using aseptic technique during procedures

A client is having shoulder surgery with regional anesthesia. What actions by the nurse are most important to enhance client safety related to this anesthesia? (Select all that apply.)

a. Assessing distal circulation to the operative arm after positioning c. Padding the clients shoulder and arm on the operating table

The nurse is administering finasteride (Proscar) and doxazosin (Cardura) to a 67-year-old client with benign prostatic hyperplasia. What precautions are related to the side effects of these medications? (Select all that apply.)

a. Assessing for blood pressure changes when lying, sitting, and arising from the bed b. Immediately reporting any change in the alanine aminotransferase laboratory test e. Asking the client to report any weakness, light-headedness, or dizziness

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.)

a. Assisting with chest tube insertion b. Facilitating pleural fluid sampling c. Performing frequent respiratory assessment d. Providing antipyretics as needed

The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.)

a. Atherosclerosis d. History of hypertension e. History of smoking

A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) (Rheumatrex) for disease control. What information does the nurse include? (Select all that apply.)

a. Avoid acetaminophen in over-the-counter medications. b. It may take several weeks to become effective on pain. d. Stay away from large crowds and people who are ill. e. You may find that folic acid, a B vitamin, reduces side effects.

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.)

a. Body mass index of 46 d. Pregnant with twins f. Glycosylated hemoglobin level of 15%

A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)

a. Bringing the client warm blankets d. Reorienting the client as needed e. Sitting with the client for reassurance

A home health care nurse is visiting a client discharged home after a hip replacement. The client is still on partial weight bearing and using a walker. What safety precautions can the nurse recommend to the client? (Select all that apply.)

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 admits an older adult client to the hospital. Which criterion should the nurse use to determine if the client can make his own medical decisions? (Select all that apply.)

a. Can communicate his treatment preferences c. Is oriented enough to understand information provided d. Can evaluate and deliberate information

A postmenopausal client is experiencing low back and pelvic pain, fatigue, and bloody vaginal discharge. What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected? (Select all that apply.)

a. Cancer antigen-125 (CA-125) c. Hemoglobin and hematocrit (H&H)

A postoperative client is being discharged with a prescription for oxycodone hydrochloride with acetaminophen (Percocet). What instructions does the nurse give the client? (Select all that apply.)

a. Check all over-the-counter medications for acetaminophen. b. Do not take more pills each day than you are prescribed. c. Eat a diet that is high in fiber and drink lots of water. e. You shouldnt drive while you are taking this medication.

A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.)

a. Chemo gloves b. Facemask c. Isolation gown

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.)

a. Cognition b. Dexterity d. Range of motion e. Vision

A nurse teaches a client who has severe allergies to prevent bug bites. Which statements should the nurse include in this clients teaching? (Select all that apply.)

a. Consult an exterminator to control bugs in and around your home. b. Do not swat at insects or wasps. e. Use screens in your windows and doors to prevent flying insects from entering.

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.)

a. Contact the provider immediately. b. Lower the head of the bed.

What actions by the circulating nurse are important to promote client comfort? (Select all that apply.)

a. Correct positioning b. Introducing ones self c. Providing warmth d. Remaining present

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.)

a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

The nurse understands that malnutrition can occur in hospitalized clients for several reasons. Which are possible reasons for this to occur? (Select all that apply.)

a. Cultural food preferences c. Increased need for nutrition d. Need for NPO status e. Staff shortages

A student nurse asks why older adults are at higher risk for complications after surgery. What reasons does the registered nurse give? (Select all that apply.)

a. Decreased cardiac output b. Decreased oxygenation c. Frequent nocturia d. Mobility alterations

A client is being discharged on warfarin (Coumadin) therapy. What discharge instructions is the nurse required to provide? (Select all that apply.)

a. Dietary restrictions c. Follow-up laboratory monitoring d. Possible drug-drug interactions e. Reason to take medication

A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this clients education? (Select all that apply.)

a. Do not share utensils, plates, and cups with anyone else. d. Wash your clothing separate from others in the household. e. Take a laxative 2 days after therapy to excrete the radiation.

