Med Surg (LIVE)
A nurse is preparing to open a sterile package insert an indwelling urinary catheter for a female client. In what order should the nurse perform the following actions?
- Perform hand hygiene - Place the package on a work surface - Open the outermost flap away from the body - Open the side flaps pulling to the sides - Open the innermost flap toward the body
A nurse is caring for a client whose NG tube has 475 mL of drainage in the suction canister. Previously, the nurse instilled 30 mL normal saline through the NG tube twice during the shift without drawing it. Calculate the amount of NG output the nurse should document on the client's medical record.
415 mL
A nurse is observing the cardiac rhythms of four client's receiving continuous cardiac monitoring. The nurse should recognize that which of the following rhythms requires immediate intervention?
B
A nurse is contributing to the plan of care for a client who is 2 hr postoperative and has an SaO2 of 89% at rest. The client is receiving oxygen at 3 L/min via nasal cannula. Which of the following images indicates an appropriate intervention the nurse should recommend?
C
A nurse is auscultating an apical pulse on a client before administering metoprolol. The nurse should place the stethoscope at which of the following locations to auscultate at the point of maximal impulse?
D The nurse should auscultate the point of maximal impulse at the fourth or fifth left intercostal space at or medial to the left midclavicular line. This is the location of the apex of the heart. The nurse should listen to the apical pulse for 1 min before administering the medication. The nurse should withhold the medication and notify the provider for an apical heart rate of less than 50/min
A nurse is caring for a client who had a lumbar laminectomy and has a prescription for an oral opioid analgesic. Which of the following actions should the nurse take? a. Ask the client after 15 min if the pain medication is effective b. Administer the medication after the client ambulates c. Instruct the client to increase oral fluids to 1,500 mL daily d. Recommend the client increase her intake of fiber rich foods
Recommend the client increase her intake of fiber rich foods The nurse should encourage the client to increase intake of fiber rich foods to improve the consistency of the feces and to ease bowel movements. Constipation is an adverse effect of opioid analgesia because the medication slows peristalsis. The feces dry out and become compacted from the prolonged time in the colon. The nurse should administer stool softeners or laxatives if needed to alleviate this adverse effect
A nurse is assisting in the plan of care for a client who may have meningitis and is scheduled for a lumbar puncture. Which of the following actions should the nurse plan to include following the procedure? (SATA) a. Provide pain medication as needed b. Administer a sedative c. Maintain lateral recumbent position d. Check level of consciousness e. Check sensation in the toes
a, d, e
A nurse is reinforcing teaching with a client who has a history of pulmonary embolism about reducing the risk of developing deep vein thrombosis (DVT) when traveling. Which of the following statements should the nurse include in the teaching? a. "Get up and walk every 2 hours when traveling by car" b. "Reduce fluid intake while traveling by plane" c. "Plan to wear knee high hose when traveling" d. "You can cross your legs after walking for 10 minutes when traveling by train"
a. "Get up and walk every 2 hours when traveling by car" The client should stop and walk every 1 to 2 hr when traveling by car to improve circulation and decrease venous stasis, which can cause DVT. Then thrombus can break off and migrate to the lung causing a pulmonary embolism
A nurse is preparing to reinforce teaching with a client who is 1 day postoperative following a bilateral mastectomy with drains. Which of the following information should the nurse plan to include in the teaching? a. "Wear protective gloves if working in the garden" b. "Begin range of motion exercises of the shoulder while the drains are still in place" c. "Someone else should brush your hair for 2 weeks after the surgery" d. "Perform wall exercises by standing 18 inches away while pushing yourself away from the wall"
a. "Wear protective gloves if working in the garden" The nurse should instruct the client how to limit the risk of developing complications, such as infection, that could cause lymphedema. One way to do this is to wear protective gloves while washing dishes and working in a garden
A nurse is preparing to provide care for a group of clients. Which of the following client's should the nurse see first? a. A client who has a blood glucose of 68 mg/dL and reports mild sweating b. A client who has a calcium level of 10mg/dL and reports a headache c. A client who has acute glomerulonephritis and reports output of reddish brown urine d. A client who has macular degeneration and reports difficulty seeing shapes
