Med Surge (Monica) + Random Banks Q&A

A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?

Basal cell carcinoma is a localized lesion that seldom metastasizes.

A nurse is reviewing the laboratory results for four clients. The nurse should recognize that which of the following clients has a manifestation of primary hyperparathyroidism?

The client who has an increased magnesium level Magnesium level is increased in a client who has primary hyperparathyroidism.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? The fourth heart sound (S4) A friction rub The third heart sound (S3) A split second heart sound S2

The fourth heart sound (S4) S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle.

A nurse is teaching a client about the uses of aloe vera. Which of the following information should the nurse include in the teaching?

"Aloe vera can act as a laxative Aloe vera has a laxative effect when taken orally

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.) Affects weight-bearing joints Crepitus can occur in affected joints Affects bilateral, symmetrical joints Causes joint stiffness Causes joint pain

Affects weight-bearing joints is correct. Crepitus can occur in affected joints is correct. Causes joint stiffness is correct. Causes joint pain is correct.

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care? Airway protection Decreasing intracranial pressure Stabilizing cardiac arrhythmias Preventing musculoskeletal disability

Airway protection When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway.

A nurse in a clinic is caring for a client who has recently begun taking warfarin. The nurse is reviewing potential drug and food interaction risks and should instruct the client to avoid which of the following?

Cabbage Cabbage should be limited in the diet when taking warfarin, because it is rich in vitamin K.

A nurse is teaching a class about providing emergency care for clients who have a sports-related injury. Which of the following information should the nurse include?

Compress the injury for 24 hr. he nurse should apply compression for the first 24 to 48 hr to reduce swelling.

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?

Cytotoxic The nurse should recognize myasthenia gravis as a cytotoxic hypersensitivity. Other examples of this hypersensitivity include autoimmune hemolytic anemia and Goodpasture's syndrome.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition? ?Anorexia ?Knuckle deformity ?Low-grade fever Weight loss

Knuckle deformity ?Joint deformity is a late manifestation of RA.

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect? Lethargy Exophthalmos Weight loss Photophobia

Lethargy The nurse should identify that lethargy is a manifestation of hypothyroidism. A client who has hypothyroidism reports weakness, fatigue, and somnolence.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?

Manifestations of the virus are similar to flu-like symptoms. The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction? Check the client's blood pressure. Auscultate heart tones. Perform a 12-lead ECG Determine if pain radiates to the left arm.

Perform a 12-lead ECG ?The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction

A nurse is planning care for a client following a cardiac catheterization accessed through his femoral artery. Which of the following actions should the nurse plan to take?

Perform neurovascular checks with vital signs. The nurse should assess color, temperature, and pulse in the affected extremity and monitor the client for neurovascular changes that can indicate a stroke, such as slurred speech and visual disturbances.

A nurse is teaching a client who has gout about medications. The nurse should teach the client to avoid the use of which of the following types of medication?

Salicylates Salicylates, such as aspirin, and diuretics can trigger gout attacks.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following? Serous Purulent Sanguineous Serosanguineous

Serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Skin tenting present A client who has dehydration has poor skin turgor, or skin tenting, which the nurse should observe for over the sternum or the back of the hand.

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? Edematous bruise on forehead Small drops of clear fluid in left ear Pupils are 4 mm and reactive to light Glasgow Coma Scale (GCS) score of 12

Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia.

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

identification wristband This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority..

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear?

loud, scratchy sounds Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy.

A nurse is caring for a client who has expressive aphasia following a cerebrovascular accident (CVA). Which of the following parameters should the nurse use first in order to assess the client's pain level?

A self-report pain rating scale Expressive aphasia results from damage to an area of the frontal lobe and is a motor speech problem. The client who has expressive aphasia is able to understand what is said but is unable to communicate verbally

A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching?

CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires.

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

I will be certain to take enteric-coated medications."

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?

Identify effective stress reduction techniques. Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?

Quantitative RNA assay A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain? Prone with her arms raised above her head Semi-Fowler's with a pillow under her knees Supine with her arms elevated on pillows Supine with the head of the bed elevated to 15°

Semi-Fowler's with a pillow under her knees. Low back pain is an expected manifestation of a herniated lumbar disc. Sitting partially upright with knee flexion helps to relax the lumbar muscles and takes pressure off the spinal nerve root, which promotes comfort for the client.

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect? Loss of consciousness lasting 30 to 60 min Glasgow Coma Scale score of 11 Nuchal rigidity Sensitivity to light

Sensitivity to light The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise.

A nurse is caring for a client who is scheduled for a bone marrow aspiration. The client asks the nurse about the sites the provider might use for the procedure. Which of the following locations should the nurse identify as one of the sites used for this procedure? Femur Humerus Sternum Ribs

Sternum Providers most often extract bone marrow from the iliac crest of adults, but they sometimes use the sternum.

A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include? "Cover areas of excoriated skin with cream." "Use hot water to soothe the lesions." "Cover area with an occlusive dressing after application." "Use the cream for a few days after the area has healed."

