Medical Surgical Nursing ATI PREP
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP), Which of the following statements should the nurse include in the teaching?
After the procedure you will be encouraged to drink plenty of fluids The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN) Which of the following lab values indicates the treatment is effective?
Albumin 4.2g/dL Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2g/dL is within the expected reference rand and indicates the client is receiving adequate amounts of protein
A nurse is assessing an older adult who is receiving digoxin. The nurse should recognize that which of the following findings is a manifestation of digoxin therapy?
Anorexia Anorexia, Vomiting, Confusion, Headache, visual changes are manifestations of digoxin toxicity
A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?
Apex of the heart The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart
A nurse is caring for a client who has right sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent foot drop?
Apply a protective boot to the right ankle The nurse should apply padded splints or protective boots to the right ankle to keep the foot at a right angle to the leg to prevent foot drop
After radiation treatment, a client reports dryness, redness and scaling of his skin occuring within the designed 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 caring for a client who is postoperative following a knee arthroplasty and has a continuous passive motion (CMP) machine. Which of the following actions should the nurse take?
Apply ice to the operative knee The nurse should apply ice to the client's operative knee to reduce edema postoperatively, which will decrease pain and bruising
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 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
A nurse is caring for client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do , as the damage is done. Which of the following is the correct nursing response?
Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely. With this response the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation to the client
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
Check the client's voice every 2 hour The nurse should assess the client's voice every 2 hours to monitor for hoarseness which is a manifestation of laryngeal nerve damage
A nurse in a providers clinic is assessing a client who has cancer and a prescription of methotrexate PO Which of the following actions should the nurse take when the client reports bleeding gums?
Check the value of the client's current platelet count The nurse should recognize that the bleeding is likely due to the adverse effect of chemotherapy and needs to be evaluated further. Bleeding gums is a sign of thrombocytopenia (decreased platelet count) secondary to bone marrow suppression which can be life threatening in a client who is receiving chemotherapy
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid
Chocolate The client should avoid foods that reduce pressure on the lower esophageal sphincter. These include fatty fried foods, caffeine, alcohol and carbonated drinks
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?
Cigarette smoking Smoking cigarettes is an action clients can change or stop; therefore the nurse should include smoking cessation as a modifiable risk factor
A nurse is educating a group of clients about the contraindications of warfarin therapy. Which of the following statements should the nurse include in the teaching?
Clients who are pregnant should not take warfarin Warfarin therapy is contraindicated in the pregnant because it crosses the placenta and places the fetus at risk for bleeding
A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform which her right hand
Combing her hair Abduction of the arm is the most difficult and usually the last type of movement to be regained by a client following a mastectomy
A nurse is caring for an older adult who has a urinary tract infection (UTI) Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
Confusion Confusion is a clinical finding of UTIs specifically associated with older adult clients
A nurse is teaching a client who has gastroesophageal reflux disease about managing his illness. Which of the following recommendations should the nurse include in the teaching?
Avoid eating within 3 hours of bedtime The nurse should instruct the client to eat small, frequent meals but to avoid eating within 3 hour sof bedtime
A nurse is teaching a class about preventive care to clients who are at risk for acquiring viral hepatitis,. Which following information should the nurse include in the presentation?
Avoid foods prepared with tap water To decrease the risk for acquiring viral hepatitis, clients should prepare foods with purified water.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for?
Hemorrhage Using the airway breathing circulation (ABC) approach to client care the nurse determines that the priority complication to monitor for is the client hemorrhaging, therefore, the nurse should monitor the client's urinary output for blood clots and bright red blood tinged urine following surgery
A nurse is caring for a client who has thrombophlebitis and is receiving heparin by continuous IV infusion. The client asks the nurse how long it will take for the heparin to dissolve the clot. Which of the following responses should the nurse give?
Heparin does not dissolve clots. It stops new clots from forming This statement accurately answers the client's question
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT) The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history?
History of breast cancer Women with a history of breast cancer should be counseled against using HT
A nurse is caring for a female client who has rheumatoid arthritis and ask the nurse if it safe for her to take aspirin. The nurse should recognize which of the following findings in the client's history is a contraindication to this medication?