A student nurse observing in the operating room notes that the functions of the Certified Registered Nurse First Assistant (CRNFA) include which activities? (Select all that apply.)

a. Dressing the surgical wound d. Suctioning the surgical site e. Suturing the surgical wound

The nurse is working with clients who have connective tissue diseases. Which disorders are correctly paired with their manifestations? (Select all that apply.)

a. Dry, scaly skin rash, Systemic lupus erythematosus (SLE) b. Esophageal dysmotility, Systemic sclerosis e. Vasculitis causing organ damage, Rheumatoid arthritis

The nurse assesses clients for the cardinal signs of inflammation. Which signs/symptoms does this include? (Select all that apply.)

a. Edema d. Redness e. Warmth

The nursing student observing in the perioperative area notes the unique functions of the circulating nurse, which include which roles? (Select all that apply.)

a. Ensuring the clients safety e. Monitoring traffic in the room

A nurse wants to reduce the risk potential for transmission of chlamydia and gonorrhea with a female client diagnosed with both diseases. Which items should be included in the clients teaching plan? (Select all that apply.)

a. Expedited partner therapy b. Abstinence until therapy is completed d. Proper use of condoms e. Re-screening for infection

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.)

a. Family history of prostate cancer d. Advanced age e. Eating too much red meat f. Race

A student nurse is learning about the health care needs of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) clients. Which terms are correctly defined? (Select all that apply.)

a. Gender dysphoria - Distress caused by incongruence between natal sex and gender identity b. Gender queer - A label used when gender identity does not conform to male or female c. Natal sex - The sex one is born with or is assigned to at birth

A client has rheumatoid arthritis (RA) and the visiting nurse is conducting a home assessment. What options can the nurse suggest for the client to maintain independence in activities of daily living (ADLs)? (Select all that apply.)

a. Grab bars to reach high items b. Long-handled bath scrub brush d. Toothbrush with built-up handle

A nurse evaluates laboratory results for a client with heart failure. Which results should the nurse expect? (Select all that apply.)

a. Hematocrit: 32.8% b. Serum sodium: 130 mEq/L e. Proteinuria f. Microalbuminuria

An emergency department nurse moves to a new city where heat-related illnesses are common. Which clients does the nurse anticipate being at higher risk for heat-related illnesses? (Select all that apply.)

a. Homeless individuals b. Illicit drug users e. Older adults

The nurse is teaching a client who is taking an oral antibiotic for treatment of a sexually transmitted disease (STD). Which statements by the client indicate a correct understanding of the treatment? (Select all that apply.)

a. I need to drink at least 8 glasses of fluid each day with my antibiotic. b. I should read the instructions to see if I can take the medication with food. d. I need to wait 7 days after the last dose of the antibiotic to engage in intercourse.

The nurse is giving discharge instructions to a client who had a total abdominal hysterectomy. Which statements by the client indicate a need for further teaching? (Select all that apply.)

a. I should not have any problems driving to see my mother, who lives 3 hours away. b. Now that I have time off from work, I can return to my exercise routine next week.

The student nurse is learning about the functions of different antibodies. Which principles does the student learn? (Select all that apply.)

a. IgA is found in high concentrations in secretions from mucous membranes. c. IgE is associated with antibody-mediated hypersensitivity reactions. d. IgG comprises the majority of the circulating antibody population. e. IgM is the first antibody formed by a newly sensitized B cell.

After teaching a client with congestive heart failure (CHF), the nurse assesses the clients understanding. Which client statements indicate a correct understanding of the teaching related to nutritional intake? (Select all that apply.)

a. Ill read the nutritional labels on food items for salt content. d. I will eat oatmeal for breakfast instead of ham and eggs. e. Substituting fresh vegetables for canned ones will lower my salt intake.

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this clients teaching? (Select all that apply.)

a. Increased carbohydrates c. Increased calorie intake e. Increased proteins

A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the clients level of consciousness has decreased. Which actions should the nurse take? (Select all that apply.)

a. Infuse intravenous fluids. b. Cover the client with warm blankets. d. Maintain a patent airway.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.)

a. Lower sodium c. Lower potassium e. Higher calories

A woman has been using acupuncture to treat the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.)

a. Lymphedema b. Bleeding tendencies c. Low white blood cell count

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.)