"Use the cream for a few days after the area has healed." The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence.

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

"Wash your hair with a mild protein shampoo." Clients who have SLE are prone to hair loss and should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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The nurse should inform the family to monitor for syncope, which places the client at risk for falling.

Acetaminophen According to the American Pain Society, acetaminophen is the primary drug of choice for treating osteoarthritis. The provider would likely begin with this medication.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first? Insert an oral airway. Administer the abdominal thrust maneuver. Turn the client to the side. Perform a blind finger sweep.

Administer the abdominal thrust maneuver. The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client that which of the following beverages can trigger an attack?

Alcohol Alcohol can trigger painful gout attacks.

FLAG A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment? Breast cancer survivor for 8 years Pacemaker 65-years of age Alcohol use disorder

Alcohol use disorder The nurse should identify that a substance use disorder is a contraindication for kidney transplant

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?

Apply direct pressure over the wound. The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take is to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding.

FLAG A nurse is interpreting the ECG strip of a client who has bradycardia. Which of the following cardiac components should the nurse identify as the role of the P wave? Ventricular depolarization Slow repolarization of ventricular Purkinje fibers Atrial depolarization Early ventricular repolarization

Atrial depolarization The P wave reflects atrial depolarization, typically initiated in the sinoatrial node

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.) Avoid prolonged sitting. Apply heat for 10 min every hour. Sleep in a side-lying position with flexed knees. Sleep on a soft mattress. Try padded shoe insoles.

Avoid prolonged sitting is correct. Staying in any one position for too long, even lying down, can worsen back pain. Changing positions frequently is essential. Sleeping in a side-lying position with flexed knees is correct. Try padded shoe insoles is correct.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Blood pressure 115/68 mmHg The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client to take which of the following supplements while taking this medication?

Calcium and vitamin D Long-term use of glucocorticoids, such as prednisone, places the client at risk for osteoporosis. The nurse should instruct the client to take calcium and vitamin D supplements to reduce this risk.

FLAG A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions? Carbon monoxide poisoning Heat stroke Hypersensitivity reaction Oxygen toxicity

Carbon monoxide poisoning These findings are consistent with a moderate level (21% to 41%) of carbon monoxide poisoning.

The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

Change the IV tubing every 24 hr. The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing.

A nurse is planning to perform a blood transfusion for a client. Which of the following actions should the nurse plan to take? (Select all that apply.)

Check vital signs before transfusion is correct. The nurse should check the client's vital signs immediately before starting the transfusion to create a baseline in order to assess a change in the vital signs during the transfusion. Insert an IV with a 19-gauge needle is correct. The nurse should insert a large bore IV to transfuse the blood easily. Check the expiration date of the blood product with a second nurse is correct.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

Cover the area with saline-soaked sterile dressings. The nurse should cover the wound with a sterile, saline-soaked dressing to keep the exposed organs and tissues moist.

nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Decreased serum calcium level A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown.

A nurse is assessing a client who is in a body cast. Which of the following manifestations should the nurse identify as possible cast syndrome?

Dilated pupils cast syndrome is a reaction to wearing a large cast, which produces physical and psychological effects on the client, similar to claustrophobia. Cast syndrome can lead to paralytic ileus, or gangrenous bowel.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

Drink 3 L of fluid every day. The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.

A nurse is assessing a client who has infective endocarditis. Which of the following findings should be the priority for the nurse to report to the provider?

Dyspnea The client who has infective endocarditis and develops dyspnea, tachycardia, or a cough might be developing heart failure or experiencing pulmonary emboli, two complications of the infection.

A nurse is assessing a client who is 24 hr postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)? Dyspnea Red-brown petechiae Headache Agitation

Dyspnea Dyspnea is an early manifestation of FES that occurs due to hypoxemia.

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions? Immerse the legs in cool water. Elevate the legs. Massage the legs. Apply dry heat to the legs.

Elevate the legs. When the extremities are rewarmed, it is necessary to handle the injured area carefully because the skin and tissues are fragile. Elevating the client's legs above the level of the heart is done to help prevent an increase in edema.

FLAG A nurse is preparing an in-service for coworkers about various herbal supplements clients might report using. The nurse should include in the presentation that which of the following herbal supplements is used to help the client lose weight? Licorice Feverfew Comfrey Ephedra

Ephedra The nurse should identify that ephedra is an extremely dangerous weight loss supplement; however, clients may still report using it for weight loss

A charge nurse is teaching a group of nurses about agonists and antagonists. The nurse should include in the teaching that which of the following agonist medications binds to receptors and causes activation that affects the cardiovascular system?

Epinephrine The nurse should include that epinephrine is an agonist that activates the receptors that affect the cardiovascular system in clients who are at risk for cardiac collapse.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial rash SLE causes a characteristic facial "butterfly" rash that is dry, scaly, red, and raised.

check .......A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

Fat embolism The nurse should suspect that client has fat embolism syndrome. This complication develops within 12 to 48 hr of a fracture and can cause dyspnea, respiratory distress, alterations in mental status, tachycardia, and other manifestations. Older adults who have hip fractures are at greater risk.