History of gastric ulcers Aspirin is contraindicated for client who have a history of gastrointestinal bleeding and peptic ulcer disease because it impedes platelet aggregation. An adverse effect of aspirin is gastric bleeding
A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse should instruct the client to expect which of the following findings as an adverse effect of the medication
Hot flashes The nurse should instruct the client to expect hot flashes as an adverse effect of tamoxifen because is it an anti estrogen medication that blocks estrogen receptors
A nurse is giving a presentation to a community group about preventing atherosclerosis. Which of the following should the nurse include as a modifiable factor for this disorder?
Hypercholesterolemia, Hypertension, Obesity, Smoking Cholestrol levels outside the healthful range increase clients risk for heart disease and they can change these levels. Although it may not be possible to eliminate hypertension, client can change their blood pressure levels and thus reduce their risk for atherosclerosis. Clients who are overweight or obese can reduce their risk for heart disease by losing weight. Clients who smoke can reduce their risk for heart disease by quitting smoking.
A nurse is caring for a client who has nephrotic syndrome and is receiving high dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?
Hypokalemia If the nephrotic syndrome is immunologic in origin, it is often treated with the administration of corticosteroids such as methylprednisolone. Corticosteroid use can lead to hypokalemia which features manifestations of muscle weakness and cardiac arrhythmia
A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving the medication
Hypotension Verapamil, a calcium channel blocker can be used to control supraventricular tachyarrhythmias. It can also decrease blood pressure and acts as a coronary vasodilator and antianginal agent. A major adverse effect of verapamil is hypotension, therefore blood pressure and pulse must be monitored before and during parenteral administration
A nurse is teaching a client who has a new prescription for ranitidine to treat peptic ulcer disease. Which of the following statements by the client indicate an understanding of the teaching?
I can take this medication with or without food I will eat five small meals each day Food does not affect the absorption of ranitidine. The client should eat 5 to 6 small meals each day to enhance the therapeutic effect of ranitidine
A nurse in a medical clinic is providing teaching to an older adult client who has osteoarthritis that is affecting her knees. Which of the following client statements indicates understanding of the teaching?
I can use either hear or ice to help relieve discomfort The nurse should reinforce that different treatment modalities, such as heat or cold therapy can be tried to determine which one is more effective for the client. Heat application can help with muscle relaxation in the area around the affected joint. The application of cold numbers nerve endings and decrease joint inflammation
A nurse is reviewing the laboratory results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by the client indicates the nurse should plan follow up teaching on a low cholesterol diet
I eat two eggs for breakfast each morning The client should limit egg yolks to two or three per week
The 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 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 Wiping the perineal area from back to front increases the risk for urethral contamination and resulting in a UTI
A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching?
I will store the medication at room temperature Nystatin oral suspension should be stored at room temperature
A nurse is teaching a client who has a new prescription for sucralfate to treat a gastric ulcer. Which of the following statements by the client indicates an understanding of the teaching?
I will take this medication 1 hour before meals and at bedtime The client should take sucralfate on an empty stomach, 1 hour before each meal and at bedtime to create a protective coating over the ulcer
A nurse is caring for a client who is scheduled for an exercise stress test. Which of the following comments made by the client should indicate to the nurse that the client requires further teaching?
Ill take my heart medications the morning of my test The provider will give the client specific instructions about his medication but generally the client should avoid medications that will prevent fluctuation in heart rate during the tests, such as calcium channel blockers and beta blockers
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Inability to recognise his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.
A nursing is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate
Incorporate nonverbal cues in the conversation Nonverbal cues enhance the client's ability to comprehend and use language
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Increase in the heart rate from 88 to 110/min Hypovolemic shock is a condition in which the heart is unable to supply enough blood to the body because of blood loss or inadequate blood volume. In an effort to compensate for this, the heart rate continues to accelerate to more than 150/min. In the final (irreversible or refractory) stage, the heart rate becomes very erratic and may develop asystole
A nurse is providing dietary teaching for a client who takes furosemide. The nurse should recommend which of the following foods as the best source of potassium?
Bananas The nurse should determine that bananas are the best food source to recommend because 1 cup of bananas contains 806mg of potassium. In addition to the potassium supplements the provider might prescribe, the client should increase his daily intake of foods that have high potassium content, such as bananas, orange juice and spinach
A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation of levothyroxine overdose?
