Med Surg Hesi

30. During spring break, a young adult presents at the urgent care clinic and reports a stiff neck, fever for the past 6 hours, and a headache. Which intervention is most important for the nurse to implement? a. initiate isolation precautions b. prepare for a lumbar puncture c. admin an antipyretic d. draw blood cultures

A. Initiate isolation precautions

35. An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing intervention is most important for the nurse to provide this client? A. Maintain prescribed eye drop regimen B. Avoid frequent eye pressure measurements C. Wear prescription glasses D. Eat a diet high in carotene

A. Maintain prescribed eye drop regimen

39. An older client with long term type 2 diabetes (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 DM is experiencing long term complications? Select all that apply. A. Signs of respiratory tract infection B. Sensation in feet and legs C. Skin condition of the lower extremities D. Serum creatinine and blood urea nitrogen (BUN)E. Visual acuity

B. Sensation in feet and legs C. Skin condition of the lower extremities E. Visual acuity

15. A client with acute renal injury (AKI) weighs 50 kg and a potassium level of 6.7 mEq/L is admitted to the hospital. Which prescribed medication should the nurse administer first? A. Calcium acetate one tablet by mouth B. Sodium polystyrene sulfonate 15 grams by mouth C. Epoetin alfa, recombinant 2,500 units subcutaneously D. Sevelamer one tablet by mouth

B. Sodium polystyrene sulfonate 15 grams by mouth

25. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? A. Monitor hemoglobin and hematocrit B. Encourage turning and deep breathing C. Administer IV antibiotics as prescribed D. Auscultate for presence of bowel sounds

C. Administer IV antibiotics as prescribed

11. Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? A. Elevate extremities on pillows B. Evaluate edema for pitting C. Assess pulses with a vascular doppler D. Wrap the feet with warmed blankets

C. Assess pulses with a vascular doppler

34. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? A. Have small frequent meals and sit up for at least two hours after meals B. Eat a bland diet and avoid spicy foods C. Eat a high-fiber diet and increase fluid intake D. Eat a soft diet with increased intake of milk and milk products

C. Eat a high-fiber diet and increase fluid intake

28. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? A. Presence and activity of bowel sounds B. Color and consistency of feces C. Eating patterns and dietary intake D. Level and amount of physical activity

C. Eating patterns and dietary intake

13. The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? A. Teach the client use of basic sign language B. Speak slowly to the client C. Encourage client's use of picture charts D. Ask the client simple questions

C. Encourage client's use of picture charts

8. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and an inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Call the clinic if undesirable side effects of medications occur B. Avoid crowded enclosed areas to reduce pathogen exposure C. Increase the daily intake of oral fluids to liquify secretions D. Teach anxiety reduction methods for feelings of suffocation

C. Increase the daily intake of oral fluids to liquify secretions

10. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the best initial nursing action? A. Provide additional oral fluid intake B. Measure the client's intake and output C. Increase the flow of the bladder irrigation D. Administer a PRN dose of an antispasmodic agent

C. Increase the flow of the bladder irrigation

14. After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are: heart rate 122 beats/minute, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? A. Irregular pulse rate B. Bile colored emesis C. ST elevation in three leads D. Complaint of radiating jaw pain

C. ST elevation in three leads

43. An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg PO daily. Which laboratory values should the nurse monitor? A. Platelet count and hematocrit B. Serum electrolytes C. Serum iron and ferritin D. Neutrophils and eosinophils

C. Serum iron and ferritin

4. To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) A. Initiate passive range of motion exercises B. Establish a regular bladder routine C. Teach the client breathing exercises D. Perform chest physiotherapy E. Encourage use of incentive spirometer

C. Teach the client breathing exercises D. Perform chest physiotherapy E. Encourage use of incentive spirometer

45. The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client? A. The nurse will encourage the client to walk 30 minutes every day B. The client's family will state signs and symptoms about the disease C. The client's daily blood pressure will be less than 140/80 mmHg this month D. The client's blood pressure readings will be less than 160/90 mmHg