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

An emergency department (ED) nurse is preparing to transfer a client to the trauma intensive care unit. Which information should the nurse include in the nurse-to-nurse hand-off report?

a. Mechanism of injury b. Diagnostic test results e. Isolation precautions

A nurse is caring for several clients prior to surgery. Which medications taken by the clients require the nurse to consult with the physician about their administration? (Select all that apply.)

a. Metformin (Glucophage) c. Phenytoin (Dilantin) d. Pilocarpine hydrochloride (Isopto Carpine) e. Warfarin (Coumadin)

A nurse assesses a client with Cushings disease. Which assessment findings should the nurse correlate with this disorder? (Select all that apply.)

a. Moon face d. Petechiae e. Muscle atrophy

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.)

a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth.

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the clients electronic medical record? (Select all that apply.)

a. Peau dorange c. Nipple retraction d. Mobile mass at two oclock

A hospice nurse plans care for a client who is experiencing pain. Which complementary therapies should the nurse incorporate in this clients pain management plan? (Select all that apply.)

a. Play music that the client enjoys. c. Rub lavender lotion on the clients feet.

A nurse assesses a client with nephrotic syndrome. For which clinical manifestations should the nurse assess? (Select all that apply.)

a. Proteinuria b. Hypoalbuminemia d. Lipiduria

The complex care provided during an emergency requires interdisciplinary collaboration. Which interdisciplinary team members are paired with the correct responsibilities? (Select all that apply.)

a. Psychiatric crisis nurse Interacts with clients and families when sudden illness, serious injury, or death of a loved one may cause a crisis e. Paramedic Provides prehospital advanced life support, including cardiac monitoring, advanced airway management, and medication administration

A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select all that apply.)

a. Pulmonary crackles b. Confusion, restlessness e. Cough that worsens at night

A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.)

a. Reduce the pain by low-level heat. c. Relieve anxiety by relaxation techniques and education e. Suggest resources such as the Endometriosis Association.

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.)

a. Registered dietitian c. Clinical pharmacist e. Health care provider

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client with congestive heart failure. Which instructions should the nurse provide to the UAP when delegating care for this client? (Select all that apply.)

a. Reposition the client every 2 hours. c. Accurately record intake and output. d. Use the same scale to weigh the client each morning.

A nurse is providing health education at a community center. Which instructions should the nurse include in teaching about prevention of lightning injuries during a storm? (Select all that apply.)

a. Seek shelter inside a building or vehicle. c. Do not take a bath or shower. d. Turn off the television. f. Put down golf clubs or gardening tools.

A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select all that apply.)

a. Shortness of breath b. Abdominal bloating c. New-onset bradycardia

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.)

a. Smoking b. Multiple sexual partners c. Poor diet e. Younger than 18 at first intercourse

A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values should the nurse associate with this disorder? (Select all that apply.)

a. Sodium: 150 mEq/L c. Potassium: 2.5 mEq/L e. pH: 7.28

An interdisciplinary team is caring for a client on a rehabilitation unit. Which team members are paired with the correct roles and responsibilities? (Select all that apply.)

a. Speech-language pathologist Evaluates and retrains clients with swallowing problems b. Physical therapist Assists clients with ambulation and walker training

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.)

a. Stridor d. Ecchymosis behind the ear

A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the nurse include in this clients discharge teaching? (Select all that apply.)

a. Take your blood pressure every morning. b. Weigh yourself at the same time each day. d. Contact your provider if you have visual disturbances.

A hospice nurse is caring for a dying client and her family members. Which interventions should the nurse implement? (Select all that apply.)

a. Teach family members about physical signs of impending death. b. Encourage the management of adverse symptoms. d. Encourage reminiscence by both client and family members.

A nurse prepares to discharge a client who has heart failure. Based on the Heart Failure Core Measure Set, which actions should the nurse complete prior to discharging this client? (Select all that apply.)

a. Teach the client about dietary restrictions. b. Ensure the client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. d. Confirm that an echocardiogram has been completed.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.)

a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage.

The nursing student is studying hypersensitivity reactions. Which reactions are correctly matched with their hypersensitivity types? (Select all that apply.)

a. Type I Examples include hay fever and anaphylaxis c. Type III Immune complex deposits in blood vessel walls d. Type IV Examples are poison ivy and transplant rejection

A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.)

a. Urine output is increased. d. Specific gravity is decreased. f. Urine osmolality is decreased.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.)

a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg

A nurse is teaching a wilderness survival class. Which statements should the nurse include about the prevention of hypothermia and frostbite? (Select all that apply.)

a. Wear synthetic clothing instead of cotton to keep your skin dry. d. Wear sunglasses to protect skin and eyes from harmful rays. e. Know your physical limits. Come in out of the cold when limits are reached.

