Med surg part 2

1. The nurse is performing an otoscopic examination on a client with mastoiditis. On examination of the tympanic membrane, which finding should the nurse expect to observe? a. A pink-colored tympanic membrane b. A pearly colored tympanic membrane c. A transparent and clear tympanic membrane d. A red, dull, thick, and immobile tympanic membrane

D A red, dull, thick, and immobile tympanic membrane

A patient with an allergy to heparin has an order for Refludan 0.1 mg/kg/h. The pharmacy dilutes 100 mg of Refludan in 250 mL of D5W. For a patient weighing 70 kg, how many milliliters per hour should the Refludan drip be infused?

18 ml/hr

A patient with an admitting blood pressure of 230/140 mm Hg is receiving nitroprusside at 50 ml/h. The patient's weight is 70 kg. The nitroprusside concentration is 50 mg/250 ml of D5W. How many micrograms per kilograms per minute of nitroprusside are infusing?

2.4 mcg/kg/min

The physician has ordered a Levophed drip at 8 mcg/min for a patient with hypotension. The Levophed concentration is 4 mg/250 mL D5W. How many milliliters per hour should the Levophed be infused?

30 ml/hr

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder? 1. A 25-year-old woman who runs 2. A 36-year-old man who has asthma 3. A 70-year-old man who consumes excess alcohol 4. A sedentary 65-year-old woman who smokes cigarettes

4

A patient with supraventricular tachycardia has a maintenance infusion of Brevibloc 100 mcg/kg/min ordered. The Brevibloc concentration is 10 mg/mL. The patient's weight is 80 kg. How many milliliters per hour should the IV pump be set for?

48 ml/hr

A client has a brain tumor and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying that the client does not have a seizure disorder. What response by the nurse is correct? a. "Increased pressure from the tumor can cause seizures." b. "Preventing febrile seizures with a tumor is important." c. "Seizures always occur in clients with brain tumors." d. "This drug is used to sedate with a brain tumor."

A

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. "Do you have a one- or two-story home?" b. "Can you check your own pulse rate?" c. "Do you have any alcohol in your home?" d. "Can you prepare your own meals?"

A

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel sounds. d. Check pupil reaction to light.

A

A patient who has Ménière's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patient's room. b. Encourage increased oral fluid intake. c. Change the patient's position every 2 hours. d. Keep the head of the bed elevated 45 degrees.

A

The nurse has given medication instructions to a patient receiving phenytoin (Dilantin). Which statement by the patient indicates that the patient has an adequate understanding of the instructions? a. "I will need to take extra care of my teeth and gums while on this medication." b. "I can go out for a beer while on this medication." c. "I can skip doses if the side effects bother me." d. "I will be able to stop taking this drug once the seizures stop."

A

A nurse prepares a client for a percutaneous kidney biopsy. What actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Review coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the client's urine. e. Administer client's antihypertensive medications.

A B E

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 B• Smoking C• Obesity D• Advanced age E• Eating too much red meat F• Race

A D E F

The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count

A b c d e f

The nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members would the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian nutritionist b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Primary health care provider

A c e

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? a. Corneal staining b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

A. . Corneal staining

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

ANS: A

A nurse assess a client recovering from a cystoscopy. Which assessment findings would alert A patient passing bloody urine has scheduled a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? a. "Your doctor will place a catheter into an artery in your groin and inject a dye to visualize the blood supply to the kidneys." b. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidneys." c. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye to outline your bladder on x-ray." d. "Your doctor will inject a radioactive solution into a vein in your arm, then the isotope in your kidneys and bladder will be visible on a scanner."

C

The nurse interviews a client with systemic lupus erythematosus (SLE) who reports to the emergency department with severe back pain after a minor fall. What aspect of the client's medical history is most relevant to the potential cause of this injury?

Ans. Prescription for steroid therapy.

A nurse prepares a client for a percutaneous kidney biopsy. What action should the nurse take prior to this procedure?

Ans. Review coagulation study results.

A client has a history of osteoarthritis. Which signs and symptoms should the nurse expect to find on physical assessment?