C. The client's daily blood pressure will be less than 140/80 mmHg this month

50. A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based? A. A thoracentesis is a brief procedure that has minimal discomfort B. Orthopnea is frequently caused by a client's uncontrolled anxiety C. The procedure is performed with the client in an upright position D. Extra pillows can be used if needed to elevate the client's head

C. The procedure is performed with the client in an upright position

2. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? A. Frequent use of chewable and liquid antacids for indigestion B. Severe abdominal cramps and diarrhea after eating spicy foods C. Upper mid-abdominal pain described as gnawing and burning D. Marked loss of weight and appetite over the last 3 or 4 months

C. Upper mid-abdominal pain described as gnawing and burning

42. The nurse is caring for a client in the post-anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Medicate for pain and monitor vital signs according to protocol B. Administer intravenous fluid bolus as prescribed by the healthcare provider C. Apply oxygen at 10 L via a nonrebreather mask and monitor pulse oximeter D. Encourage the client to splint the incision with a pillow to cough and deep breathe

A. Medicate for pain and monitor vital signs according to protocol

12. A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take? A. Monitoring catheter drainage B. Decreasing the flow rate C. Irrigating the catheter manually D. Discontinuing infusing solution

A. Monitoring catheter drainage

49. The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? A. Notify the healthcare provider of the client's medication history B. Observe the heparin injection sites for signs of bruising C. Have the client sign the surgical and transfusion permits D. Ensure that the potential for bleeding is explained to the client

A. Notify the healthcare provider of the client's medication history

22. The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis? Select all that apply: A. Pneumatic compression devices B. Incentive spirometry C. Assisted ambulation D. Patient-controlled analgesia E. Calf-pump exercises F. Prescribed anticoagulant therapy

A. Pneumatic compression devices E. Calf-pump exercises F. Prescribed anticoagulant therapy

40. The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care of the portal site should the nurse provide? A. Protect the skin of the radiation portal site from sunlight exposure B. Apply moisture lotions daily to the radiation portal site C. Avoid washing the skin inside the radiation portal site D. Remove the ink marks of the portal after each radiation treatment

A. Protect the skin of the radiation portal site from sunlight exposure

33. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?A. Rapid weight gain B. Abdominal striae C. Moon facies D. Gastric irritation

A. Rapid weight gain

1. The nurse is caring for a client with diabetes insipidus (DI). Which data warrants the most immediate intervention by the nurse? A. Serum sodium of 185 mEq/L (185 mmol/L) B. Dry skin with inelastic turgor C. Apical rate of 110 beats per minute D. Polyuria and excessive thirst

A. Serum sodium of 185 mEq/L (185 mmol/L)

7. The healthcare provider prescribes diagnostic tests for a client whose chest x-ray indicates pneumonia. Which diagnostic tests should the nurse review for implementation in the most therapeutic treatment of pneumonia? A. Sputum culture and sensitivity B. Blood cultures C. Arterial blood gases (ABGs) D. Computerized tomography of the chest

A. Sputum culture and sensitivity

27. A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the client's blood pressure drops from 150/90 to 80/30 mmHg. Which action should the nurse take first? A. Stop the dialysis treatment B. Administer 5% albumin IV C. Monitor blood pressure q45 minutes D. Lower the head of the chair and elevate feet

A. Stop the dialysis treatment

6. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the clients distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply: A. Verify pedal pulses using a Doppler pulse device B. Evaluate the application of the splint to the left leg C. Offer ice chips and oral clear liquids D. Monitor left leg for pain, pallor, parenthesis, paralysis, pressure E. Administer oral antispasmodics and narcotic analgesics

A. Verify pedal pulses using a Doppler pulse device B. Evaluate the application of the splint to the left leg D. Monitor left leg for pain, pallor, parenthesis, paralysis, pressure

44. While caring for a client with a full thickness burn covering 40% of the body the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. White blood cell count (WBC) B. Platelet count C. Blood pH level D. Hematocrit

A. White blood cell count (WBC)

The healthcare provider prescribes metoclopramide 7.5 mg/mL IM every 3 hours PRN vomiting for a client who is receiving chemotherapy. The nurse prepares an injection using a 2 mL prefilled syringe cartridge labeled, "metoclopramide 5 mg/mL." How many mL should the nurse administer?