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?

Graham crackers After establishing that the client has hypoglycemia, the nurse should give the client about 15 g of a rapid-acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk, 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. The nurse should recheck the client's blood glucose level in 15 minutes.

A client who has a fever of unknown origin Prophylactic antibiotic therapy is not recommended for clients who have a fever of unknown origin.

Hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

A nurse is assessing a client who has right ventricular failure. Which of the following findings should the nurse expect? Dry, hacking cough Hepatomegaly Dizziness Crackles in the lungs

Hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache? Administer pain medication. Darken the client's room and close the door. Increase fluid intake. Elevate the head of the bed to 30º.

Increase fluid intake. The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes. The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take? Place the client in a negative airflow room. Keep blood pressure equipment in the client's room. Monitor the client's vital signs once every 8 hr. Provide the client with 1,000 mL of water to drink every 12 hr.

Keep blood pressure equipment in the client's room. The nurse should keep and use dedicated equipment, such as blood pressure monitor, stethoscope and thermometer in the client's room to prevent the spread of infection from client to client.

A nurse is providing discharge teaching for a client who is postoperative following an inner maxillary fixation for facial fractures. Which of the following instructions should the nurse include in the teaching?

Keep wire cutters with you. The client should have wire cutters at all times to cut the mandibular wires if vomiting occurs, to reduce the risk for aspiration

This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority..

Limit IM injections. The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward.

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

Lubricate lips with water-soluble ointment is correct. Brush teeth with a soft toothbrush is correct. Blow nose gently is correct.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is teaching with a client about taking high doses of oral glucocorticoids for an extended period of time to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

Monitor for compression fractures of the back and neck." High-dose, long-term use of glucocorticoids can result in bone loss in the back and neck within weeks of starting the medication. Clients experience an increase in parathyroid hormone, which causes calcium to move out of the bones can result in fractures.

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity? "I am gaining weight." "I am constipated." "My vision seems yellow." "My tongue is red and beefy."

My vision seems yellow." Blurred and yellow vision is an indication of digoxin toxicity.

A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?

Naloxone The nurse should plan to administer naloxone, which is an opiate antagonist that competes with opioids at opiate receptor sites making the opioid ineffective.

FLAG A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following information should the nurse include in the plan? (Select all that apply). Obtain a urine specimen prior to the procedure. Obtain written, informed consent. Administer diphenhydramine (Benadryl) prior to the procedure. Maintain NPO status prior to the procedure. Obtain coagulation studies.

Obtain a urine specimen prior to the procedure is correct. Obtain written, informed consent is correct. Maintain NPO status prior to the procedure is correct. Obtain coagulation studies is correct

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client? Cryoprecipitates Platelets Albumin Packed RBCs

Packed RBCs Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.

A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? Mastoiditis Ménière's disease Acoustic neuroma Perforated tympanic membrane

Perforated tympanic membrane The client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

Positive Phalen's sign If a client who has carpal tunnel syndrome holds his wrist in flexion for 60 seconds, it will produce tingling and numbness over the median nerve, the palmar surface of the thumb, the index finger, the middle finger, and part of the ring finger. This is a positive Phalen's test.

A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply.)

Reduce cholesterol and saturated fat intake is correct. Increase physical activity and daily exercise is correct. Enroll in a smoking-cessation program is correct. Maintain optimal blood pressure to prevent kidney damage is correct.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take? Provide a nonskid mat to alleviate plate movement. Encourage the client to use his right hand when feeding himself. Remind the client to look for food on the left side of the tray. Encourage the use of the wide grip utensils.

Remind the client to look for food on the left side of the tray. The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.

A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.)

Sedentary lifestyle is correct. Carbonated beverages is correct. Caffeine intake is correct Smoking tobacco products is correct.

A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain?

Semi-Fowler's with a pillow under her knees Low back pain is an expected manifestation of a herniated lumbar disc. Sitting partially upright with knee flexion helps to relax the lumbar muscles and takes pressure off the spinal nerve root, which promotes comfort for the client.

FLAG A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client? High Fowler's with neck extended High Fowler's with neck in a neutral position. Semi-Fowler's with neck extended Semi-Fowler's with neck in a neutral position

Semi-Fowler's with neck in a neutral position Semi-Fowler's is the most comfortable position for a client who has had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the sutures. A neutral position is essential.

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

Serum creatinine 7 mg/dL A serum creatinine of 7 mg/dL is a critical value that indicates serious impairment of renal function. Clients who have chronic glomerulonephritis usually develop the disease over 20 to 30 years. Gradual changes occur in the kidney resulting in atrophy and a decreased number of functioning nephrons

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Slight pain at the insertion site is correct. Serous drainage on the dressing is correct. Minimal edema around the pin is correct.

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Slurred speech is correct. Bone pain is correct. Pruritus is correct.