Insomnia Levothyroxine overdose will result in manifestations of hyperthyroidism, which insomnia, tachycardia and hyperthermia
A nurse is speaking with a 35 year old client who has fibrocystic disease of the breast. At which of the following times should the nurse inform the client that manifestations are most evident?
Before menstruation begins Manifestations of benign fibrocystic breast changes include painful breast, smooth movable lumps, and possible swelling of the breast, which tends to worsen premenstrually. Reducing salt and caffeine intake sometimes helps
A nurse is assessing with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take?
Inspect the electrode pads Instruct the client not to talk during the test The gel is necessary to promote electrical conduction between the skin and the electrodes; therefore the nurse should inspect the electrode pad to check that the gel is present. The nurse should instruct the client to lie quietly and not talk or move to prevent the recording of artifact.
A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan?
Instruct the client to avoid drinking carbonated beverages The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation
A nurse in a provider clinic is caring for a client who reports erectile dysfunction and request a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication of taking sildenafil?
Isosorbide Clients who are on nitrates including isosorbide and nitroglycerine preparations cannot take sildenafil because of the serious medical interaction. There is a possibility of sudden death due to hypotension
A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instructions should the nurse include about the test?
It requires lying quietly on one side For an electrocardiogram the client lies quietly on the left side with slight head elevation
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?
Knuckle deformity Joint deformity is a late manifestation of RA
A nurse is teaching a client about strategies to manage gastroesophageal reflux disease (GERD) Which of the following statements should the nurse include?
Lie on your right side when sleeping The nurse should instruct the client to lie on the right side when sleeping to prevent nighttime reflux
A nurse is planning care for a client who has immunosuppression following chemotherapy. Which of the following instructions should the nurse include in the plan of care?
Limit the number of health care workers entering the room The nurse should limit the number of healthcare workers entering the clients room to prevent possible overexposure to microorganisms that can lead to an infection
A nurse is providing instructions for a 52 year old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
Before the examination, your provider will give you a sedative that will make you sleepy This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure
A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?
Both are inflammatory The nurse should inform the client that both disease processes are an inflammatory processes of the gestational tract
A community health nurse is developing a pamphlet about breast self-examinations (BSE) for a local health fair. Which of the following instructions should the nurse include?
Breast can be examined in the shower with soapy hands The nurse should encourage clients to perform BSE or do an extra examination while showering. This allows clients to concentrate more easily on feeling for tissue changes
A nurse is reviewing the medical record of a client who has been on levothyroxine for several months. Which of the following findings indicates a therapeutic response to the medication?
Decrease in level of thyroid stimulating hormone (TSH) In hypothyroidism the non functioning thyroid gland is unable to respond to the TSH and no endogenous thyroid hormone are released. This results in an elevation of the TSH level as the anterior pituitary continue to release the TSH to stimulate the thyroid gland. Administration of exogenous thyroid hormones, such as levothyroxine, turn off this feedback loop which results in a decreased level of TSH
A nurse is teaching a client who has benign prostate hypertrophy and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching?
Decrease libido is an adverse effect of this medication The nurse should include in the teaching that the client may experience decreased libido as an adverse effect of the medication because of the androgenic effect on the prostate
A nurse is caring for a client who is taking lisinopril. Which of the following outcomes indicates a therapeutic effect of the medication?
Decreased blood pressure Lisinopril is an ACE inhibitor, may be used alone or in combination with other antihypertensives in the management of hypertensive and congestive heart failure. A therapeutic effect of the medication is a decrease in blood pressure
A nurse is caring for a client who has a postoperative ileus and an NG tube that has drained 2,500ml in the past 6 hours. Which of the following electrolyte imbalances should the nurse monitor the client for?
Decreased potassium level Hypokalemia is an electrolyte imbalance in which the serum potassium level is less than 3.5 mEq/L Hypokalemia may be the result of diuretic use diarrhea, vomiting and prolonged nasogastric suctioning
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI) Which of the following findings should the nurse recognize as a risk factor?
Diabetes mellitus Diabetes mellitus is a risk factor for a UTI due to the increased amount of glucose present in the urine
A nurse is caring for a client who has benign prostatic hyperplasia (BPH) The nurse should expect which of the following findings?