ANS: 1.5 ml

The healthcare provider prescribed DaW 1800 mL IV to infuse in 24 hours. The IV administration set delivers 60 microdrops/mL. The nurse should program the infusion pump to deliver how many mL per hour? (Enter numeric value only.)

ANS: 75 1800 ml/24 hr = 75

During a preoperative assessment phone call, a client states taking several "pills" every day. Which response should the office nurse provide? a. "Obtain a copy of your medication records from your healthcare provider" b. "Bring all your pill containers to your preoperative appointment" c. "Discuss with your healthcare provider which medications to take before surgery" d. "Bring copies of all your prescriptions to your preoperative appointment"

ANS: A

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? a. Increase the flow of the bladder irrigation b. Measure the client's intake and output c. Administer a PRN dose of an antispasmodic agent d. Provide additional oral fluid intake

ANS: A. Increase the flow of the bladder irrigation

A client with COPD arrives at the emergency department reporting of shortness of breath upon exertion and weakness. The client tells the nurse of normally receiving dialysis three times a week but missed the last treatment. The client's serum potassium is 4.8 mEq/L and creatinine is 1.4, accompanied with a blood pressure of 200/120 mmHg. The client has salt crystals present on the skin. Which finding is most important for the nurse to bring to the attention of the healthcare provider? a. Potassium level b. Blood pressure c. Uremic frost d. Creatinine results.

ANS: B Blood pressure

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "imbalanced nutrition, less than body requirements". Which cause is contributing to the problem? a. Altered taste sensation b. Nausea c. Fatigue d. Pain when eating

ANS: D Pain when eating

58. An older client has been diagnosed with chronic venous insufficiency. To prevent venous return, which action should the nurse encourage the client to a. Wear cotton socks and enclosed toe shoes whenever outside b. Drink 8 to 10 ounces of water a day c. Sit at the side of the bed for 15 minutes before standing d. Lie down in bed 2 times a day

Ans. A

60. An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and implant. During the immediate postoperative period, which intervention should the nurse implement a. Provide an eye shield to be worn while sleeping b. Obtain vital signs every 2 hours during hospitalization c. Encourage deep breathing and coughing exercises d. Teach a family member to administer eye drops

Ans. A

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. Irregular apical pulse b. Purple marks on skin of the abdomen c. Pitting ankle edema d. Quarter size blood spot on dressing

Ans. A

The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PERF is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? a. Albuterol 2.5 to 5 mg per nebulization b. Epinephrine auto-injector 0.15mg c. Salmeterol 2 puffs per measured- dose inhaled d. Oxygen at 6 liters. Minute by nasal cannula

Ans. A

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Platelet count b. Red blood cell count c. Hemoglobin levels d. White blood cell count

Ans. A

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? a. Has everyone at home already had varicella? b. Do you have any dry patches on your feet and hands? c. Do your family members share combs and brushes? d. Have the antifungal creams been effective?

Ans. A

The nurse is planning care for an older adult male who experienced a cerebrovascular accident several weeks ago. Because of expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement? a. Encourage client's use of picture charts b. Ask the client simple questions c. Teach the client use of basic sign language d. Speak slowly to the client

Ans. A

Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. Fortified milk and cereals b. Citrus fruits and juices c. Red meats and eggs d. Green leafy vegetables

Ans. A

An older client with long-term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse ---- determine if the patient with type 2 DM is experiencing long-term complications? (SATA) a. Visual acuity b. Skin condition of lower extremities c. Sensation in feet and legs d. Serum creatinine and blood urea nitrogen (BUN) e. Signs of respiratory tract infection

Ans. A, B, C, D

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (SATA) a. Encourage use of incentive spirometer b. Establish a regular bladder routine c. Perform chest physiotherapy d. Initiate passive range of motion exercises e. Teach the client breathing exercises