A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

Stridor When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is stridor, which indicates narrowing of the airway. The nurse should position the head of the client's bed at 45° or more, if tolerable, and call for emergency assistance.

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation? Tachypnea Hypertension Bradycardia Swollen calf

Tachypnea Tachypnea, dyspnea, and hypoxemia are early manifestations of fat emboli syndrome.

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take? Place the client in a negative airflow room. Keep blood pressure equipment in the client's room. Monitor the client's vital signs once every 8 hr. Provide the client with 1,000 mL of water to drink every 12 hr.

Thyroid stimulating hormone (TSH) The nurse should anticipate that TSH will be elevated.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Western blot analysis The Western blot analysis is used to confirm seropositivity when the ELISA test has a positive result. ELISA is inexpensive and accurate with few false-positives. Western blot is expensive, so is done only for confirmation.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention? Auscultate the client's lungs. Assist the client to a side-lying position. Provide oral hygiene. Withhold oral fluids and food.

Withhold oral fluids and food. o rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

A client is prescribed 1 g potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g potassium phosphate in 250 mL dextrose 5% water (D5W). The nurse should set the IV pump to run at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

X mL/hr = 41.6666 mL/hr= 42

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching?

You may experience drowsiness while taking this medication." The nurse should instruct the client that drowsiness can occur while taking this medication and to exercise caution while performing activities that require alertness.

FLAG A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg

pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.

A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching? "I will be able to eat solid food when I wake up from anesthesia." "I will have a glass of juice the morning of my surgery." "I understand what risks I can expect with this surgery." "I will take time to relax if I get nervous the night before surgery."

"I will be able to eat solid food when I wake up from anesthesia Clients who undergo open abdominal surgery will usually have an NG tube in place. The client will remain NPO until the nurse removes the tube. Once the nurse removes the tube, the client can start to drink clear liquids and progress to more solid fluids as she is able to tolerate them

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

"I will feel shaky."Manifestations of hypoglycemia include feeling shaky and nervous.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

"I will lie on my right side to sleep at night." Sleeping in a right side-lying position helps reduce the manifestations of nighttime reflux. The client can also elevate the head of the bed about 10.2 cm (4 in) to 30.5 cm (12 in) on blocks

A nurse is teaching the family of a client who has Alzheimer's disease about donepezil. Which of the following information should the nurse include in the teaching?

"Syncope episodes may occur when taking this medication." The nurse should inform the family to monitor for syncope, which places the client at risk for falling.

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

"This procedure will replace my joint to improve function." Arthroplasty is the reconstruction or replacement of a joint. This procedure is done to relieve pain, improve or maintain range of motion, and correct the present deformity.

A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include? "An indurated area of 4 millimeters indicates a positive result." "The injection site will be evaluated within 24 hours." "This test is performed if previous results are negative." "A positive result suggests active infectious disease."

"This test is performed if previous results are negative." The nurse should assess whether the client has tested positive to a prior PPD test. For clients who have tested positive, chest x-ray is performed to determine exposure.

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD). Which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so that the environment is warm. The client's instructions should include keeping the environment warm to prevent vasoconstriction. Wearing gloves, warm clothes, and socks will help prevent vasoconstriction.

A nurse in the emergency department is assessing a newly admitted client who has facial trauma. Which of the following assessments is the nurse's priority? Soft-tissue edema Facial asymmetry Active bleeding Altered respirations

Altered respirations When using the airway, breathing, circulation approach to client care, the nurse determines that the priority is to assess the client's respirations, because edema from the client's injuries could cause airway obstruction. The nurse should assess the client's airway for stridor, shortness of breath, and dyspnea.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Apply hydrating lotions. The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take? Place the client in a negative airflow room. Keep blood pressure equipment in the client's room. Monitor the client's vital signs once every 8 hr. Provide the client with 1,000 mL of water to drink every 12 hr.

Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect? Decreased brain natriuretic peptide (BNP). Elevated central venous pressure (CVP). Increased pulmonary artery wedge pressure (PAWP). Decreased specific gravity

Elevated central venous pressure (CVP). CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure

A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make?

Encourage the client to write down questions to ask the provider. The nurse does not know the answers to the client's questions, so helping the client to prepare questions for the provider addresses the client's needs.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? Atelectasis Flail chest Hemothorax Pneumothorax

Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.

A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations?

Frequent mood changes Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They often cannot sit quietly.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect? Jugular venous distention Abdominal distension Dependent edema Hacking cough

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication? Hot flashes Insomnia Increased appetite Constipation

Hot flashes are a common adverse effect of tamoxifen. Other adverse effects include fluid retention and vaginal discharge. The nurse should advise the client these effects should subside when therapy is discontinued.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort. Which of the following instructions should the nurse include in the teaching? "Limit your dietary intake of salt prior to menses." ?"Reduce your fluid intake to 1 liter per day during menstruation." "Remove your bra at night while sleeping." "Take tub baths to avoid hot water running over your breast tissue."