a. A client who has a blood glucose of 68 mg/dL and reports mild sweating A blood glucose of less than 70 mg/dL indicates hypoglycemia. Early findings include diaphoresis, anxiety, and hunger, which can progress to confusion and seizures. The nurse should provide prompt treatment to prevent harm to the client
A nurse is observing a client who has type 1 diabetes mellitus and is experiencing fine hand tremors. The nurse measures the client's blood glucose level and obtains a reading of 65 mg/dL. Which of the following actions should the nurse take? a. Administer 12 g of carbohydrates b. Retest the blood glucose c. Administer 1 mg of glucagon IM d. Check the urine for ketones
a. Administer 12 g of carbohydrates The nurse should recognize the client who has diabetes mellitus and who has a blood glucose of 65mg/dL is hypoglycemic. To treat the hypoglycemia, the nurse should administer 15 to 20 g of carbohydrates by administering one of the following: 3 to 4 glucose tablets, 4 oz fruit juice, 8 oz milk, 3 graham crackers, or 3 tsp of honey. the nurse should retest the client's blood glucose level 15 min after administration of carbohydrates to insure the value is within the expected reference range of 70 to 110 mg/dL for a fasting glucose or less than or equal to 200 mg/dL of a casual glucose
A nurse is reviewing the plan of care for a client who is at risk for increased intracranial pressure following a closed head injury. Which of the following interventions should the nurse identify as contraindicated for this client? a. Assist client to cough and deep breathe b. Elevate the head of the client's bed to 30 degrees c. Perform passive arm range of motion exercises for the client d. Log roll the client slowly when repositioning
a. Assist the client to cough and deep breathe A closed head injury is caused by blunt trauma to the head. As a result, edema can occur within the brain and lead to increased intracranial pressure (ICP). The client should avoid deep breathing, coughing, performing Valsalva maneuvers, and blowing her nose because these actions can increase ICP. An initial sign of increased ICP is often a decrease in the level of conscoiusness
A nurse is preparing to reinforce preoperative teaching with a client. Which of the following actions is the nurse's priority? a. Check the client's comfort level b. Determine the client's motivation to learn c. Check the client's preferences for learning methods d. Determine the client's health literacy
a. Check the client's comfort level When using Maslow's hierarchy of needs, the nurse should recognize that checking the physiological needs of the client, such as pain, is the priority
A nurse is caring for a client who is postoperative following a total left hip arthroplasty. Which of the following interventions should the nurse implement to prevent dislocation? a. Maintain a foam wedge between the client's legs b. Encourage the client to use elastic stockings c. Monitor for shortening of the client's affected leg d. Perform passive range of motion by flexing the client's hip to 120 degrees
a. Maintain a foam wedge between the client's legs The client is at risk for hip dislocation when the surrounding supportive tissues have been cut to expose and replace the diseased joint. Proper body alignment after total hip arthroplasty includes keeping the affected leg slightly abducted. A major complication of total hip arthroplasty is subluxation (partial dislocation) or total dislocation. In some facilities, abduction devices, such as foam wedges and pillows are placed between the legs. Adduction of the hip should be avoided to prevent dislocation
A nurse is assisting with a plan of care for a client who has cirrhosis of the liver. Which of the following interventions should the nurse recommend? a. Maintain the client in high fowlers position b. Measure the client's rectal temperature every 8 hr c. Weigh the client every 48 hr d. Cleanse the client's perineal area with warm, soapy water
a. Maintain the client in high fowlers position Upright position promotes expansion of the client's lungs. The upright position also prevents ascities from putting pressure on the diaphragm
A nurse is contributing to the plan of care for a client who has a halo stabilization device. Which of the following interventions should the nurse include in the plan of care? a. Provide pin site care every shift b. Turn the client by holding the halo device c. Remove the jacket to inspect the client's skin integrity d. Allow three fingers to slide easily between the client and the jacket
a. Provide pin site care every shift The nurse should provide pin site care, cleaning and assessment every shift, or more often as indicated by condition or facility protocol
A nurse in a long term care facility is assisting with an in service about legal torts. The nurse should explain that communicating false information that damages the client's reputation is an example of which of the following types of torts? a. Slander b. Battery c. Malpractice d. Assault
a. Slander Slander occurs when a nurse uses false oral communication about a client that is harmful to the client's reputation. Libel refers to written or print communication that defames the client's character