Difficulty starting the flow of urine Hesitancy or difficulty starting the flow of urine is an expected finding of BPH
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
Do not apply heat to the area of irradiation This instruction will help the client avoid tissue damage. Radiated tissue becomes thinner and might lack tissue receptors that would otherwise alert the client to a potential burn injury. When outdoors in the sunlight, the client should wear protective clothing over the area of irradiation
A nurse is providing teaching for a client who has gastroesophageal reflux disease (GERD) about ways to manage his condition. Which of the following instructions should the nurse include?
Eat four small meals each day The client should avoid eating large meals because of the pressure it places on the stomach. Instead, he should eat four to six small meals per day
A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?
Encourage the intake of at least 3 L of fluids per day The nurse should encourage the client to consume at least 3,000ml of fluids per day to dilute the urine, increase hydrostatic pressure behind the stone and move the calculi down the urinary tract
A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?
Erythrocyte sedimentation rate (ESR) Rheumatoid arthritis is a chronic inflammatory disease/. ESR is useful in detecting and monitoring tissue inflammation in with RA. As the disease improves the ESR decreases
A nurse is assessing a client who has myxedema. Which of the following findings should nurse expect?
Facial edema Facial edema is an expected finding of myxedema which is a severe form of hypothyroidism. A client who has myxedema typically experiences non-pitting edema everywhere, especially around the eyes and in the hands and feet
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?
Family history Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation
A nurse is preparing a client for a radiation treatment who is postoperative follow a mastectomy. The nurse should inform the client to expect which of the following adverse effect from the treatment?
Fatigue The nurse should inform the client to expect fatigue with her radiation treatment. Fatigue occurs regardless of the radiation target site
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 hormone that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They cannot sit quietly
A nurse is providing nutritional teaching to a client who has dumping syndrome following a hemicolectomy. Which of the following foods should the nurse instruct the client to avoid?
Fresh apples Clients with dumping syndrome following hemicolectomy should avoid fresh fruits and choose canned or well cooked fruits instead
A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?
Fresh flowers and potted plants in the room Client who are receiving chemotherapy and radiation therapy are likely to become immunocompromised as a result of neutropenia a decreased white blood cell (WBC) count. Because micro-organisms are likely to be present on fresh flowers and plants, immunocompromised clients are instructed not to accept gifts into the room. In addition, the client is instructed to eat only thoroughly cooked meats and thoroughly washed fruits and vegetables. Immunocompromised clients are more susceptible to infection and illness from food borne bacteria than other clients.
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingual for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
A headache is an expected adverse effect of the medication The vasodilator nitroglycerin induces increases blood flow to the head and typically results in a headache
A nurse is caring for a client who asks to be screened for cervical cancer because a relative has been diagnosed with it. Which of the following test should the nurse expect the provider to use?
A papanicolaou test A papanicolaou test involves sampling cells from the cervix to detect abnormal cells and growth. The nurse should recommend the client have an annual pap smear between ages 21-29 and every 5 years from ages 30 to 65
A nurse is caring for a client who has atrial fibrillation and received digoxin daily. Before administering this medication, which of the following actions should the nurse take?
Measure the clients apical pulse Digoxin decreases the heart rate, so the nurse should count the apical pulse for at least 1 minute before administering. The nurse should hold the medication and notify the provider if the client's heart rate is below 60/min or if a change in heart rhythm is detected
A nurse is caring for a client who has Crohn's disease and is receiving parenteral nutrition. Which of the following interventions should the nurse include in the care of this client?
Monitor daily laboratory values and report as needed Laboratory data, as well as observation of clinical signs, are important to prevent the development of nutrient deficiencies or toxicities
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 is caring for a client who is 2 hours postoperative following transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?
Output of burgundy colored urine Output of burgundy colored urine may indicate venous bleeding a potential complication of a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter
A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?
Perform a Romberg's Test The nurse should perform a Romberg's test to check the client's ability to maintain an upright position without swaying when standing with feet close together, with eyes open and with eyes closed. The nurse must stand close enough to prevent the client from falling
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4kg (12lbs) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low stimulus environment Thyroid crisis can occur in response to a stressor so the nurse should minimize stressful stimuli in the client's environment
A nurse is taking a health history of a client who reports occasional taking several over the counter medication including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic?