Limit your dietary intake of salt prior to menses." The nurse should instruct the client to limit sodium intake before menstruation, which helps minimize swelling and reduces pain and tenderness

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take? Insert a padded tongue blade into the client's mouth. Place a pillow under the client's head. Gently restrain the client's extremities. Apply a face mask for oxygen administration.

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse take? Apply an ice pack to the site of the bite. Apply a tourniquet just above the elbow. Administer a corticosteroid. Place the extremity in a dependent position.

Place the extremity in a dependent position. The affected area should be placed in a dependent position to decrease the circulation of venom.

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings? Poor impulse control Unable to discriminate words and letters Deficits in the right visual field Motor retardation

Poor impulse control A client who had a stroke involving the right cerebral hemisphere is likely to have personality changes, which can include impulsiveness, confabulation, and poor judgment.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider? Client report of feelings of depression. Dry, raised rash on the face. Presence of peripheral edema. Joint pain in hands and knees.

Presence of peripheral edema. The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen A rigid, boardlike abdomen is a manifestation of peritonitis.

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

Semi-Fowler's The nurse should expect a prescription to place the client in semi-Fowler's position following a traditional cholecystectomy to facilitate lung expansion as well as coughing and deep breathing. This position will place minimal stress on the abdomen and increase comfort.

FLAG A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.) Color Temperature Ecchymosis Skin integrity Sensation

color is correct. Temperature is correct. Sensation is correct.

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? "I will need to wipe my perineal area from back to front after urination." "I will need to empty my bladder regularly and completely." "I will need to drink apple cider vinegar each day." "I need to drink 8 cups of liquid each day."

"I will need to wipe my perineal area from back to front after urination." Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

A nurse is caring for a client who has just undergone insertion of a femoral head prosthesis. The nurse should instruct the client to avoid which of the following activities?

Putting on shoes and socks The client should not bend over to put on shoes and socks. It increases the risk of dislocation of the prosthesis to create more than 90º of flexion at the hip. The client should use an assistive or adaptive device for putting on shoes and socks.

The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.

A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching? "Expect the foot to be numb for several days postoperatively." "Rest frequently with your foot elevated." "Expect the foot to take at least 3 weeks to heal." "Walk primarily on the heel to relieve pressure on the toes."

Rest frequently with your foot elevated." The client should rest and elevate the foot to help reduce discomfort and prevent edema.

A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication? The antidote for warfarin is protamine. The client's aPTT should be monitored. The client should be observed for manifestations of hemorrhage. Warfarin can be administered along with NSAIDS.

The client should be observed for manifestations of hemorrhage. The nurse should observe for manifestations of hemorrhage because it is an adverse side effect of warfarin, which has anticoagulant and anti-inflammatory actions.

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? "Rest in a side-lying position after the tube is removed." "Use the incentive spirometer every 4 hr after the tube is removed." "Avoid speaking for long periods." "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed."

"Avoid speaking for long periods." The client should avoid speaking for long periods to promote gas exchange

A nurse is teaching a client who is starting to take methotrexate to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Drink at least 2 liters of water daily." The client should drink 2 to 3 L of water per day because methotrexate can cause kidney damage. Adequate hydration optimizes drug excretion and helps prevent renal damage.

A nurse is providing discharge instructions to a client following a cardiac catheterization. Which of the following information should the nurse include?

"You will notice a small hematoma at the incision site." Bruising and a small hematoma at the incision site are expected.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available? 10% dextrose in water (D10W) 0.45% sodium chloride (0.45% NaCl) Lactated Ringer's solution 5% dextrose in lactated Ringer's solution (D5LR)

10% dextrose in water (D10W) TPN solution has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if there is not another bag of TPN solution available. This will ensure that the client receives the adequate amount of glucose and a solution with the appropriate osmolarity until another TPN solution is available.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?

Cheyne-Stokes respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death).

A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (Select all that apply.)

Ciprofloxacin is correct. Doxycycline is correct. Amoxicillin is correct.

Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

Establish the ability to communicate effectively. A CVA is an interruption of the blood supply to any part of the brain, resulting in damaged brain tissue. The left hemisphere is usually dominant for language. Because this client had a left-side CVA, the nurse should anticipate the client will have some degree of aphasia and will require speech therapy to establish communication.

Until the gag reflex returns, and the sedation effects have resolved, the client is at high risk for aspirating food or fluids. Also, oxygen saturation should be checked every 15 min. for 2 hr.

First, the nurse should determine the amount of loss for each source of output. Client voids: 400 mL + 350 mL = 750 mL urine output this shift Chest drainage: To calculate the chest output for the current shift, the nurse should determine the difference between the previous drainage level mark and the current drainage level mark. 175 mL - 155 mL = 20 mL drainage this shift NG tube: 575 mL output this shift Jackson-Pratt drain: 25 mL output this shift Finally, the nurse should total the amounts: 750 mL + 20 mL + 575 mL + 25 mL = 1,370 mL. The nurse should document the client's output as 1,370 mL.