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.)

a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery.

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 accurate 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. d. You have flexible scheduling for the exchanges.

The nursing student studying rheumatoid arthritis (RA) learns which facts about the disease? (Select all that apply.)

b. Antibodies lead to inflammation. c. It consists of an autoimmune process.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.)

b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

What nonpharmacologic comfort measures should the nurse include in the plan of care for a client with severe varicose veins? (Select all that apply.)

b. Applying elastic compression stockings c. Elevating the legs when sitting or lying d. Reminding the client to do leg exercises

A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the clients blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.)

b. Assess distal pulses every 10 minutes. d. Notify the Rapid Response Team. e. Take vital signs every 10 minutes

A nurse collaborates with an occupational therapist when providing care for a rehabilitation client. With which activities should the occupational therapist assist the client? (Select all that apply.)

b. Attaining independence with dressing e. Performing activities of daily living (ADLs)

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.)

b. Attend local Alcoholics Anonymous (AA) meetings weekly. d. Use cooking spray when you cook rather than margarine or butter. f. We can talk to your doctor about a prescription for nicotine patches.

The nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?

b. Baked chicken breast, broccoli, tomatoes

A nurse assesses a client who is recovering from a nephrostomy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.)

b. Bloody drainage at site d. Foul-smelling drainage e. Urine draining from site

A client with an infection has a fever. What actions by the nurse help increase the clients comfort? (Select all that apply.)

b. Change the clients gown and linens when damp. c. Offer cool fluids to the client frequently.

A nurse working in the preoperative holding area performs which functions to ensure client safety? (Select all that apply.)

b. Check that consent is on the chart. c. Ensure the client has an armband on. d. Have the client help mark the surgical site. e. Allow the client to use the toilet before giving sedation.

A client in the family practice clinic reports a 2-week history of an allergy to something. The nurse obtains the following assessment and laboratory data: Physical Assessment Data Laboratory Results Reports sore throat, runny nose, headache Posterior pharynx is reddened Nasal discharge is seen in the back of the throat Nasal discharge is creamy yellow in color Temperature 100.2 F (37.9 C) Red, watery eyes White blood cell count: 13,400/mm3 Eosinophil count: 11.5% Neutrophil count: 82% About what medications and interventions does the nurse plan to teach this client? (Select all that apply.)

b. Chlorpheniramine (Chlor-Trimaton) c. Future allergy scratch testing d. Proper use of decongestant nose sprays e. Taking the full dose of antibiotics

A nurse is caring for clients as a member of the rehabilitation team. Which activities should the nurse complete as part of the nurses role? (Select all that apply.)

b. Coordinate rehabilitation team activities to ensure implementation of the plan of care. e. Support the clients choices by acting as an advocate for the client and family.

A clients small-bore feeding tube has become occluded after the nurse administered medications. What actions by the nurse are best? (Select all that apply.)

b. Determine if any of the medications come in liquid form. c. Flush the tube before and after administering medications. e. Try to flush the tube with 30 mL of water and gentle pressure.

A nurse on the postoperative nursing unit provides care to reduce the incidence of surgical wound infection. What actions are best to achieve this goal? (Select all that apply.)

b. Disposing of dressings properly d. Performing proper hand hygiene e. Removing and replacing wet dressings

A student nurse is learning about the types of different cells involved in the inflammatory response. Which principles does the student learn? (Select all that apply.)

b. Eosinophils increase during allergic reactions and parasitic invasion. c. Macrophages can participate in many episodes of phagocytosis. d. Monocytes turn into macrophages after they enter body tissues. e. Neutrophils can only take part in one episode of phagocytosis.