Relief of heartburn Histamine 2 receptor antagonist are used to treat duodenal ulcers and prevent their return. In over the counter strengths these medications such as cimetidine and ranitidine are used to relieve or prevent heartburn, acid indigestion and sour stomach
A nurse is planning care for a client who is 2 hour postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Remind the client he might feel a constant urge to void The client who is receiving continuous bladder irrigation will experience a continuous urge to void because of pressure on the internal sphincter from the catheter balloon
A nurse is assessing a client who returned to the unit 4 hours ago after a partial colectomy. Which of the following findings should the nurse attend to first?
Report of severe incisional pain The nurse using the urgent vs non urgent approach to care for the client determines the priority action is to administer pain medication to establish comfort
A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is a priority?
Respiratory rate When using the airway, breathing, circulation approach to client care, the nurse should determine the priority assessment is the respiratory rate. Morphine can cause respiratory depression. The nurse should withhold the medication and notify the prescriber if the client has a respiratory rate less than 12/min
A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE) Which of the following values should give the nurse the best indication of the client's renal function?
Serum Creatine A renal function disorder reduces the excretion of creatine, resulting in increased levels of blood creatine. Creatine is a specific and sensitive indicator of renal function.
A nurse is discussing a good food choice with a client who is recovering from an exacerbation of inflammatory bowel disease and is to start a low lactose diet. Which of the following foods is the best choice for the client?
Soy milk Soy milk is the best choice for this client because soy milk is lactose free
A nurse in an emergency department is assessing a client who is having a suspected acute myocardial infraction (MI). Which of the following manifestation should the nurse expect to find for a client experiencing an acute MI? (Select all that apply)
Tachycardia, Nausea, Diaphoresis A client experiencing an MI typically manifests dyspnea. Chest pain and sometimes jaw, back, and shoulder pain are manifestations of an acute MI. Nausea and vomiting are manifestations of an acute MI. Tachycardia can also occur as a result of the clients anxiety, Diaphoresis is correct. Profuse sweating and anxiety are manifestations of an acute MI
A nurse is caring for a client who is postoperative following a right sided mastectomy and has a drain connected to a portable drainage evacuator. Which of the following actions should the nurse take?
Take blood pressure on the clients non-affected arm The nurse should plan to only take blood pressure, give injections or perform venipuncture on the clients non-affected arm to avoid compromising circulation. The nurse should instruct other staff to follow these precautions as well
A nurse is providing discharge instructions to a client who has rheumatoid arthritis and a prescription for oral betamethasone. Which of the following statements should the nurse make about how to take this medication?
Take the medication with milk Betamethasone should be administered with milk or food to prevent gastric irritation
A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following response should the nurse male?
Tell me more about these fears of dying from a heart attack With this response the nurse uses the therapeutic communication technique of exploring to encourage further communication about the client's feelings
A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40mg twice daily. Which of the following findings in the history should the nurse report to the provider?
The client has a history of bronchial asthma Beta-adrenergic blockers can cause bronchospasm in clients who have bronchial asthma, therefore this is a contraindication to its use and should be reported to the provider
A nurse is caring for a client who is receiving cisplatin for treatment of ovarian cancer. The client's most recent complete blood count (CBC) is shown in the table below. It is important for the nurse to consider which of the following for this client? WBC 1,400/mm3
The client has an increased risk of infection The low white blood count places the client at increased risk for infection. The nurse should assess the client's skin and mucous membranes, lung sounds, and venous access sites every 8 hours for signs of infection
A client who is scheduled for a barium swallow asks the nurse why a laxative is necessary following the procedure. Which of the following responses should the nurse make?
The laxative helps eliminate the barium The nurse statement that the laxative will help eliminate the barium is appropriate and provide the client with the reason for a laxative
A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsation in the pulmonic area, at which anatomic location should the nurse place her fingers
The left second intercostal space The left second intercostal space is the location where the nurse can palpate pulsations at the pulmonic valve area. This is the site for palpating lifts and heaves in this area
A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?
The nurse should instruct the client to report any tendon discomfort as well as swelling or inflammation of the tendons due to their risk of tendon rupture
A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include?
Lubricate lips with water-soluble ointment Brush teeth with a soft toothbrush Blow nose gently The nurse should instruct the client to lubricate his lips with water soluble ointment to void cracking, which can result in spontaneous bleeding from the site. The nurse should instruct the client to brush his teeth with a soft toothbrush to avoid spontaneous bleeding from the gums. The nurse should instruct the client to limit blowing the norse, and if needed to blow the nose gently to minimize spontaneous bleeding from the nares.