Ans. A, C, E

57. A client who has been taking finasteride, an enzyme (5 alpha reductase) inhibitor used to shrink the prostate gland, is admitted because of continuing benign prostate prostatic hypertrophy (BPH) symptoms when planning care. Which nursing problem should the nurse address first? a. Chronic pain b. Urinary retention c. Risk for infection d. Disturbed sleep pattern

Ans. B

62. A client takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory values should the nurse review? a. Serum electrolytes b. Complete blood count c. Liver enzymes d. Platelet count

Ans. B

63. The nurse is caring for a client post-anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/ minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Administer IV fluid bolus as prescribed by the healthcare provider b. Medicate for pain and monitor vital signs according to protocol c. Encourage the client to splint the incision with a pillow to cough and deep breathe d. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter

Ans. B

A client is receiving combination chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment findings warrants intervention by the nurse? a. Polycythemia b. Leukopenia c. Ascites d. Nystagmus

Ans. B

A client with a history of chronic obstructive disease (COPD) is admitted with pneumonia. Vital signs include oxygen saturation 89% temperature 100.5 F (38 C) heart rate 120 beats/minute, respirations 28 breaths/minute and blood pressure 170/90 mmHg. Which finding warrants immediate intervention by the nurse? a. Shortness of breath on exertion b. Coarse breath sounds c. Bilateral diffuse wheezing d. Yellow expectorated sputum

Ans. B

The healthcare provider prescribes radiation therapy (RT) for a client with terminal metastatic cancer who is experiencing increased pain due to spinal compression. The client asks the nurse why radiation therapy is prescribed. Which mechanism supports the use of RT in the client's metastatic cancer? a. Implementation of all possible treatments offers clients the best chance of survival b. Pain relief can be provided by shrinking tumors that press against spinal nerves c. Evidence indicates that RT can prolong life in clients with metastatic cancers d. RT is an alternative to surgery that affects tumor growth and eradicates cancer

Ans. B

The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? a. Ecchymotic area b. Enlarged vein c. Pulselessness d. redness

Ans. B

64. A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fraction (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? (SATA) a. Offer ice chips and oral clear liquids b. Verify pedal pulses using a doppler pulse device c. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure d. Evaluate the application of the splint to the left leg e. Administer oral antispasmodics and narcotics analgesics

Ans. B, C, D

The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which finding should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) a. Hypothyroidism b. Increased triglyceride levels c. Hyperglycemia d. Blood pressure of 150/96 e. Elevated high density lipoproteins f. Abdominal obesity

Ans. B, C, D, F

56. Following long-term administration of warfarin sodium to a client with a medical diagnosis of deep vein thrombosis, the nurse should expect which treatment? a. The hemoglobin will be greater than 10 g/dl b. The hematocrit will be less than 35% c. The PT will be 1.5 times the normal d. The PTT will be 1.5 times the normal

Ans. C

A client is hospitalized after experiencing a myocardial infarction (MI) to reduce cardiac workload, which intervention should the nurse include in the client's plan of care? a. Teach to sleep in a side-lying position b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Assist with ambulation in the hallway

Ans. C

A client with ureterolithiasis is preparing for discharge after a ureteroscopy removal. Which instruction should the nurse include in this client's postoperative discharge teaching? a. Use incentive spirometer b. Report when hematuria becomes pink triggered c. Monitor urinary stream for decreased output d. Restrict physical activities

Ans. C

A male client is admitted to the emergency department with vomiting of dark brown, foul- smelling emesis. He reports he had a surgical repair of a recurrent inguinal hernia one week ago and complains of intense abdominal pain. After assessing that his bowel sounds are hyperactive, which prescription should the nurse implement first? a. Place an indwelling urinary catheter and attach a bedside drainage unit b. Give a prescribed analgesic for temp above 101 F c. Insert a NGT and attach to low suction d. Send the patient to x-ray for a flat plate of the abdomen

Ans. C

A young adult male client has a leg cast following an open reduction for fractured tibia. He is in skeletal traction with 10 lbs of weight. Approximately two hours after returning to the unit, he reports severe pain in the affected extremity, and the nurse observes that the limb is blue and blanched. Which action should the nurse promote first? a. Release the traction and notify the healthcare provider b. Administer PRN pain medication routinely as prescribed c. Notify the healthcare provider of the assessment findings d. Record the observations and check the limb every 15 minutes.