The nurse working in the rheumatology clinic assesses clients with rheumatoid arthritis (RA) for late manifestations. Which signs/symptoms are considered late manifestations of RA? (Select all that apply.)

b. Feltys syndrome c. Joint deformity e. Weight loss

A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For which clinical manifestations should the nurse assess? (Select all that apply.)

b. Flank pain c. Increased abdominal girth e. Hematuria

A postanesthesia care unit (PACU) nurse is assessing a postoperative client with a nasogastric (NG) tube. What laboratory values would warrant intervention by the nurse? (Select all that apply.)

b. Hemoglobin: 7.8 mg/dL c. pH: 7.68 d. Potassium: 2.9 mEq/L

The student nurse caring for clients understands that which factors must be present to transmit infection? (Select all that apply.)

b. Host c. Mode of transmission d. Portal of entry e. Reservoir

A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.)

b. Hypertension c. Leukemia d. Cocaine use

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.)

b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

A nurse is designing a community education program to meet the Healthy People 2020 objectives for nutrition and weight status. What information about these goals does the nurse use to plan this event? (Select all that apply.)

b. Increase the amount of vegetables to 1.1 cups/1000 calories. d. Reduce the number of adults who are obese by 10%. e. Reduce the consumption of saturated fat by nearly 10%.

The student nurse caring for clients who have cancer understands that the general consequences of cancer include which client problems? (Select all that apply.)

b. Increased risk of infection from white blood cell deficits c. Nutritional deficits such as early satiety and cachexia d. Potential for reduced gas exchange e. Various motor and sensory deficits

A new perioperative nurse is receiving orientation to the surgical area and learns about the Surgical Care Improvement Project (SCIP) goals. What major areas do these measures focus on preventing? (Select all that apply.)

b. Infection c. Serious cardiac events e. Thromboembolism

A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.)

b. International normalized ratio (INR): 6.3 c. Prothrombin time: 35 seconds

A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium 7.2 mg/dL Sodium 144 mEq/L Magnesium 1.2 mEq/L Potassium 5.7 mEq/L Based on these results, which medications should the nurse anticipate administering? (Select all that apply.)

b. Intravenous calcium chloride d. 50% magnesium sulfate

A nurse teaches a client with Cushings disease. Which dietary requirements should the nurse include in this clients teaching? (Select all that apply.)

b. Low carbohydrate d. Low calories e. Low sodium

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.)

b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice.

A nurse recently hired to the preoperative area learns that certain clients are at higher risk for venous thromboembolism (VTE). Which clients are considered at high risk? (Select all that apply.)

b. Morbidly obese client c. Client who underwent a prolonged surgical procedure d. Client with severe heart failure e. Wheelchair-bound client

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.)

b. My weight should be maintained at a body mass index of 30. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history?

b. Myocardial infarction

An emergency room nurse is caring for a trauma client. Which interventions should the nurse perform during the primary survey? (Select all that apply.)

b. Needle decompression c. Initiating IV fluids e. Endotracheal intubation f. Removing wet clothing

A nurse assesses a client who is diagnosed with infective endocarditis. Which assessment findings should the nurse expect? (Select all that apply.)

b. Night sweats c. Cardiac murmur e. Oslers nodes

A nurse orienting to the postoperative area learns which principles about the postoperative period? (Select all that apply.)

b. Phase I care may last for several days in some clients. d. Phase II ends when the client is stable and awake. e. Vital signs may be taken only once a day in phase III.

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.)

b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client.

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.)

b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

A rehabilitation nurse is caring for an older adult client who states, I tire easily. How should the nurse respond? (Select all that apply.)

b. Use a cart to push your belongings instead of carrying them. d. Plan to gather all of the supplies needed for a chore prior to starting the activity. e. Try to break large activities into smaller parts to allow rest periods between activities.

. A nurse is caring for clients in a busy emergency department. Which actions should the nurse take to ensure client and staff safety? (Select all that apply.)

b. Use two identifiers before each intervention and before mediation administration. c. Attempt de-escalation strategies for clients who demonstrate aggressive behaviors. d. Search the belongings of clients with altered mental status to gain essential medical information.

A client is scheduled to start external beam radiation therapy (EBRT) for her endometrial cancer. Which teaching by the nurse is accurate? (Select all that apply.)

b. Your skin needs to be inspected daily for any breakdown. c. It is not wise to stay out in the sun for long periods of time. d. The perineal area may become damaged with the radiation.