Ans. Swelling, joint pain, and tenderness on palpation

A client with acquired immune deficiency syndrome has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most consistent with this condition? a. Auscultating the lungs b. Assessing mucous membranes c. Listening to bowel sounds d. Performing a neurologic examination

B

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance would the nurse assess? a. Agitation b. Kussmaul respirations c. Seizures d. Positive Chvostek sign

B

The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient? A. Diarrhea B. Urinary retention C. Risk for infection D. Insomnia

B

The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome? a. Having fluid and electrolyte balance b. Maintaining normal respiratory function c. Expressing satisfaction with pain control d. Developing no ongoing pancreatic disease

B

When caring for a patient after cystoscopy, what should the nurse include in the plan of care? a. The patient learns to request narcotics for pain. b. The patient understands to expect blood-tinged urine. c. The patient restricts activity to bed rest for 4 to 6 hours. d. The patient remains NPO for 8 hours to prevent vomiting.

B

A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in health teaching to reduce symptoms for this disorder? (Select all that apply.) a. "Apply heat to the ear for 20 minutes three times a day." b. "Move the head slowly to prevent worsening of the vertigo." c. "Avoid food additives such as monosodium glutamate (MSG)." d. "Quit smoking to increase blood flow to the inner ear." e. "Avoid caffeinated beverages." f. "Avoid standing on chairs, step stools, or ladders."

B c d e f

The nurse teaches a patient with osteoarthritis (OA) of the hip about how to manage the OA. Which patient statement indicates to the nurse a need for additional teaching? A. "A shower in the morning will help relieve stiffness." B. "I can exercise every day to help maintain joint mobility." C. "I will take 1 gram of acetaminophen (Tylenol) every 4 hours." D. "I can use a cane to decrease the pressure and pain in my hip."

C

When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

C

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Muscle twitching and finger numbness d. Upper abdominal tenderness and guarding

C

A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? a. Assess vital signs every 15 minutes. b. Dim or turn off lights in the client's room. c. Place the client in bed with the upper side rails up. d. Provide a cool, wet cloth for the client's face.

C

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? a. Hyperreflexia b. Positive reflexes c. Flaccid paralysis d. Reflex emptying of the bladder

C - Flaccid paralysis.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has slight elevations in liver function test results.

D

After teaching a client who is diagnosed with new-onset epilepsy and prescribed phenytoin, the nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "To prevent complications, I will drink at least 2 L of water daily." b. "This medication will stop me from getting an aura before a seizure." c. "I will not drive a motor vehicle while taking this medication." d. "Even when my seizures stop, I will continue to take this drug."

D

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? a. Diabetes b. Alcohol use c. High-protein diet d. Cigarette smoking

D

Which assessment finding is of most concern for a patient with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D

The nurse states on shift handoff that the client has an elevated uric acid level of 8.2 mg/dL (487.8 mmol/L). Which inflammatory process would the nurse assess for during client assessment? a. Lupus erythematosus b. Osteoporosis c. Rheumatoid arthritis d. Gout

D. Gout

When caring for a client with myasthenia gravis, the nurse should assess the client for which manifestations of cholinergic crisis? (Select all that apply.) ccn Flaccid paralysis Bradycardia Abdominal cramps Hypersecretions

I think all of them **

A female client is suspected of having a vaginal infection caused by the organism Candida albicans. Which assessment question would elicit data associated with this infection? ccn a. "Have you had any vaginal discharge?" b. "Do you have any blood in your urine?" c. "Have you had any flank pain or headaches?" d. "Have you noticed any swelling in your feet?"

a. "Have you had any vaginal discharge?"

A client has recurrent vulvovaginitis. Which statements by the client indicate a need for further teaching? a. "I can take a long, hot bath to relieve itching." b. "I need to take all of my antibiotics as prescribed." c. "I should avoid having sex until my infection is gone." d. "I should not douche or use feminine hygiene sprays." e. "I should use antibacterial soap to clean the area." f. "I should switch to wearing only cotton underwear."

a. "I can take a long, hot bath to relieve itching." b. "I need to take all of my antibiotics as prescribed." e. "I should use antibacterial soap to clean the area."

A client asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). Which response is correct? a. "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." b. "OA affects joints on both sides of the body. RA is usually unilateral." c. "OA is more common in women. RA is more common in men." d. "OA and RA are very similar. OA affects the smaller joints and RA affects the larger, weight-bearing joints."

a. "OA is a noninflammatory joint disease. RA is characterized by inflamed, swollen joints."

A nurse is promotion teaching to a group of older adults. Which information will the nurse include when teaching about routine glaucoma testing? a. A tono-pen will be applied to the surface of the eye. b. The test involves reading a Snellen chart from 20 feet. c. Medications will be used to dilate the pupils for the test. d. The examination involves checking the pupil's reaction to light.

a. A tono-pen will be applied to the surface of the eye.