Ans. C

An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ----- sulfate 300 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Platelet count and hematocrit c. Serum iron and ferritin d. Neutrophils and eosinophils

Ans. C

The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon? a. The fecal matter is brown and has a solid consistency b. There are no bowel sounds in the left lower quadrant c. The stoma mucosa is purple in color d. The stoma has streaks of bright red blood

Ans. C

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Encourage the client to lie down and rest after meals b. Remind the client to avoid high-fiber foods c. Teach the client to elevate the head of the bed on blocks d. Instruct the client to use antacids only as a last resort

Ans. C

66. A nurse is caring for a client with Diabetes Insipidus (DI). which data warrants the most immediate intervention by the nurse? a. Dry skin with inelastic turgor b. Apical rate of 110 beats per minute c. Polyuria and excessive thirst d. Serum sodium of 185 mEq/L

Ans. D

A client is admitted to the hospital for shortness of breath and chest pain after an episode of syncope. Which laboratory finding is most important for the nurse to report to the healthcare provider? a. Hematocrit b. Blood glucose c. Oxygen saturation d. Troponin I

Ans. D

After assessing in a left lateral thoracentesis for a client with pleural effusion, the nurse takes the pleural fluid samples and sends them to the lab procedure, which finding warrants immediate intervention by the nurse? a. Oxygen saturation 90% on 4 liters nasal cannula b. Left-sided pain on inhalation c. Subcutaneous emphysema around insertion site d. Decreased left lung breath sounds

Ans. D

The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant causing a wide-eyed appearance and eye discomfort. a. Review the client's serum electrolyte values b. Prepare to administer intravenous levothyroxine c. Assess for signs of increased intracranial pressure d. Obtain a prescription for artificial tear drops

Ans. D

The nurse determines that an adult client who is admitted to the post-anesthesia care unit (PACU) following abdominal surgery has a tympanic temperature of 94.6 F (34.8 C), a pulse rate of 88 beats/minute, a respiratory rate of 14 breaths/minute, and a blood pressure of 94/64 mmHg. Which action should the nurse implement? a. Take the client's temperature using another method b. Check the blood pressure every five minutes for one hour c. Ask the client to cough and deep breathe d. Raise the head of the bed to 60 to 90 degrees

Ans. D

The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider? a. Skull radiography b. Computerized tomography (CT) scan c. Magnetic resonance imaging (MRI) d. Lumbar puncture

Ans. D

The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a PUVA treatment. Which assessment finding indicates that the client has been overexposed to the treatment? a. Brown, rough, greasy, wart-like papules on the face b. Thick skin plagues topped by silvery white scales c. Requires sunglasses because sunlight hurts eyes d. Tenderness upon palpation and generalized erythema

Ans. D

61. After several days of coughing and taking acetaminophen to treat temperatures of 101 F (38. 3 C), a client with DI is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? a. Reassess vital signs b. Obtain sputum for culture c. Obtain a fingerstick glucose d. Administer an antipyretic

Ans. c

41. The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled "Penicillin 500,000 units/mL." How many mL should the nurse administer to the client?

1 ml/500,000 *200,000 = 2/5 = 0.4 ml

17. A client receives a prescription for 1 liter of lactated Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? Enter a numerical value only. If rounding is required, round to the nearest whole number.