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Place the client in a private room with a special ventilation system. Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? Unilateral swelling on the posterior of the vulva Extreme abdominal pain with intercourse Green, malodorous vaginal discharge Postmenopausal bleeding

Postmenopausal bleeding Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women.

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first? Attach the leads for a 12-lead ECG. Obtain a blood sample. Initiate oxygen therapy. Insert the IV catheter.

initiate oxygen therapy. The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

"Eating a high fiber diet will reduce my risk for developing skin cancer." A high-fiber diet is recommended to reduce the risk for colon cancer.

A nurse is preparing a presentation about ginkgo biloba to a group of clients. Which of the following information should the nurse include in the teaching? "Ginkgo biloba can help reduce feelings of restlessness." "Ginkgo biloba may enhance wound healing." "Ginkgo biloba can improve memory." "Ginkgo biloba relieves pain and inflammation of the mouth."

"Ginkgo biloba can improve memory." Ginkgo biloba can improve memory by improving blood flow due to ginkgo-induced vasodilation.

A nurse is providing teaching to a client who has a prescription for heat therapy for treatment of cellulitis of the right lower leg. Which of the following client statements indicates an understanding of the teaching?

"I'll wrap a warm, wet towel around my right calf every 4 hours." Moist heat is more effective than dry heat in treating cellulitis. Moist heat relieves the manifestations of inflammation by increasing blood flow to the affected area. The nurse should instruct the client to elevate the right leg 8 to 15 cm (3 to 6 in) above the level of the heart and apply warm, moist heat to the site every 2 to 4 hr.

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include? "You should avoid foods high in fiber." "You should expect redness at the catheter exit site." "You should anticipate pain the first week during the inflow of dialysate." "You should warm the dialysate in a microwave oven before instillation

"You should anticipate pain the first week during the inflow of dialysate." Abdominal pain is expected during inflow of the dialysate during the first few weeks of therapy.

A nurse is reviewing guidelines for prophylactic antibiotics. The nurse should identify that prophylactic antibiotic therapy is not recommended for which of the following clients? A client who has a fever of unknown origin A client who has a prosthetic heart valve is having dental surgery A client following total hip arthroplasty A client who had an emergency cesarean section

A client who has a fever of unknown origin Prophylactic antibiotic therapy is not recommended for clients who have a fever of unknown origin.

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

Acute compartment syndrome Edema is an early manifestation of acute compartment syndrome, which is a complication that involves increased pressure within the fascia that leads to reduced circulation to the affected area.

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first? Assess the client's level of consciousness. Administer epinephrine. Auscultate for wheezing. Monitor for hypotension.

Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure? edema of the stoma Urine in the drainage appliance Redness of the stoma Feces in the drainage appliance

Feces in the drainage appliance Feces in the drainage appliance is an unexpected finding associated with this procedure. The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum that has been resected from its anatomical position and now functions as a reservoir or conduit for urine. Feces should not be draining from the conduit.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching

Instruct the client about the use of a sequential compression device. The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Instruct the client to look up and down without moving his head. The nurse should observe the client's extraocular eye movements by instructing him to look at the cardinal fields of gaze as part of an evaluation of the function of cranial nerve III (Oculomotor).

A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type 1 (HSV-1) lesions. The nurse should assess which of the following areas of the body for the recurrence of HSV-1 lesions?

Mouth HSV-1 most commonly occurs on the mouth.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)

Night sweats is correct. Low-grade fever is correct. Blood in the sputum is correct.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? Oxygen saturation of 95% No fluctuations in the water seal chamber No reports of pleuritic chest pain Occasional bubbling in the water-seal chamber

No fluctuations in the water seal chamber Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take?

Offer to administer analgesia. The nurse should offer to premedicate the client prior to painful procedures, such as physical therapy, to help keep pain under control.

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider? Report of discomfort during dialysate inflow Blood-tinged dialysate outflow Dialysate leakage during inflow Purulent dialysate outflow

Purulent dialysate outflow Peritonitis is an inflammation of the peritoneum and a major complication of peritoneal dialysis. Manifestations of peritonitis include cloudy dialysate outflow, fever, nausea, and vomiting. If untreated, the client can become severely ill, progressing to bacterial septicemia and hypovolemic shock. Peritonitis can be prevented with meticulous site care. The nurse and client should wear a mask when accessing the catheter. Strict aseptic technique should be used when connecting and disconnecting the catheter.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? Review the client's electrolyte values. Check the client's perianal skin integrity. Investigate the client's emotional concerns. Obtain a dietary history from the client.

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values? Thyroid stimulating hormone (TSH) Free T4 Serum T4 Serum T3

Thyroid stimulating hormone (TSH) The nurse should anticipate that TSH will be elevated.

A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.) Tingling in the arms Low back pain Shoulder pain Hip pain Stiff neck

Tingling in the arms is correct. . Shoulder pain is Numbness and tingling in the upper extremities are common manifestations of a herniated cervical intervertebral disc.correct.Shoulder pain, particularly on the top of the shoulders, is a common manifestation of a herniated cervical intervertebral disc Stiff neck is correctPain and stiffness in the neck are common manifestations of a herniated cervical intervertebral disc.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement? Vitamin B12 injections Iron supplements Blood transfusions Vitamin B6 supplements

Vitamin B12 injections The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption.