A nurse is observing an assistive personnel (AP) providing care for a group of clients. For which of the following actions by the AP should the nurse intervene? a. The AP offers a client a drink of cool water 1 hr before a schedule liver biopsy b. The AP weighs a client who has heart failure before the client eats breakfast c. The AP assists a client who is 36 hr postoperative from an above the knee amputation into the prone position d. The AP provides a high protein snack for a client who has aids
a. The AP offers a client a drink of cool water 1 hr before a schedule liver biopsy Client should have nothing to eat or drink for at least 4 hr before the procedure
A nurse in a long term care facility is reviewing ventilator settings with a newly licensed nurse. Which of the following information should the nurse use to describe the assist control ventilator mode? a. The ventilator delivers a set tidal volume that helps the client's breathing pattern b. The ventilator provides a set number of breaths to synchronize with the client' breathing pattern c. The ventilator controls the rate and depth of all breathing d. The ventilator maintains positive pressure throughout the breathing cycle
a. The ventilator delivers a set tidal volume that helps the client's breathing pattern Assist control ventilation uses the client's own breathing effort to trigger a response by the ventilator. When the client breathes, the ventilator delivers a set tidal volume of air to promote oxygenation and provide rest for the client's lungs. This mode includes setting a minimum respiratory rate and will provide breaths if the client's rate falls below the prescribed number
A nurse working in a provider's office is reinforcing teaching with a client who has a Grade 1 (mild) ankle sprain. Which of the following instructions should the nurse include? (SATA) a. Immobilize the ankle for 4-6 weeks b. Elevate the ankle above the level of the heart c. Take a muscle relaxant as needed d. Wrap the ankle with an elasticized compression bandage e. Apply an intermittent cold compress to the ankle for the firse 24 to 48 hr
b,d, e
A nurse in a provider's office is reinforcing teaching with a client following the initial check of a client's permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching? a. "Using my cell phone won't affect my pacemaker" b. "I might be able to check my pacemaker from home by using the telephone" c. "My pacemaker will need reprogramming if I stand too close to a microwave oven" d. "I will report any increase of my pulse rate over the preset pacemaker pulse rate"
b. "I might be able to check my pacemaker from home by using the telephone" The client usually has an initial pacemaker check at the provider's office. If the client's pacemaker contains a device for telephone or telemetry monitoring, follow up pacemaker checks can occur remotely from home. The client will use a telephone transmitting device to send basic information electronically from the pacemaker to the clinic. If the pacemaker requires reprogramming, the client will need to return to the provider's office.
A nurse is reinforcing teaching with a client who has dumping syndrome as a complication of gastric bypass surgery. Which of the following statements indicates to the nurse the client understands the teaching? a. "I will take a short walk after each meal" b. "I will eat some type of protein with each meal" c. "I will drink at least 8 ounces of liquid with each meal" d. "I will eat only three meals a day"
b. "I will eat some type of protein with each meal" The nurse should instruct the client to eat protein with each meal to slow gastric emptying. Dumping syndrome can occur following gastric bypass surgery because a large amount of undigested food enters the intestines at a rapid rate. The client should minimize his intake of simple carbohydrates and increase intake of fats and proteins
A nurse is reinforcing teaching with a client about managing hearing loss. Which of the following statements by the client indicates an understanding of the teaching? a. "Reading lips is a good alternative to wearing a hearing aid" b. "It can take a several weeks to adjust to a hearing aid when it is first used" c. "I should wait to use hearing aids until other alternatives no longer work" d. "Cleaning my ears daily with a cotton tipped swab can prevent further hearing loss"
b. "It can take several weeks to adjust to a hearing aid when it is first used" After a client is initially fitted for a hearing aid, the client might need to return to the audiologist for repeated fittings and adjustments of the settings. It is important for the client to understand the difficulties associated with adjusting to a hearing aid to prevent the client from getting frustrated and giving up