The nurse is teaching a client about medications for HIV 2 treatment. What drugs are paired with the correct information? a. Abacavir: avoid fatty and fried foods. b. Efavirenz: take 1 hour before or 2 hours after antacids. c. Atazanavir: check pulse daily and report pulse greater than 100 beats/min. d. Dolutegravir: do not take this medication if you become pregnant. e. Enfuvirtide: teach client how to operate syringe infusion pump for administration. f. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

a. Abacavir: avoid fatty and fried foods. b. Efavirenz: take 1 hour before or 2 hours after antacids. f. All drugs: you must adhere to the drug schedule at least 90% of the time for effectiveness.

A 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? a. Alpha-fetoprotein (AFP) b. Prostate-specific antigen (PSA) c. Prostate acid phosphatase (PAP) d. C-reactive protein (CRP)

a. Alpha-fetoprotein (AFP)

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? a. Altered breathing pattern b. Increased likelihood of injury c. Ineffective oxygen consumption d. Increased susceptibility to aspiration

a. Altered breathing pattern

A client with HIV 3 is hospitalized with P. jiroveci pneumonia and is started on the drug of choice for this infection. What laboratory values would be most important for the nurse report to the primary health care provider? (Select all that apply.) a. Aspartate transaminase, alanine transaminase: elevated b. CD4+ cell count: 180/mm3 c. Creatinine: 1.0 mg/dL d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

a. Aspartate transaminase, alanine transaminase: elevated d. Platelet count: 80,000/mm3 e. Serum sodium: 120 mEq/L

53. The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? (Select all that apply.) a. Avoid activities that require bending over. b. Contact the surgeon if eye scratchiness occurs. c. Place an eye shield on he surgical eye at bedtime d. Episodes of sudden severe pain in the ye are expected e. Contact the surgeon if a decrease in visual acuity occurs f. Take acetaminophen (Tylenol) for minor eye discomfort.

a. Avoid activities that require bending over. c. Place an eye shield on he surgical eye at bedtime e. Contact the surgeon if a decrease in visual acuity occurs f. Take acetaminophen (Tylenol) for minor eye discomfort.

The nurse is reviewing a client's record and notes that the health care provider has documented that the client has chronic renal disease. On review of the laboratory results, the nurse most likely would expect to note which finding? a. Elevated creatinine level b. Decreased hemoglobin level c. Decreased red blood cell count d. Increased number of white blood cells in the urine

a. Elevated creatinine level

The nurse is obtaining a health history from a client who has a sliding hiatal hernia associated with reflux. The nurse should ask the client about the presence of which symptom? a. Heartburn. b. Jaundice. c. Anorexia. d. Stomatitis.

a. Heartburn

The nurse is preparing a plan of care for a client with sickle cell crisis who will be admitted to the nursing unit. The nurse should include which intervention as a priority in the plan of care for the client? a. Initiate an intravenous (IV) line for the administration of fluids. b. Consult with the psychiatric department regarding genetic counseling. c. Call the blood bank and request preparation of a unit of packed red blood cells. d. Call the respiratory department to prepare for intubation and mechanical ventilation.

a. Initiate an intravenous (IV) line for the administration of fluids.

The nurse has determined that a client with a neurological disorder also has difficulty breathing. Which activities would be appropriate components of the care plan for this client? (Select all that apply.) a. Keep suction equipment at the bedside. b. Elevate the head of the bed 30 degrees. c. Keep the client lying in a supine position. d. Keep the head and neck in good alignment. e. Administer prescribed respiratory treatments as needed.

a. Keep suction equipment at the bedside. b. Elevate the head of the bed 30 degrees. d. Keep the head and neck in good alignment. e. Administer prescribed respiratory treatments as needed.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? (Select all that apply.) a. Nocturia b. Incontinence c. Enlarged Prostate d. Nocturnal Emissions e. Decreased desire for sexual intercourse

a. Nocturia b. Incontinence c. Enlarged Prostate

The client has just had a total knee replacement. When assessing the client, which finding should lead the nurse to suspect possible nerve damage? a. Numbness b. bleeding c. dislocation d. pinkness