167 mL/hr

55. A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis. Which information should the nurse prioritize? A. Adherence to the regimen is imperative B. Medications should be taken with food C. Serum liver panels are collected regularly D. Enhanced sun protection measures will be needed

A. Adherence to the regimen is imperative

32. An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Assist client to an upright position B. Administer a prescribed sedative C. Apply a high-flow venturi mask D. Encourage the client to drink water

A. Assist client to an upright position

26. A client with cholelithiasis is admitted with jaundice due to the obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? A. Distended, hard, and rigid abdomen B. Clay-colored stool C. Radiating, sharp pain in the right shoulder D. Bile-stained emesis

A. Distended, hard, and rigid abdomen

23. A nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? A. Eats a vegetarian diet with cheese 2-3 times a day B. Experiences additional stress since adopting a child C. Jogs more frequently than usual daily routine D. Drinks several bottles of carbonated water daily

A. Eats a vegetarian diet with cheese 2-3 times a day

51. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? A. Family members can help with regular foot exams B. Heating pads are useful if on the lowest settings C. Aching feet may be soaked in lukewarm water for one hour or more D. Shoes should be worn outside the house, but it is fine to be barefoot inside

A. Family members can help with regular foot exams

20. Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? A. Fortified milk and cereals B. Citrus fruits and juices C. Green leafy vegetables D. Red meats and eggs

A. Fortified milk and cereals

37. A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325 mg/dL (18 mmol/L SI). The client describes to the nurse not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement? Select all that apply. A. Have the client describe a typical day at work, home, and social activities B. Determine if the client is using a new insulin needle each administration C. Evaluate the client's asthma medications that can elevate the blood glucose D. Ask the client if they want a different manufacturer's glucose monitoring device E. Have the client demonstrate the technique used to monitor blood glucose levels

A. Have the client describe a typical day at work, home, and social activities E. Have the client demonstrate the technique used to monitor blood glucose levels

47. A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? A. "Whenever I am sitting in a chair I will keep my legs up to reduce swelling. B. "I can use a mirror to check the bottoms of my feet for any signs of breakdown." C. "I will try to keep moving if leg pain occurs to help promote good circulation. "D. "I will use my swimming pool early in the day while the water is still very cool."

B. "I can use a mirror to check the bottoms of my feet for any signs of breakdown."

36. Which client has the highest risk for developing skin cancer? A. A 16-year-old dark-skinned female who tans in tanning beds once a week B. A 65-year-old fair-skinned male who is a construction worker C. A 25-year-old dark-skinned male whose mother had skin cancer D. A 70-year-old fair-skinned female who works as a secretary

B. A 65 year-old fair-skinned male who is a construction worker

46. The family suspects that the acquired immune deficiency syndrom (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicions? A. He has begun to sleep 18 out of 24 hours B. A change has recently occurred in his handwriting C. He refuses to see any of his friends or to return their phone calls D. He exhibits angry outbursts when the subject of dying is approached

B. A change has recently occurred in his handwriting

18. A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of two hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL and the hematocrit is 35%. Which action should the nurse prepare to take? A. Continue to monitor for blood loss B. Administer 1,000 mL of normal saline C. Transfuse 2 units of platelets D. Prepare the client for emergency surgery

B. Administer 1,000 mL of normal saline

54. A client with lung cancer who wears a subcutaneous morphine sulfate patch is short of breath and difficult to arouse. When performing a head-to-toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first? A. Remove all of the morphine patches B. Administer a narcotic antagonist C. Apply oxygen per face mask D. Measure the client's blood pressure

B. Administer a narcotic antagonist

9. The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen while sitting and pinching the skin where they are injecting, which instruction should the nurse provide? A. Select a different injection site B. Continue with the insulin injection C. Keep the skin flat rather than bunched D. Lie down flat for better skin exposure

B. Continue with the insulin injection

16. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? A. Eat high protein foods to achieve ideal body weight B. Drink at least 8 cups (1920 mL) of water per day C. Use electric heating pad when pain is at its worst D. Encourage active range of motion to limit stiffness

B. Drink at least 8 cups (1920 mL) of water per day

19. An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the patient will be discharged with oxygen. Which information is the most important for the nurse to emphasize in the discharge teaching plan? A. Methods for weight loss B. Guidelines for oxygen use C. Approaches to conserve energy D. Strategies for smoking cessation