The nurse is teaching a client who is undergoing brachytherapy about what to immediately report to her health care provider. Which signs and symptoms would be included in this teaching? (Select all that apply.)

c. Abdominal pain d. Visible blood in the urine e. Heavy vaginal bleeding

A nurse has delegated feeding a client to an unlicensed assistive personnel (UAP). What actions does the nurse include in the directions to the UAP? (Select all that apply.)

c. Ensure warm and cold items stay at appropriate temperatures. d. Remove bedpans, soiled linens, and other unpleasant items. e. Sit with the client, making the atmosphere more relaxed.

Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.)

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.

The nurse is caring for a client with systemic sclerosis (SSc). What comfort measures can the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

c. Keep the room at a comfortably warm temperature. d. Place a foot cradle at the end of the bed to lift sheets. e. Remind the client to elevate the head of the bed after eating.

A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take? (Select all that apply.)

c. Monitor the apical pulse. e. Initiate telemetry monitoring.

A nurse reviews laboratory results for a client with glomerulonephritis. The clients glomerular filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should the nurse interpret this finding? (Select all that apply.)

c. Reduced GFR d. Potential for fluid overload

A nurse teaches a clients family members about signs and symptoms of approaching death. Which manifestations should the nurse include in this teaching? (Select all that apply.)

d. Decreased appetite e. Congestion and gurgling

A client has a possible connective tissue disease and the nurse is reviewing the clients laboratory values. Which laboratory values and their related connective tissue diseases (CTDs) are correctly matched? (Select all that apply.)

d. Positive human leukocyte antigen B27 (HLA-B27) Reiters syndrome or ankylosing spondylitis e. Positive rheumatoid factor, Possible kidney disease

A nurse is preparing a client for a femoropopliteal bypass operation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

d. Raising the siderails on the bed e. Recording baseline vital signs

A nurse prepares to discharge an older adult client home from the emergency department (ED). Which actions should the nurse take to prevent future ED visits? (Select all that apply.)

d. Screen for depression and suicide. e. Complete a functional assessment.

Which statements are true regarding Standard Precautions? (Select all that apply.)

d. Use personal protective equipment as needed for client care. e. Wear gloves when touching client excretions or secretions.

A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue?

Have something to drink every 1 to 2 hours.

A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors?

Bring a list of all medications and what they are for.

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?

Building strength and flexibility

A nurse is looking for the best interventions for postoperative pain control. When are the facilitys policies and procedures an appropriate source of evidence?

When policies are based on high-quality clinical practice guidelines

A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety?

Have another nurse double-check the pump settings.

A nurse cares for a client who has a specific mutation in the a1AT (alpha1-antitrypsin) gene. Which action should the nurse take?

Advise the client to limit exposure to secondhand smoke and other respiratory irritants.

A nurse wishes to provide client-centered care in all interactions. Which action by the nurse best demonstrates this concept?

Assesses for cultural influences affecting health care

A health care facility is implementing a new evidence-based nursing protocol. Which action is necessary to ensure successful implementation?

Attain support from nurses who are implementing the protocol.

A client has received an opioid analgesic for pain. The nurse assesses that the client has a Pasero Scale score of 3 and a respiratory rate of 7 shallow breaths/min. The clients oxygen saturation is 87%. What action should the nurse perform first?

Attempt to arouse the client.

A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse is best?

Call the Rapid Response Team.

A client is being discharged from the hospital after surgery on hydrocodone and acetaminophen (Lorcet). What discharge instruction is most important for this client?

Check any over-the-counter medications for acetaminophen.

A nurse is caring for four clients receiving pain medication. After the hand-off report, which client should the nurse see first?

Client with a Pasero Scale score of 4

A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient-controlled analgesia (PCA) pumps. Which client should the nurse see first?

Client with a respiratory rate of 8 breaths/min

A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first?

Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale

A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?

Client's self report

A nurse manager educates staff nurses in the use of clinical practice guidelines. Which statement should the nurse include in this teaching?

Clinical practice guidelines are official recommendations based on evidence.

A health care provider prescribes genetic testing for a client who has a family history of colorectal cancer. Which action should the nurse take before scheduling the client for the procedure?

Confirm that informed consent was obtained and placed on the clients chart.

A nurse cares for a client of Asian descent who is prescribed warfarin (Coumadin). What action should the nurse perform first?

Confirm the prescription starts warfarin at a lower-than-normal dose.

A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.)

Confusion Incontinence Sleep disorders

A nurse performs passive range-of-motion exercises on a semiconscious client and meets resistance while attempting to extend the right elbow more than 45 degrees. Which action should the nurse take next?