a. Numbness

The nurse is assessing the patency of a client's left arm arteriovenous fistula prior to initiating hemodialysis. Which finding indicates that the fistula is patent? a. Palpation of a thrill over the fistula b. Presence of a radial pulse in the left wrist c. Absence of a bruit on auscultation of the fistula d. Capillary refill less than 3 seconds in the nail beds of the fingers on the left hand

a. Palpation of a thrill over the fistula

In monitoring a client's response to disease-modifying antirheumatic drugs (DMARDs), which assessment findings would the nurse consider acceptable responses? (Select all that apply.) a. Symptom control during periods of emotional stress b. Normal white blood cell, platelet, and neutrophil counts c. Radiological findings that show no progression of joint degeneration d. An increased range of motion in the affected joints 3 months into therapy e. Inflammation and irritation at the injection site 3 days after the injection is given f. A low-grade temperature on rising in the morning that remains throughout the day

a. Symptom control during periods of emotional stress b. Normal white blood cell, platelet, and neutrophil counts c. Radiological findings that show no progression of joint degeneration d. An increased range of motion in the affected joints 3 months into therapy

68. Upon waking up in the post anesthesia care unit and seeing a drain with bright red fluid in it exiting from his total hip incision, a client asks the nurse, "Is this the way it's supposed to be?" What should the nurse tell the client? a. The drainage is blood and fluid that must be drained out for healing. b. Don't worry about it. I'll explain it when you are more awake c. This blood is being kept sterile and will be given back to you. d. I'll give you something to make you sleep so you won't worry.

a. The drainage is blood and fluid that must be drained out for healing.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? (Select all that apply.) a. Turning and repositioning the client at least every 2 hours b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours

a. Turning and repositioning the client at least every 2 hours b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs

A client suspected of having systemic lupus erythematosus (SLE) is being scheduled for testing. The client asks which of the tests ordered will determine if the client is positive for the disorder. Which statement by the nurse is most accurate? a. "You should discuss that matter with your physician." b. "The diagnosis won't be based on the findings of a single test but by combining all data found." c. "SLE is a very serious systemic disorder." d. "Tell me more about your concerns about this potential diagnosis."

b. "The diagnosis won't be based on the findings of a single test but by combining all data found."

A client has a neurological deficit involving the limbic system. On assessment, which finding is specific to this type of deficit? a. Is disoriented to person, place, and time. b. Affect is flat, with periods of emotional lability. c. Cannot recall what was eaten for breakfast today. d. Demonstrates inability to add and substract; does not know who is the president of the United States.

b. Affect is flat, with periods of emotional lability

A client with Crohn's disease is scheduled to receive an infusion on infliximab. What intervention by the nurse will determine the effectiveness of treatment? a. Monitoring the leukocyte count for 2 days after the infusion b. Checking the frequency and consistency of bowel movements c. Checking serum liver enzyme levels before and after the infusion d. Carrying out a Hematest on gastric fluids after the infusion is completed

b. Checking the frequency and consistency of bowel movements

The community health nurse is preparing an educational class on ovarian cancer for a group of women. Which signs and symptoms should the nurse include in the presentation? (Select all that apply.) a. Feeling hungry all the time b. Having urinary urgency or frequency c. Experiencing pelvic or abdominal swelling d. Sense of feeling that something is "falling out" e. Developing a macular-papular rash over the abdomen

b. Having urinary urgency or frequency c. Experiencing pelvic or abdominal swelling

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? (Select all that apply.) a. Ice b. Heat c. Analgesics d. Muscle relaxers e. Intermittent traction

b. Heat c. Analgesics d. Muscle relaxers e. Intermittent traction

The nurse assigned to the care of an unconscious client is making initial daily rounds. On entering the client's room, the nurse observes that the client is lying supine in bed, with the head of the bed elevated approximately 5 degrees. The nasogastric tube feeding is running at 70 mL/hr, as prescribed. The nurse assesses the client and auscultates adventitious breath sounds. Which judgement should the nurse formulate for the client? a. Impaired nutritional intake b. Increased risk for aspiration c. Increased likelihood for injury d. Susceptibility to fluid volume deficit

b. Increased risk for aspiration

. The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? a. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure c. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure d. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

b. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The nurse is caring for a client with acute kidney injury (AKI). The nurse should test the client's urine for proteinuria to determine which type of AKI? a. Prerenal b. Intrinsic c. Atypical d. Postrenal

b. Intrinsic

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? a. Nausea and vomiting b. Severe boring abdominal pain c. Jaundice and itching d. Elevated temperature

b. Severe boring abdominal pain

A client has been on treatment for rheumatoid arthritis for 3 weeks. During the administration of etanercept, which is most important for the nurse to assess? a. The injection site for itching and edema. b. The white blood cell counts and platelet counts c. Whether the client is experiencing fatigue and joint pain. d. Whether the client is experiencing a metallic taste in the mouth, and a loss of appetite.