A nurse is reinforcing teaching with a client who has a prescription for a periodic aPTT testing. Which of the following statements made by the client indicates an understanding of the teaching? a. "I will need to avoid eating or drinking prior to the test" b. "This test measures the effectiveness of clotting factors" c. "I might need to receive vitamin K if my levels are too low" d. "This test will help my provider adjust my warfarin dosages"
b. "This test measures the effectiveness of clotting factors" An aPTT test measures the effectiveness of coagulation factors in the clotting cascade. Clients who are receiving heparin therapy should have regular testing of the aPTT. The therapeutic range of heparin therapy is 1.5-2.5 times the expected range in seconds. Prolonged times indicate a risk for serious bleeding
A nurse is caring for a client who is scheduled for a cardiac catheterization with coronary angiography. The client has a history of coronary artery disease and takes cardiac medications. Which of the following actions should the nurse take? a. Instruct the client to take nothing by mouth 12 hr before the procedure. b. Ask the client if she has a history of seafood allergy c. Withhold the client's cardiac medications before the procedure d. Inform the client that an urge to void will occur following the injection of the contrast dye
b. Ask the client if she has a history of seafood allergy The nurse should check the client for allergies and notify the provider. Identifying allergies to seafood, iodine, and other radiographic dyes may prevent an anaphylactic reaction to the contrast dye
A nurse is collecting data from a client who experienced a brief loss of consciousness after falling and hitting his head 12 hr ago. Which of the following is the priority finding to report to the charge nurse? a. Large bruise on forehead b. Clear fluid present in left ear c. Pupils are 4 mm and reactive to light d. Blood pressure 105/64 mm Hg
b. Clear fluid present in left ear Clear fluid in the ear canal or nose can indicate a tear in the meninges, which would allow cerebrospinal fluid (CSF) to escape. Leaking CSF increases the client's risk for meningitis
A nurse is reinforcing teaching about infection transmission with an assistive personnel (AP) who is caring for a client who has Clostridium difficile infection. Which of the following instructions should the nurse include? a. Use alcohol based hand sanitizer after caring for the client b. Leave the blood pressure cuff in the client's room c. Keep the door to the client's room closed d. Wear an N95 respirator when within 3 feet of the client
b. Leave the blood pressure cuff in the client's room C difficile is spread by indirect contact with equipment such as blood pressure cuffs, thermometers, and stethoscopes. Therefore, the AP should leave the blood pressure cuff and other equipment in the client's room
A nurse is reinforcing teaching about treatment for food blockage in the intestine with a client who has an ileostomy. Which of the following information should the nurse include in the teaching? a. Lavage the ileostomy b. Massage around the ileostomy stoma c. Take a stimulating laxative d. Begin a diet high in fiber
b. Massage around the ileostomy stoma The nurse should tell the client to massage the abdominal area around the stoma to create pressure behind the food blockage to move it forward through the stoma. Changing positions or taking a warm bath can help promote passage of the blockage
A nurse is caring for a postoperative client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take? a. Increase fluids b. Perform a bladder scan c. Instruct the client to perform Kegel exercises d. Encourage the client to take a cool shower
b. Perform a bladder scan The nurse should collect data to determine the presence of urine in the bladder by performing a bladder scan. The scanner is hand held and calculates the volume of residual urine using ultrasound. The client is at risk for developing urinary retention following removal of an indwelling urinary catheter. As urine collects in the bladder, the muscles of the bladder stretch to accommodate the added volume. The client might feel pressure, discomfort, and tenderness over the symphysis pubis
A nurse is caring for a client who is receiving intravenous therapy through a peripheral catheter. The nurse notes that the skin around the client's IV catheter site feels tight and cool to touch. Which of the following actions should the nurse take? a. Straighten the client's arm b. Stop the infusion c. Raise the height of the IV infusion bag d. Apply a pressure dressing to the IV site
b. Stop the infusion The nurse should identify that the client's IV catheter has been infiltrated. The nurse should stop the infusion, remove the catheter, elevate the client's arm to promote absorption of the infiltrated fluid, and apply either a warm or cold compress to promote comfort. Manifestations of infiltration include edema, skin blanching, cool, taught skin, and pain. If the IV solution is a vesicant, the catheter should remain in place in case an antifote is to be administered