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider? Hct 45% WBC 1,700/mm3 Hgb 14.7 g/dL Platelets 160,000/mm3

WBC 1,700/mm3 A WBC count of 1,700/mm3 is a critical value that indicates the client is susceptible to infection. The nurse should report this value to the provider.

A nurse is caring for a client who has multiple sclerosis. Nurses' Notes Diagnostic Results Vital Signs Day 1 Speech is slurred. Bilateral hand grasps weak with intermittent fine tremors. Breath sounds clear and present throughout. Client coughs when swallowing and drools. Suction equipment placed at client's bedside. Day 3 Intermittent cough noted. Breath sounds with crackles heard in left upper lobe. A nurse is caring for a client who has multiple sclerosis. Nurses' Notes Diagnostic Results Vital Signs Day 1 Hct 38% (37% to 47%) Hgb 14 g/dL (12 g/dL to 16 g/dL) WBC 8,000/mm3 (5,000 to 10,000/mm3) Day 3 Hct 42% (37% to 47%) Hgb 16 g/dL (12 g/dL to 16 g/dL) WBC 12,000/mm3 (5,000 to 10,000/mm3) Day 1 Temperature 37.2° C (99° F) Blood pressure 118/60 mm Hg Heart rate 88/min Respiratory rate 18/min Pulse oximetry 95% on room air Day 3 Temperature 39.6° C (103.3° F) Blood pressure 106/50 mm Hg Heart rate 106/min Respiratory rate 28/min Pulse oximetry 88% on room air Select the 3 findings from day 3 that require immediate follow-up.? Hct level WBC count Respirations Blood pressure Temperature

WBC count is correct. The client's WBC count is greater than the expected reference range, indicating an infection. Therefore, this finding requires immediate follow-up. Respirations is correct. Tachypnea and a decreased oxygen saturation could indicate potential respiratory distress. Therefore, this finding requires immediate follow-up. Temperature is correct. The client's temperature is greater than the expected reference range, indicating an infection. Therefore, this finding requires immediate follow-up.

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

Withhold food and liquids until the client's gag reflex returns. Until the gag reflex returns, and the sedation effects have resolved, the client is at high risk for aspirating food or fluids. Also, oxygen saturation should be checked every 15 min. for 2 hr.

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?

Bleeding from the gums Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

Clients should have a yearly test for fecal occult blood. According to the American Cancer Society, all clients should have a yearly test to check for fecal occult blood.

A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency? A raised red rash around the fistula site Pain in the right arm proximal to the fistula site Cold and numb numbness distal to the fistula site Foul-smelling drainage from the fistula site

Cold and numb numbness distal to the fistula site Pallor and numbness distal to the fistula site are possible indicators of venous insufficiency and should be immediately reported to the provider.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Comminuted With a comminuted fracture, the impact fragments the bone into several pieces.

A nurse is caring for a client in the emergency department. Nurses' Notes 1300: A 26-year-old client presents to the emergency department. Client reported they went to their provider for a "routine physical" for their employment and "they told me to come here because my labs were abnormal." Client is alert and oriented x 3. Jaundice observed to both sclera. Respirations even and unlabored; bilateral breath sounds clear. Heart sound with S3 auscultated. Capillary refill in 4 seconds in bilateral upper and lower extremities Abdomen soft, nondistended and nontender with active bowel sounds in all quadrants. Pulses in bilateral upper extremities at +2; pulses in bilateral lower extremities +1 and cool to touch. Active ROM to all extremities but reports some stiffness and pain in both their knees. Rates pain at 3 or 4 on a 0 to 10 pain scale and states "I just live with it." 1400: Nurse called to the client's room with client reporting sudden onset of pain in their hands, legs, chest, and back. Rates pain as 7 on a pain scale of 0 to 10 as dull and achy. "This happens from time to time, but it typically goes away after a while, but it's very painful." Upon further questioning, the client states "this happens about once a month, mostly after strenuous exercise, playing a game or two of basketball, or if I have had a hard day at work." Client states "I also have priapism sometimes." lab result v1300: Hemoglobin 7.2 g/dL (14-18 g/dL) Hematocrit 22% (40%-52%) Ferritin 150 ng/mL (12-300 ng/mL) Transferrin Saturation 35% (20-50%) Total bilirubin 2.1 mg/dL Vital Signs 1300: Temperature 37.7 °C (99.9 °F) Respirations 20/min Apical pulse 88/min Blood pressure 128/64 mm Hg SaO2 94% 1400: Temperature 37.7 °C (99.9 °F) Respirations 22/min Apical pulse 94/min Blood pressure 136/72 mm Hg SaO2 92% Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Type and cross match Elevate affected extremity while in bed Venous Thromboembolism Splenic tenderness Provide client education on vasodilators Actions to Take Apply warm gloves to the client's hands open_with Perform a doppler ultrasound open_with Administer O2 at @ 2L open_with Potential Condition Sickle Cell Disease open_with Peripheral Vascular Disease open_with Raynaud's Phenomenon open_with Parameters to Monitor Hydration Status open_with Shortness of breath or chest pain open_with Ankle-brachial Index (ABI) open_with Upon recognizing and analyzing the client cues of anemia, jaundice, and acute vaso-occlusive symptoms, the nurse's priority hypotheses is that this client is most likely experiencing sickle cell anemia. It is important to generate solutions and take actions that will improve anemia and reduce the sickling of blood cells. Therefore, the nurse should draw a type and cross match and administer oxygen to increase tissue perfusion and improve gas exchange, thereby, reducing sickling of red blood cells. To evaluate these interventions, the nurse should monitor the client's hydration status and their abdomen for splenic tenderness which may indicate damage from episodes of ischemia and hypoxia.