b. The white blood cell counts and platelet counts

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. The client reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? a. Bell's palsy b. Trigeminal neuralgia c. Migraine headache d. Angina pectoris

b. Trigeminal neuralgia

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? a. Calcium level of 9.0 mg/dL (2.25 mmol/L) b. Uric acid level of 9.0 mg/dL (0.54 mmol/L) c. Potassium level of 4.1 mEq/L (4.1 mmol/L). d. Phosphorus level of 3.1 mg/dL (1.0 mmol/L)

b. Uric acid level of 9.0 mg/dL (0.54 mmol/L)

The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further teaching if the client makes which statement? a. "I will wash my face with cotton pads." b. "I'll have to start chewing on my unaffected side." c. "I'll try to eat my food either very warm or very cold." d. "I should rinse my mouth if toothbrushing is painful." e. "I'll try to eat my food either very warm or very cold."

c. "I'll try to eat my food either very warm or very cold."

An adolescent seen in the health care clinic has been diagnosed with endometriosis. The client asks the clinic nurse to describe this condition. Which response should the nurse provide? ccn a. "It always causes infertility." b. "It causes the cessation of menstruation." c. "It is the presence of tissue outside the uterus." d. "It is also known as primary dysmenorrhea."

c. "It is the presence of tissue outside the uterus."

A miotic medication has been prescribed for the client with glaucoma and the client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client? a. "The medication will help dilate the eye to prevent pressure from occurring." b. "The medication will relax the muscles of the eyes and prevent blurred vision." c. "The medication causes the pupil to constrict and will lower the pressure in the eye." d. "The medication will help block the responses that are sent to the muscles in the eye."

c. "The medication causes the pupil to constrict and will lower the pressure in the eye."

A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen? a. "My ulcer will heal because these medications will kill the bacteria." b. "These medications are only taken when I have pain from my ulcer." c. "The medications will kill the bacteria and stop the acid production." d. "These medications will coat the ulcer and decrease the acid production in my stomach."

c. "The medications will kill the bacteria and stop the acid production."

A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication would the nurse identify as the cause of the client's complaint? a. Doxycycline b. Atropine sulfate c. Acetylsalicylic acid d. Diltiazem hydrochloride

c. Acetylsalicylic acid

The client has a regular 32-day cycle. She asks on which day she most likely ovulates. How should the nurse reply? a. Day 14 b. Day 16 c. Day 18 d. Day 20

c. Day 18

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration? a. Using adult diapers b. Inserting a Foley catheter c. Establishing a toileting schedule d. Padding the bed with an absorbent cotton pad

c. Establishing a toileting schedule

Betaxolol hydrochloride eye drops have been prescribed for a client with glaucoma. Which nursing action is most appropriate related to monitoring for side and adverse effects of this medication? a. Assessing for edema b. Monitoring temperature c. Monitoring blood pressure d. Assessing blood glucose level

c. Monitoring blood pressure

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successful to this problem if the client demonstrates proper use of which item? a. Walker b. Slider board c. Raised toilet seat d. Adaptive eating utensils

c. Raised toilet seat

A client has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed? a. Weight loss b. Relief of heartburn c. Reduction of steatorrhea d. Absence of abdominal pain

c. Reduction of steatorrhea

A client is admitted with acute pancreatitis. The nurse should monitor which laboratory values: a. Creatinine and BUN. b. Troponin and CK-MB. c. Serum amylase and lipase. d. Serum bilirubin and calcium.

c. Serum amylase and lipase.

The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? a. Speak loudly, but mumble or slur the words. b. Speak loudly and clearly while facing the client. c. Speak at normal tone and pitch, slowly and clearly. d. Speak loudly and directly into the client's affected ear.

c. Speak at normal tone and pitch, slowly and clearly.