A nurse is reinforcing teaching with a client who is scheduled to have an ileostomy. Which of the following information should the nurse include in the teaching? a. An NG tube will be inserted 2 days prior to surgery b. The liquid output from the stoma is to be measured c. The stoma will appear purple in color following surgery d. Prepare to take laxative 1 week prior to surgery
b. The liquid output from the stoma is to be measured The nurse should tell the client all liquid output from the stoma is measured and calculated every 8 hrs until the client is well hydrated and the nutritional intake is stable
A nurse is determining a client's ability to perform self care following a stroke. Which of the following findings should the nurse identify as the priority? a. Weak grip b. Vision impairment c. Aphasia d. Emotional lability
b. Vision impairment The greatest risk to this client is injury from a fall. A visual impairment resulting from a stroke alters the client's visual field and increases the risk for falls while performing self care activities. Therefor, the nurse should identify this as the priority finding. Visual impairments following a stroke can include partial to total blindness in one or both eyes
A nurse is reviewing the ABG findings of a client who has COPD and was admitted with pneumonia. Which of the following ABG results should the nurse anticpate? a. pH 7.48, PaCo2 38 mm Hg; HCO3 32 mEq/L b. pH 7.33; PaCo2 58 mm Hg; HCO3 25 mEq/L c. pH 7/52; PaCO2 22 mm Hg; HCO3 22 mm Hg d. pH 7/32; PaCO2 38 mm Hg; HCO3 20 mEq/L
b. pH 7.33; PaCO2 58 mm Hg; HCO3 25 mEq/L
A nurse is collecting data from an older adult client who is confused and has received a scheduled opioid analgesic. The client now appears drowsy. Which of the following actions should the nurse implement? (SATA) a. Raise four side rails b. Apply restraints PRN c. Measure the client's SaO2 d. Instruct the client in the use of the call light e. Apply an ambulation alarm to the client's leg
c, d, e
A nurse is reinforcing teaching with a client who has rheumatoid arthritis and a new prescription for methylprednisolone. Which of the following information should the nurse include? a. "Take the medication each evening" b. "Take the medication on an empty stomach" c. "Avoid individuals who are sick" d. "Weigh yourself each week to monitor for weight loss"
c. "Avoid individuals who are sick" The nurse should instruct the client to report manifestations of infection, such as a fever or sore throat, to the provider because glucocorticoids can suppress the immune system. A suppressed immune system can increase the risk of contracting an illness from a microorganism
A nurse is reinforcing teaching about glucose monitoring with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates to the nurse an understanding of the teaching? a. "I will check my urine once per day for glucose" b. "I will notify my doctor if my blood glucose is more than 120 milligrams per deciliter" c. "I will check my blood glucose every 4 hr when I am sick" d. "I will treat myself for hypoglycemia if I notice a fruity breath odor"
c. "I will check my blood glucose every 4 hr when I am sick" The client's should check blood glucose levels every 2 to 4 hr when sick. The client should also continue to take insulin or oral antidiabetic agents; consume 4 oz of sugar free, noncaffeinated liquid every 30 min; and meet carbohydrate needs through soft food if possible. The client should also test urine for ketones and report to the provider if the level is abnormal. The level should be negative to small
A nurse is reinforcing teaching with a client who has asthma and a new prescription for salmeterol using a dry powder inhaler. Which of the following statements by the client demonstrates an understanding of the teaching? a. "I will blow into the mouthpiece to activate the inhaler" b. "I will shake the inhaler for 3 to 5 seconds prior to using it" c. "I will hold my breath for 10 seconds after I remove the inhaler from my mouth" d. "I will rinse my inhaler once per week to keep it clean"
c. "I will hold my breath for 10 seconds after I remove the inhaler from my mouth" The client should hold his breath for 5 to 10 seconds after using the inhaler to promote absorption of the medication into the lungs. This action promotes distribution of the medication in the lungs. The client should also rinse his mouth and then spit to minimize the amount of medication that is absorbed systemically
A nurse is collecting data from the child of an older adult client concerning the development of dementia. Which of the following statements by the client's child is the priority? a. "Sometimes it takes a few minutes for my mother to find the right word" b. "This mouth, my mother forgot to pay her water bill" c. "Last week, I found my mother's cell phone in the dryer" d. "Yesterday my mother called my brother by the wrong name"
c. "Last week, I found my mother's cell phone in the dryer" The inability to find misplaced items and putting them in odd places can be a manifestation of serious memory deficit
A nurse is caring for a client who has bacterial meningitis. Which of the following treatments should the nurse expect to administer? a. Acyclovir b. Oral antibiotics followed by an IV antibiotic c. Dexamethasone d. Narcotics for pain control