A nurse is caring for a client who recently had surgery for insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?
MRI of the chest Permanent pacemaker is a contraindication of the MRI of the chest. The magnets in the machine can create electromagnetic interference and cause the pacemaker to malfunction
A nurse is teaching the partner of the client who had an acute myocardial infraction (MI) about the reason blood was drawn from the client. Which of the following statement should the nurse make regarding cardiac enzymes studies?
These tests help determine the degree of damage to the heart tissues Cardiac enzymes studies are obtained because the degree of enzyme elevation reflects the degrees of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It mat take 4 hour or more after the onset of manifestations of the test to become abnormal and up to 24 hour for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzymes levels
The nurse is caring for an 8 month old infant who screams when the parent leaves the room. The parent begins to cry and says "I don't understand why my child is so upset" I've never seen my child act this way around others before. Which of the following statements should the nurse make?
This is a normal, expected reaction for a child of this age The 8 month old is exhibiting a normal response to separation from the parent by protesting loudly. Explaining this expected separation anxiety reaction to the parent might help the parent to cope with feelings of guilt when leaving the child's bedside
A nurse is caring for a female client who has rheumatoid arthritis and new prescription for methotrexate. The client tells the nurse she is planning a pregnancy. Which of the following instruction should the nurse give the client?
This medication should be discontinued 3 months prior to a planned pregnancy Methotrexate should be discontinued 3 months prior to planning a pregnancy because of the risk of birth defects
A nurse is talking with a client whose thyroid stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test?
This test determine whether your thyroid gland is overactive, appropriately active, or underactive This describes the TSH test, which helps determine thyroid status and helps monitor the effectiveness and dosage of thyroid hormone replacement therapy
A nurse in a clinic is reviewing the laboratory values of a client who has primary hyperthyroidism. The nurse should anticipate an elevation of which of the following laboratory values
Thyroid stimulating hormone (TSH) The nurse should anticipate that TSH will be elevated
A nurse is teaching a client who is receiving radiation therapy about skin care. Which of the following instructions should the nurse include?
Walk outside in the early mornings A client who is recieving radiation treatment has special skin care needs due to the drying and irritation that occurs to the skin. The client's skin is especially prone to burning, and he should be encouraged to limit time outdoors in the sun. The nurse should instruct the client to go outside during the early morning or evening to avoid intense sun rays and should encourage the client to stay under the awanings, umbrellas, and other forms of shafe during the time when the sun's rays are the most intense
A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting and diarrhea. Which of the following findings should the nurse expect?
Weak, irregular pulse Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue and ventricular dysrhythmias
A nurse is providing teaching to a client who has a new prescription for hydroxychloroquine to treat mild manifestations of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?
Wear sunglasses when out in bright sunshine The nurse should instruct the client to wear sunglasses to decrease photophobia when taking hydroxychloroquine. Clients should have an ophthalmologic examination before treatment because the medication can cause retinopathy
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse "I wish I could stay but I need to go home to see how my children are doing. I really hate to leave" Which of the following responses should the nurse make?
You are feeling drawn in two seperate directions This response illustrates the therapeutic communication technique of restaurant. This open ended statement encourages further communication by the son
A client who has chronic lymphocytic leukemia is starting chemotherapy treatments and asks if she needs to make any dietary changes. Which of the following statements should the nurse make?
You should avoid drinking liquids an hour before the treatments Clients should be encouraged to decrease fluid intake just before treatments because fluids may cause nausea and vomiting
The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, I always get a rash when I eat shellfish. Which of the following is the priority nursing action?
Notify the provider of the clients allergies The greatest risk to the client is an allergic reaction to the iodine-containing contrast agent the client will receive IV for the procedure, because shellfish also contains iodine. A steroid and or antihistamine will be given to a client with a iodine allergy to prevent or minimize a reaction
A nurse is caring for a client who is receiving therapy to treat lung cancer. Which of the following actions should the nurse take?
Observe for signs of infection Radiation therapy to sites containing bone marrow (such as the sternum) can lower the WBC count (leukopenia) thus increasing the client's risk for infection. Screening the client for signs of infection is essential at this time
A nurse is assessing a client's radial pulse and determines that the pulse is irregular. Which of the following actions should the nurse take?