Continue to move the joint only to the point at which resistance is met.

n older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important?

Determine if there are new medications.

A nurse who wants to incorporate evidence-based practices into client care on a medical unit is meeting resistance. Which barrier does the nurse identify as preventing nurses from engaging in evidence-based practices?

Difficulty accessing research materials

The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome?

Discuss acceptable pain control after your operation with the surgeon.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best?

Discuss concerns with the health care team.

A client is put on twice-daily acetaminophen (Tylenol) for osteoarthritis. What finding in the clients health history would lead the nurse to consult with the provider over the choice of medication?

Drinking 3 to 5 beers a day

An older adult has diabetic neuropathy and often reports unbearable foot pain. About which medication would the nurse plan to educate the client?

Duloxetine (Cymbalta)

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety?

Encourage the client and family to be active partners.

A new nurse is working with a preceptor on an inpatient medical-surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse?

Ensuring client safety

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal?

Exercise program to improve physical function

A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment?

FACES Pain Scale-Revised

A nurse consults a genetic counselor for a client whose mother has Huntington disease and is considering genetic testing. The client states, I know I want this test. Why do I need to see a counselor? How should the nurse respond?

Genetic testing can be a stressful experience. Counseling can provide support and education throughout the process.

The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is on the light constantly asking for more pain medication. When assessing this clients pain, what statement or question by the nurse is most appropriate?

Help me understand how pain is affecting you right now.

A hospitalized client has a history of depression for which sertraline (Zoloft) is prescribed. The client also has a morphine allergy and a history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse choose?

Hydromorphone (Dilaudid)

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine?

Hydromorphone hydrochloride (Dilaudid)

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping?

I have had the same best friend for decades.

A research nurse meets with the nurse manager to discuss plans for the development of evidence-based practice (EBP) guidelines using the Reavy and Tavernier model. Which statement should the nurse include in the discussion?

I will assist staff nurses with literature reviews and the synthesis of evidence.

A client is typed and crossmatched for a unit of blood. Which statement by the nurse indicates a need for further genetic education?

If the clients blood type is AB, then the client is homozygous for that trait.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps?

Install contrasting color strips at the edge of each step.

A nurse cares for a client who has a genetic mutation that increases the risk for colon cancer. The client states that he does not want any family to know about this result. How should the nurse respond?

It is not required that you tell anyone about this result. However, your siblings and children may also be at risk for colon cancer and this information might help them.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client?

Keep the light on in the bathroom at night.

A nurse teaches a client with a past history of angina who has had a total knee replacement. Which statement should the nurse include in this clients teaching prior to beginning rehabilitation activities?

Let me know if you start to experience shortness of breath, chest pain, or fatigue.

An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population?

Listening to music on a headset

A nurse obtains health histories when admitting clients to a medical-surgical unit. With which client should the nurse discuss predisposition genetic testing?

Middle-aged woman whose mother died at age 48 of breast cancer

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group?

Old Old

A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best?

Pain is so complex it takes different approaches to control it

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?

Perform an oral assessment.

A nurse cares for a client with decreased mobility. Which intervention should the nurse implement to decrease this clients risk of fracture?

Perform weight-bearing activities.

A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene?

Presses the button when the client cannot reach it

A nurse cares for a pregnant client who has a family history of sickle cell disease. The client is unsure if she wants to participate in genetic testing. What action should the nurse take?

Provide information about the risks and benefits of genetic testing.

A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the clients blood pressure is much higher than previous readings, and the clients mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

Providing more appropriate supervision of the UAP

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those are for old people. What action by the nurse would be most helpful?

Put color-coded stickers on the bottle caps.

A medical-surgical nurse asks the nurse researcher, What is the difference between qualitative and quantitative questions? How should the nurse researcher respond?

Quantitative questions identify relationships between measurable concepts.

A nurse wants to explore why clients who receive patient-controlled analgesia (PCA) after abdominal surgery ambulate sooner than clients who receive nurse-administered pain medications. Which action should the nurse take first?

Search the medical library for the best evidence.

A nurse is assessing pain in an older adult. What action by the nurse is best?

Sit down, ask one question at a time, and allow the client to answer.

A nurse is calling the on-call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication?