c. Dexamethasone A client who has bacterial meningitis can have meningeal inflammation. Therefore, the nurse should expect to administer dexamethasone as part of the treatment plan to reduce swelling of the meninges
A nurse in a provider's office is reinforcing teaching with a client who has a new prescription for sulfadiazine. Which of the following instructions should the nurse include in the teaching? a. Store the medication in the refrigerator b. Take the medication with food c. Increase fluid intake while taking this medication d. Avoid foods that contain milk while taking this medication
c. Increase fluid intake while taking this medication Sulfadiazine can cause crystallization of the urine. Therefore, the client should consume adequate oral fluids to maintain a urine output of at least 1200 mL daily, which decreases the risk of damages to the kidneys
A nurse in a providers office is collecting data from a client who is on long term glucocorticoid therapy to treat lupus erythematosus (LE). The nurse should recognize that which of the following findings is an adverse effect of long term glucocoricoid therapy? a. Paresthesia b. Weight loss c. Moon face d. Hypoglycemia
c. Moon face A client who is on long term glucocorticoid therapy can develop cushingoid adverse effects due to adrenal suppression, such as moon face, weight gain, hyperglycemia, and hypokalermia. LE is a chronic systemic condition that can cause manifestations such as pleurisy, nephritis, and pericarditis
A nurse in a long term care facility is assisting with the plan of care for a client who has functional urinary incontinence. Which of the following interventions should the nurse include in the plan of care? a. Check the client's skin once a week b. Restrict the client's intake of fluids to 1000 mL per day c. Offer to toilet the client every 2 hr d. Encourage the client to drink citrus beverages
c. Offer to toilet the client every 2 hr To minimize the client's exposure to moisture and prevent incontinence episodes, the nurse should offer to toilet the client every 2 to 4 hr
A nurse is evaluating the laboratory results for a client who has malnutrition. Which of the following laboratory results should the nurse expect? a. Lymphocytes 30% b. Hemoglobin 14 g/dL c. Prealbumin 11 mg/dL d. Calcium 10 mg/dL
c. Prealbumin 11 mg/dL A prealbumin level of 11 mg/dL is below the expected reference range of 15 to 36 mg/dL and is manifestation of malnutrition. Prealbumin is a short term indicator of insufficient nutritional intake
A nurse is contributing to the plan of care for a client who has neutropenia following chemotherapy. Which of the following interventions should the nurse recommend for the client's plan of care? a. Encourage the client to use a disposable razor for shaving b. Increase fresh uncooked produce in the client's diet c. Reinforce teaching about deep breathing exercises d. Insert an indwelling urinary catheter
c. Reinforce teaching about deep breathing exercises A client who has neutropenia is at risk for infection. Protection from and early recognition of infection is a high priority. Deep breathing exercises promote lung expansion and help clear secretions that could promote infection
A nurse is reinforcing teaching with a client who takes fluoxetine for major depressive disorder. Which of the following manifestations should the nurse include as an adverse effect of fluoxetine? a. Pupillary constriction b. Hypersalivation c. Sexual dysfunction d. Hirsutism
c. Sexual dysfunction Impaired sexual function is a very common adverse effect of taking fluoxetine. To minimize the effects, the provider might prescribe a medication holiday, having the client only take the medication on certain days of the week. Additional prescriptions might be required to help the client regain sexual function. The nurse should ask the client directly about sexual problems because the client might be reluctant to report them
A nurse is reinforcing teaching with a client about the adverse effects of consuming alcohol while taking lorazepam. Which of the following adverse effects should the nurse include? a. Hypertension b. Tachypnea c. Sleep walking d. Motor tics
c. Sleep walking Some client's perform complex behaviors during sleep while taking a benzodiazepine. Clients have reported walking, driving, cooking, eating, or making phone calls. The risk for this adverse effect is increased with high dosage or alcohol consumption. Therefore, the nurse should instruct the client to avoid alcohol while taking this medication and advise the client to report occurrence of these behaviors to the provider immediately
A nurse is assisting with the admission of a client who has tuberculosis. Which of the following actions should the nurse take? a. Ensure the client's room has a positive pressure airflow exchange b. Place the client in semi private room c. Wear a HEPA mask when providing care for the client d. Report the client's diagnosis to the facility risk manager