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

Confusion Confusion, weakness and anorexia are manifestations of pneumonia in an older adult client.

A nurse is caring for a client who has COPD. Nurses' Notes Vital Signs Medication Home health nurse admission note: Client discharged from healthcare facility yesterday following a 4-day stay for exacerbation of COPD. Lives alone; alert and oriented to person, place, and time. Lung fields with scattered rhonchi throughout, cough productive for thick white sputum, dyspnea with minimal exertion. Clubbing is noted on fingers, chest is barrel-shaped. Supplemental oxygen at 2L/min via nasal cannula. Home Health Nurse Note 3 days following discharge from health care facility: Client sleeping in recliner with nasal canula on their lap; awakens easily and is oriented to person but disoriented to place and time. Lung sounds with scattered rhonchi, cough productive for thick, yellow secretions. 2+ pitting edema bilateral in ankles and feet. Re-oriented client. Client states "I don't remember if I did that breathing machine thing you told me about." Instructed client on oxygen use, safety, and nebulizer treatments. Elevated lower extremities. Home Health Nurse Admission Note: Temperature 36.7° C (98.1° F) Heart rate 87/min Respiratory rate 22/min Blood pressure 148/89 mm Hg SaO2 92% Home Health Nurse Note 3 days following discharge from health care facility: Temperature 38.3°C (101°F) Heart rate 104/min Respiratory rate 24/min Blood pressure 132/84 mm Hg SaO2 88% Indacaterol 75 mcg, one inhalation daily Acetylcysteine 20% solution 3 to 5 mL nebulizer every 6 to 8 hr while awake Select the 5 findings that require follow-up? Disorientation Barrel-shaped chest Yellow sputum Nebulizer use Ankle edema SaO2 92% Clubbing of fingers Lives alone

Disorientation is correct. Changes in orientation can indicate hypoxia or other pathologies. Therefore, this finding requires follow-up by the nurse. Yellow sputum is correct. Thick, yellow sputum is a manifestation of a respiratory infection. Therefore, this finding requires follow-up by the nurse. Nebulizer use is correct. The client is having difficulty remembering to use the nebulizer treatment which is indicated to loosen and thin thick secretions. Therefore, this finding requires follow-up by the nurse. Ankle edema is correct. Ankle edema is a manifestation of right-sided heart failure. Therefore, this finding requires follow-up by the nurse. Lives alone is correct. The client might need assistance in their home because they are having difficulty managing medications and treatments. Evaluation is necessary to identify how to assist the client. Therefore, this finding requires follow-up by the nurse.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? Metabolic alkalosis Hypervolemia Hyperkalemia Low hemoglobin

Hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

I need something for the pain in my eye. I can't stand it." Following cataract surgery, the client should expect only mild pain and should immediately report any pain, decrease in vision, or increase in discharge from the eye. Severe eye pain after surgery might indicate increased intraocular pressure or hemorrhage.

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?

Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care? Impaired tissue perfusion Alteration in body image Alteration in activity tolerance Impaired skin integrity

Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing

Increased respiratory rate When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

Potassium Potassium levels are reduced by the process of diffusion during dialysis.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first? Change in temperature of the toes. Pallor of the toes. Edema of the toes. Inability to move toes.

Pallor of the toes. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

Place a bed cradle on the client's bed. A bed cradle can reduce pain for a client who has diabetic neuropathy by preventing sheets from touching hypersensitive skin.

A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

Place suction equipment at the client's bedside. Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?

Restrict fluid intake to 1,000 mL per day. Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa.

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all that apply.)

The student should use his quick-relief inhaler is correct. The student's asthma is not well controlled is correct. The student's peak flow is 50% to 80% of his best peak flow is correct. The nurse should obtain a second expiratory flow rate is correct.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? Check the pedal pulses. Verify the most recent calcium level. Request prescription for a relaxant. Administer an oral potassium supplement.

Verify the most recent calcium level. A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

FLAG A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored? Visual acuity Skin color Urine output Cardiac rhythm

Visual acuity A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.