This client has allergies to morphine and codeine.

A client who tests positive for a mutation in the BRCA1 gene allele asks a nurse to be present when she discloses this information to her adult daughter. How should the nurse respond?

This conversation may be difficult for both of you; I will be there to provide support.

A nurse assesses a client recovering from coronary artery bypass graft surgery. Which assessment should the nurse complete to evaluate the clients activity tolerance?

Vital signs before, during, and after activity

A nurse cares for a client who recently completed genetic testing and received a negative result. The client states, I feel guilty because so many of my family members are carriers of this disease and I am not. How should the nurse respond?

We usually encourage clients to participate in counseling after receiving test results. Can I arrange this for you?

The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment?

What pain rating would be acceptable to you?

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.)

a. 1% milk b. Carrots d. Oranges e. Vitamin D supplements

A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.)

a. Addiction is a chronic physiologic disease process. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease.

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.)

a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. d. Have the client complete a 3-day diet recall diary.

A nurse manager wants to improve hand-off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.)

a. Attend hand-off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand-off.

A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.)

a. Avoid using other medications that cause sedation. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.

A nurse teaches clients about patterns of inheritance for genetic disorders among adults. Which disorders have an autosomal dominant pattern of inheritance? (Select all that apply.)

a. Breast cancer d. Huntington disease e. Marfan syndrome

A nurse plans evidence-based care for a client on a medical-surgical unit. Which elements should the nurse assess when developing this plan of care? (Select all that apply.)

a. Client values b. Nurses experiences e. Best available evidence

A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Institute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.)

a. Collaborating with an interdisciplinary team b. Implementing evidence-based cared. d. Routinely using informatics in practice e. Using quality improvement in client care

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.)

a. Constipation b. Dehydration e. Weakness

A client reports a great deal of pain following a fairly minor operation. The surgeon leaves a prescription for the nurse to administer a placebo instead of pain medication. What actions by the nurse are most appropriate? (Select all that apply.)

a. Consult with the prescriber and voice objections. d. Notify the nurse manager of the physicians request.

A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.)

a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress

A student nurse learns that there are physical consequences to unrelieved pain. Which factors are included in this problem? (Select all that apply.)

a. Decreased immune response b. Development of chronic pain d. Possible immobility e. Slower healing

A nurse cares for a client who recently completed genetic testing that revealed that she has a BRCA1 gene mutation. Which actions should the nurse take next? (Select all that apply.)

a. Discuss potential risks for other members of her family. b. Assist the client to make a plan for prevention and risk reduction.

A nursing student is studying pain sources. Which statements accurately describe different types of pain? (Select all that apply.)

a. Neuropathic pain sometimes accompanies amputation. c. Deep somatic pain is pain arising from bone and connective tissues. d. Somatic pain originates from skin and subcutaneous tissues. e. Visceral pain is often diffuse and poorly localized.

A nurse is developing a clinical question in a PICOT format. What components are included in the question? (Select all that apply.)

b. Comparison c. Outcome e. Time

A client with a broken arm has had ice placed on it for 20 minutes. A short time after the ice was removed, the client reports that the effect has worn off and requests pain medication, which cannot be given yet. What actions by the nurse are most appropriate? (Select all that apply.)

b. Educate the client on cold therapy. d. Repeat the ice application. e. Teach the client relaxation techniques.

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.)

b. Exhaustion c. Slowed physical activity d. Weakness

A faculty member explains to students the process by which pain is perceived by the client. Which processes does the faculty member include in the discussion? (Select all that apply.)

b. Modulation c. Sensory perception d. Transduction e. Transmission

The nurse utilizing evidence-based practice (EBP) considers which factors when planning care? (Select all that apply.)

b. Nurses expertise c. Client preferences d. Research findings e. Values of the client

A nurse completes pedigree charts for clients at a community health center. Which diagnosis should the nurse refer for carrier genetic testing? (Select all that apply.)

c. Hemophilia e. Sickle cell disease f. Cystic fibrosis

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

c. Keep the clients skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

A postoperative client has an epidural infusion of morphine and bupivacaine (Marcaine). What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

c. Perform a bladder scan if the client is unable to void after 4 hours. d. Remind the client to use the incentive spirometer every hour. e. Take and record the clients vital signs per agency protocol.

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.)

c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.