B. Guidelines for oxygen use

53. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Purple marks on the skin of the abdomen B. Irregular apical pulse C. Quarter size blood spot on dressing D. Pitting ankle edema

B. Irregular apical pulse

24. A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. What action should the nurse implement? A: Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema, and excoriation D. Identify all sexual partners in the last four days

B. Obtain a specimen of urethral drainage for culture

21. A client with Herpes zoster (shingles) on the thorax tells the nurse they are having difficulty sleeping. Which is the probable etiology of this problem? A. Frequent cough B. Pain C. Nocturia D. Dyspnea

B. Pain

5. A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? A. Perform passive range of motion exercises B. Place the client in high Fowler position C. Administer oxygen per nasal cannula D. Increase the client's activity level

B. Place the client in high Fowler position

31. The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? A. Red blood cell count B. Platelet count C. Hemoglobin levels D. White blood cell count

B. Platelet count

52. A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. What action should the nurse implement? A. Hold a prescription for dantrolene until fever is reduced B. Prepare ice packs for placement in the client's axillary area C. Call the PACU nurse to prepare for prolonged ventilatory support D. Determine if prescribed antibiotics were administered preoperatively

B. Prepare ice packs for placement in the client's axillary area

48. While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. The client reports joint pain and trouble twisting a doorknob due to weakness. Which action should the nurse take in response to these findings? A. Explain that relief of the migraine pain will reduce related symptoms B. Gather additional assessment data about the pain and weakness C. Implement fall precautions to reduce the client's risk for injury D. Consult with the occupational therapist for a functional assessment

D. Consult with the occupational therapist for a functional assessment

38. The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? A. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules B. Decreased portacaval pressure with greater collateral circulation C. Decreased renin-angiotensin response to an increase in renal blood flow D. Hypoalbuminemia that results in a decreased colloidal oncotic pressure

D. Hypoalbuminemia that results in a decreased colloidal oncotic pressure

3. The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the client's plan of care? A. Assess for signs of increased intracranial pressure B. Prepare to administer intravenous levothyroxine C. Review the client's serum electrolyte values D. Obtain a prescription for artificial tear drops

D. Obtain a prescription for artificial tear drops

29. A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect the client to exhibit? A. Complaints of chest pain and shortness of breath B. Hypotension and venous pooling in the extremities C. Profuse diaphoresis and severe, pounding headache D. Pain and a burning sensation upon urination and hematuria

D. Pain and a burning sensation upon urination and hematuria

A nurse in the emergency department is assisting with the care of a client who has myasthenia gravis and is in crisis. The nurse should identify that which of the following factors can cause a myasthenic crisis?

Developing a respiratory infection

59. When caring for a client with a full thickness burn covering 40% of the body, the nurse observes pertinent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. Hematocrit b. Platelet count c. White blood cell (WBC) count d. Blood pH level

c. White blood cell (WBC) count

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. the nurse recognizes the client is exhibiting symptoms of which condition?

meningococcal meningitis

THESE ARE THE RATIONALES FOR SOME OF THE QUESTIONS IN THIS QUIZLET Raynaud's syndrome: avoid factors that initiate vasoconstriction such as cold, stress, and caffeine intake ○ A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? A. Use a space heater to keep the workplace warm B. Obtain a keyboard designed to limit wrist flexion C. Keep both hands elevated during work breaks D. Take a multivitamin that contains vitamin D daily ● Burning with urination, frequency, urgency = symptoms of cystitis: may be related to hypertension: BP will be less than 140/80 ● Diverticulosis is frequently asymptomatic until the diverticula becomes inflamed ● Hyperparathyroidism with acute flank pain: strain all urine (could be kidney stones) ● Unstable angina to reduce cardiac overload > Place commode at the bedside for toileting ● Leukopenia: Precautions should be taken to protect the client because of a weakened immune system ● In severe acute adrenal insufficiency > monitor pulse/ blood pressure ● Tuberculosis test: erythema without induration between

The Rationale for some of the questions in this quizlet