Assess the apical pulse for a full minute For clients who have a regular pulse and no cardiovascular problems, the nurse should count the apical pulsations of 30 seconds and multiply by 2. For this client, the nurse should count for 60 seconds. This will help the nurse determine the regularity or irregularity of the heart
A nurse is providing dietary teaching to a client who has frequent kidney stones. Which of the following instructions should the nurse include in the teaching?
Avoid eating tree nuts, such as almonds The nurse should instruct the client to avoid high oxalate foods, such as peanuts or tree nuts including almonds, cashews and hazelnuts to decrease the risk of stone formation
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse "I feel so isolated and alone in this room" After acknowledging the client's feelings of loneliness which of the following responses should the nurse provide?
Do you have a cell phone you can talk to friends and family on? A client who has a radiation implant must remain in random isolation. Time and distance are the factors that reduce exposure to the source. After acknowledging the client's feelings of loneliness and recognizing the sense of social isolation this solution provides an appropriate safe means of meeting the clients needs for contact
A nurse is completing dietary teaching on consuming a low fiber diet with a client who has ulcerative colitis. Which of the following foods should be eliminated in the client's diet?
Dried apricots A nurse should instruct a client who has ulcerative colitis to consume a diet low in fiber and should eliminate dried apricots from his diet. Dried apricots are high in fiber and may cause an exacerbation of the client's disease process
A nurse is teaching a client about the side effects of chemotherapy medication. Which of the following nursing statements should the nurse include in the teaching?
Hair loss is common and includes eyebrows and eyelashes The nursing statement is correct, because alopecia occurs as a whole body hair loss for most clients administered chemotherapy
A nurse is caring for a client 4 hours following a cardiac catherization. Which of the following actions should the nurse take?
Have the client lie flat in bed The nurse should have the client on lie flat in bed. Client who had manual or mechanical pressure after catheter removed requires 6 hour of bed rest. Those who had a closure device or patch only need 2 hours of bed rest
A nurse is assessing four clients on medical. The nurse should identify which of the following clients as exhibiting positive manifestations of hypercortisolism
Moon face A client who has a moon face and fat pads on his neck, back and shoulders is exhibiting manifestations of hypercortisolism or Cushing's syndrome
A nurse is caring for a client who has cushing syndrome. The nurse should recognize that which of the following are manifestations of Cushing syndrome? (Select all that apply)
Moon face, purple striations, buffalo hump Moon face is manifested by a round, red, full face, is a common manifestation of cushing syndrome. Purple striations on the skin of the abdomen, thighs and breast are common manifestations of cushing syndrome. Buffalo hump, which is a collection of fat between the shoulder blade is a common manifestation of cushing syndrome
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). The nurse should plan to administer which of the following medications after the initial phase to manage the client's pain and anxiety?
Morphine Morphine is the medication of choice for managing the pain and anxiety of an acute MI. By reducing preload and afterload, it decreases the work of the heart
A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
Platelet count of 60,000/mm3 This platelet count is below the expected reference range. A low platelet count places the client at risk for bleeding therefore the nurse should follow up on this finding
A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client?
Poor At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages
A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching?
Pyelonephritis increases a pregnant woman's risk for preterm labor Pyelonephritis is a serious complication of pregnancy that can lead to preterm labor
A nurse is teaching about risk factors of developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include in the teaching
Race Race is a non modifiable risk factor, which the client is unable to control
The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
Radial pulse in the left arm Palpating the client's pulse distal to the insertion site is essential for evaluating possible thrombocytopenia and vessel occlusion. The left radial pulse should be strong and essentially equal to the right radial pulse
A nurse is assessing a client who is on long term omeprazole therapy. Which of the following findings should indicate to the nurse the medication is effective?
Reduced dyspepsia Omeprazole, a proton pump inhibitor reduces gastric acid secretion and treats duodenal and gastric ulcers, prolonged dyspepsia, gastrointestinal reflux disease and erosive esophagitis
A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for a fat soluble vitamin supplement. The nurse should instruct the client to take a supplement for which of the following
Vitamin A The nurse should instruct the client that fat soluble vitamins include A, D, E and K