c. Wear a HEPA mask when providing care for the client The nurse should use personnel preotective equipment when caring for a client who is in transmission based precautions. For a client who has turberculosis, airborne precautions are initiated, which include the use of a HEPA mask to maintain the safety of the nurse and prevent the spread of infection
A nurse is assisting with discharge teaching about skin care for a female client who has lupus erythematosus. Which of the following statements by the client indicates an understanding of the teaching? a. "I should avoid being outside 3:00 and 5:00 pm when the sunlight is the strongest" b. "I should use an astringent to remove any remaining traces of makeup after washing my face" c. "I should avoid applying moisturizer to my arms and legs" d. "I should avoid taking oral contraceptives"
d. "I should avoid taking oral contraceptives" If using birth control, the client should choose a method other than oral contraceptives as these can exacerbate manifestations of lupus, such as a butterfly lesions or blemishes on the face. Lupus erythematosus is a systemic inflammatory connective tissue condition that affects many organs of the body. Other medications that can exacerbate lupus erythematosus include procainamide, penicillin, and sulfa based antibiotics
A nurse in an urgent care clinic is collecting data from a client who is to start taking cefaclor for streptococcal pharyngitis. Which of the following statements by the client should the nurse address as the priority? a. "I have been running a fever for the last 3 days" b. "Both my throat and my ear hurt" c. "Every time I take an antibiotic, I get diarrhea" d. "My lips swelled after taking amoxicillin last year"
d. "My lips swelled after taking amoxicillin last year" Using the urgent vs. nonurgent approach to client care, the nurse should determine the priority statement by the client is about swelling of the lips after taking amoxicillin. A client who had a severe allergic reaction to penicillin might also be allergic to cephalosporins, including cefaclor
A nurse is assisting with the care of a client who has an estimated 15% of total body surface area burn injury is taking oral nutrition, and reports following a strict vegan diet. Which of the following food choices should the nurse recommend? a. Tuna salad b. Scrambled eggs c. Cream of broccoli soup d. Black beans and rice
d. Black beans and rice The client needs an increased protein intake to aid in the promotion of tissue healing following burn injury or other disorders that cause metabolic stress. A client who follows a strict vegan diet should obtain adequate protein from nuts and legumes to promote balanced nutrition and tissue repair. Black beans and rice contain complementary proteins that form a complete protein when consumed together
A nurse is reviewing the medical record for a client who has sepsis. Which of the following findings is the priority to report to the provider? a. Temperature b. WBC C. Creatine d. Blood pressure
d. Blood pressure When using the airway, breathing, circulation approach to client care. The nurse should determine that the priority finding to report to the provider is blood pressure of 84/62 mm hG. A systolic blood pressure below 90 mm Hg indicates hypotension. Complications of sepsis include hypovolemia from fluid leak of capillaries or blood loss through impaired coagulation. This client requires emergency treatment for shock to prevent death
A nurse is collecting data from a client who has been taking lithium for 3 months. Which of the following findings is the priority to report to the provider? a. Impaired memory b. Abdominal bloating c. Headache d. Blurred vision
d. Blurred vision Blurred vision indicates the client is at greatest risk for injury from lithium toxicity; therefore, this is the priority finding for the nurse to report to the provider. Other adverse manifestations of toxicity at lithium levels greater than 2 mEq/L include ataxia, giddiness, tinnitus, muscle twitching, and coarse tremors. If not corrected, lithium toxicity can lead to seizures, coma, and death
A nurse is caring for a client who returns to the clinic after receiving abnormal cytology findings from Papanicolaou (Pap) test. Which of the following procedures should the nurse anticipate the client will undergo? a. Dilation and evacuation b. Transvaginal ultrasound c. Human chorionic gonadotropin (hCG) test d. Colposcopy with directed biopsy
d. Colposcopy with directed biopsy Follow up for a client who has an abnormal Pap test includes a colposcopy and directed biopsy. The provider will obtain a cervical tissue specimen and send it for testing to identify precancerous or cancerous cells
A nurse is collecting data from a client who has malnutrition. Which of the following findings should the nurse identify as an indication of malnutrition? a. Increased tendon reflexes b. Increased muscle tone c. Decreased risk of infection d. Decreased mental status