. A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear? a. Hearing loss b. Pruritus c. Tinnitus d. Burning of the ear

c. Tinnitus

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder? a. Total loss of vision b. Pain in the affected eye c. A yellow discoloration of the sclera d. A sense of a curtain falling across the field of vision

d. A sense of a curtain falling across the field of vision

A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan? a. Monitoring the temperature b. Monitoring complaints of heartburn c. Giving warm gargles for a sore throat d. Assessing for the return of the gag reflex

d. Assessing for the return of the gag reflex

Which medication, if prescribed for the client with glaucoma, should the nurse question? a. Betaxolol b. Pilocarpine c. Erythromycin d. Atropine sulfate

d. Atropine sulfate

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? a. Diplopia b. Eye pain c. Floating spots d. Blurred vision

d. Blurred vision

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery. a. Cranial nerve I, olfactory b. Cranial nerve IV, trochlear c. Cranial nerve III, oculomotor d. Cranial nerve VII, facial nerve

d. Cranial nerve VII, facial nerve

70. The nurse is collecting data from a client. Which symptoms described by the client is characteristic of an early symptom of benign prostatic hyperplasia? a. Nocturia b. Scrotal edema c. Occasional constipation d. Decreased force in the stream of urine

d. Decreased force in the stream of urine

The nurse is preparing to care for a client with chronic kidney disease and anemia. Which describes the relationship between chronic kidney disease and anemia? a. Lack of angiotensin I may cause anemia b. Increased production of aldosterone leads to anemia c. Anemia is caused by insufficient production of renin d. Decreased production of erythropoietin is causing anemia

d. Decreased production of erythropoietin is causing anemia

A client who was diagnosed with toxic shock syndrome (TSS) now exhibits petechiae, oozing from puncture sites, and coolness of the digits of the hands and feet. Clotting times determined for this client are prolonged. The nurse interprets these clinical signs as being most compatible with which condition? a. Heparin overdose b. Vitamin K deficiency c. Factor VIII deficiency d. Disseminated intravascular coagulopathy (DIC)

d. Disseminated intravascular coagulopathy (DIC)

The nurse is admitting a client with multiple trauma injuries to the nursing unit. The client has a leg fracture and had a plaster cast applied. Which position would be best for the casted leg? a. Flat for 12 hours, then elevated for 12 hours b. Elevated for 3 hours and then flat for 1 hour c. Flat for 3 hours and then elevated for 1 hour d. Elevated on pillows continuously for 24 to 48 hours

d. Elevated on pillows continuously for 24 to 48 hours

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. Decrease fluid intake to control the intraocular pressure b. Avoid overuse of the eyes c. Decrease the amount of salt in the diet d. Eye medications will need to be administered lifelong.

d. Eye medications will need to be administered lifelong.

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply.) a. Diarrhea b. Black, tarry stools c. Hyperactive bowel sounds d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back

d. Gray-blue color at the flank e. Abdominal guarding and tenderness f. Left upper quadrant pain with radiation to the back

The client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. Which past medical history finding makes the client most at risk for this disease? a. Meningitis or encephalitis during the last 5 years b. Seizures or trauma to the brain within the last year c. Back injury or trauma to the spinal cord during the last 2 years d. Respiratory or gastrointestinal infection during the previous month

d. Respiratory or gastrointestinal infection during the previous month

The nurse is performing an assessment on a client with a diagnosis of anemia that developed as a result of blood loss after a traumatic injury. The nurse should expect to find which sign or symptom in the client as a result of the anemia? a. Bradycardia b. Muscle cramps c. Increased respiratory rate d. Shortness of breath with activity

d. Shortness of breath with activity

Alendronate is prescribed for a client with osteoporosis and the nurse is providing instructions on administration of the medication. Which instruction should the nurse provide? a. Take the medication at bedtime. b. Take the medication in the morning with breakfast c. Lie down for 30 minutes after taking the medication d. Take the medication with a full glass of water after rising in the morning.

d. Take the medication with a full glass of water after rising in the morning.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. Which client activity suggests that teaching is most effective? a. Eating large, well-balanced meals b. Doing muscle strengthening exercises c. Doing all chores early in the day while less fatigued d. Taking medications in time to maintain therapeutic blood levels

d. Taking medications in time to maintain therapeutic blood levels

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? a. hemorrhage b. edema of the residual limb c. slight redness of the incision d. separation of the wound edges

d. separation of the wound edges

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition? a. intestinal obstruction b. peptic ulcer with melena c. diverticulitis with perforation d. vomiting following cancer chemotherapy

d. vomiting following cancer chemotherapy

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

respiratory acidosis