d. Decreased mental status A client who has malnutrition can have a decreased mental status, because the brain requires glucose to function. When the body lacks adequate glucose, the body will metabolize tissue such as muscle and fat. The resulting metabolic acidosis can decrease the client's mental status. Nutritional deficits of fluids will result in dehydration, which can also cause a decrease in mental status
A nurse is reinforcing teaching with a client who has a new prescription for alendronate 35 mg PO to prevent osteoporosis. Which of the following instructions should the nurse include? a. Take the medication once per month b. Lie down for 30 min after taking the medication c. If the medication causes heartburn, take it with an antacid d. Drink a full glass of water when taking the medication
d. Drink a full glass of water when taking the medication The client should drink a full glass of water when she takes the medication to reduce the risk of esophagitis. Other beverages decrease medication absorption. The client should avoid eating or drinking immediately after taking the medication
A nurse is reviewing the laboratory results for a client who has been receiving epoetin alpha for chronic kidney failure. The nurse should identify which of the following findings as a therapeutic effect of the medication? a. Increased hemoglobin b. Increased potassium c. Decreased calcium level d. Decreased WBC
d. Increased hemoglobin Epoetin alpha stimulates red blood cell production. Loss of kidney function can lead to decreased production of erythropoietin and cause anemia. the goal of treatment is a hemoglobin level of 10 to 11 g/dL. Hbg for client's receiving epoetin should not exceed 12 g/dL due to an increased risk of adverse effects. The lowest possible dose should be used
A nurse is caring for a client who has been receiving potassium chloride after being admitted with a serum potassium 3.1 mEq/L. Which of the following findings should the nurse identify as a therapeutic response to treatment? a. Decreased bowel sounds b. Positive Trousseau's sign c. Positive Chvostek's sign d. Increased muscle strength
d. Increased muscle strength Hypokalemia causes muscle weakness. A therapeutic response to potassium supplements would be an increase in muscle strength
A nurse is reinforcing teaching about breast self examination (BSE) with a group of client's who are premenopausal. At which of the following times should the nurse recommend the client's perform BSE? a. At the onset of ovulation b. The last day of each month c. The first day of the menstrual cycle d. One week after the mentstrual cycle begins
d. One week after the menstrual cycle begins Premenopausal clients should perform BSE once per month, 7 to 10 days after the beinning of the menstrual cycle. At this time, hormonal influence on breast tissue is decreased, so fluid retention and tenderness are reduced. Clients should inspect the breast symmetry, size, contour, skin changes (color, texture, and venous patterns) nipple changes, and lesions. One breast might be larger than the other, and inverted nipples are common. The breast exam should be completed in both the standing and supine position. A combination of BSE, a clinical breast exam, and mammography is effective in detecting early breast cancer and reducing mortality rates. Women older than age 20 should conduct a monthly BSE and schedule a clinical breast examination every 3 years and every year after age 40
A nurse is reinforcing teaching with a client who is scheduled for a colon resection. Which of the following actions should the nurse instruct the client to implement during the postoperative period? a. Take analgesia medication 1 hr before ambulation b. Wait to ambulate until the NG tube is discontinued c. Sip clear liquids to promote return of bowel peristalsis d. Splint the incision while coughing every 2 hr
d. Splint the incision while coughing every 2 hr The nurse should instruct the client to perform splinting when coughing and deep breathing every 1 to 2 hr after surgery. The purpose of coughing is to expel secretions and deep breathing enlarges the chest cavity and expands the lungs. These breathing exercises keep the lungs clear, allow full aeration, and prevent pneumonia and atelectasis. Splinting decreases discomfort and prevents the risk of wound dehiscence while coughing
A nurse is reviewing notes from the change of shift report regarding the need to remove a client's NG tube. Which of the following actions should the nurse take first? a. Disconnect the tube from the wall suction b. Perform hand hygiene before donning gloves c. Provide mouth care for the client d. Verify the provider's prescription to discontinue the tube
d. Verify the provider's prescription to discontinue the tube The greatest risk to this client is injury from early removal of the NG tube. Early NG tube removal can cause altered nutrition, fluid and electrolyte imbalance, and possible abdominal discomfort or aspiration if the tube is used for decompression. Reinserting the tube due to an error might cause the client discomfort. Therefore, the priority action the nurse should take is to verify the provider's order to discontinue the tube
