medsurg 2 cms

A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching?

broiled cod with broccoli

A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

a change in pupil size

A nurse is monitoring a client who has a nasogastric tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report?

abdominal distention

A nurse working in a provider's office is caring for a client who received penicillin G potassium 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider?

abdominal pain

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

absent bowel sounds

A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?

administer an IV bolus of lorazepam

A nurse is caring for client who has COPD with copious secretions. Which of the following actions should the nurse take?

administer high-flow oxygen

normal creatinine levels

adult men: 0.74 to 1.35 mg/dl (65.4 to 119.3 micromoles/L) adult women: 0.59 to 1.04 mg/dl (52.2 to 91.9 micromoles/L)

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?

ambulate the client in the hallway

A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?

antecubital space

A nurse is reinforcing discharge teaching with a client who had an excisional biopsy of the left breast. Which of the following instructions should the nurse include?

apply an ice pack to the incision site to treat discomfort

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

assist the client to a nearby common area

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

changed mental status

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

"It is common for one breast to be larger than the other"

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?

"Limit contact with large groups of people."

A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?

avoid direct contact

A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include?

avoid fresh flowers

A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend?

bananas

A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

check for neck vein distention?

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

check the client for increased hypopigmentation under the patch

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

client status unchanged throughout the shift

A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?

"Add oily fish to your diet twice weekly." Rationale: The nurse should reinforce teaching about dietary changes to manage coronary artery disease, such as eating fish that are rich in omega-3 fatty acids, like tuna, mackerel, or salmon, twice per week.

A nurse is reinforcing instructions with a client who has a new hearing aid. Which of the following instructions should the nurse include?

"Adjust the volume to a level where you can hear others speak at a distance of 3 feet." Rationale: The nurse should instruct the client to adjust the volume of the hearing aid to the point where they can hear sounds at a distance of 0.9 m (3 feet), which is a comfortable level for hearing others speak.

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?

"Avoid bending your hips more than 90 degrees." Rationale: The nurse should instruct the client to avoid bending their hips more than 90° to prevent dislocation of the replacement hip.

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

"Calcitonin will slow the breakdown of bone in your body." Rationale: "Calcitonin will slow the breakdown of bone in your body."

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

"Consume foods that are low in sodium." Rationale: The nurse should instruct the client to consume foods that are low in sodium to reduce the development of edema and ascites.

A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching?

"Do not allow visitors to smoke cigarettes in your home." Rationale: The nurse should inform the client that cigarette smoke is a common allergen that can increase the risk for triggering an asthma attack. Therefore, the client should not allow anyone to smoke cigarettes in their home.

A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

"Eat soft foods." Rationale: The nurse should instruct a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa.

A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make?

"Hospice care will provide support for you and your loved ones during the dying process." Rationale: The nurse should inform the client that hospice care supports clients and their loved ones with the goal of helping provide a peaceful and dignified death.

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

"I can decrease my risk for a stroke by losing excess weight"

A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching?

"I can develop TB by breathing in the infection." Rationale: TB is spread by airborne transmission. Therefore, the nurse should identify this statement as an understanding of the teaching.

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?

"I don't cross my legs anymore." Rationale: Clients who have peripheral vascular disease should not cross their legs because it can impede circulation.

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water." Rationale: To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.

A nurse is reinforcing teaching with a client about heart disease prevention. Which of the following client statements indicates an understanding of the teaching?

"I will try to maintain my blood pressure around 116/72"

A nurse is preparing to administer subcutaneous enoxparin. In which order should the nurse perform the following steps?

-Check the medication administration record to verify the client's allergies. -Ensure an air bubble is present in the prefilled enoxaparin syringe -Locate the injection site 5 cm (2 in) to the right or left of the umbilicus -Pinch clean site at the injection site and dart the needle into the skinfold at a 90 degree angle -Slowly inject the medication into the site without aspirating

A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps?

-Record the client's vital signs -Measure the client's abdominal girth -Prime the client's catheter tubing with dialysate solution -Infuse dialysate solution into the client's peritoneal cavity -Open the client's drainage tubing after 10 min of dwell time

what does it mean to have low creatinine levels

-causes: lower muscle mass caused by muscular dystrophy or aging, liver disease, excess water loss -s/s: swelling, jaundice, bloody or tar colored stools,

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?

"I had a low fever this morning." Rationale: Clients who have a febrile illness should not receive the influenza vaccine.

A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication?

"I have gained 3 pounds since my last appointment." Rationale: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective.

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.)

"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." Rationale: The client should rinse their mouth after using a budesonide inhaler to reduce the risk for oral fungal infection. The client should record the number of times that they use their albuterol inhaler. This information can assist the provider to determine the effectiveness of the medication. The client should use the albuterol inhaler before exercise to prevent exercise-induced bronchospasms.

A nurse is collecting data from a client who hyperthyroidism and is taking propylthiouracil. Which of following statements by indicate the medication is effective?

"I no longer feel nervous"

A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching?

"I should adjust the TENS unit until I feel a tingling sensation"

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching?

"I should avoid broccoli and chewing gum"

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?

"I should call my doctor if my ankles swell." Rationale: Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.

A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching?

"I should expect to have an increased risk for breast cancer"

A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following statements by the client indicates an understanding of the teaching?

"I should report episodes of diarrhea"

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching?

"I should use my wrist to test the temperature before bathing"

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching?

"I should wait at least 2 hours after eating before going to bed." Rationale: The client should wait to lie down or go to bed at least 2 hr after eating to minimize reflux.

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?

"I understand that testicular cancer is typically painless." Rationale: Clients should report a lump that is not painful because testicular cancer is typically painless.

A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter." Rationale: The client will feel heat and vibrations from the cast cutter on the affected extremity. The nurse should assure the client that cast removal should not cause any pain.

A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?

"I will have my HbA1c checked twice per year." Rationale: An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have their HbA1c tested twice yearly to manage their glucose.

A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will limit my coffee intake." Rationale: The nurse should encourage the client to limit their intake of caffeinated products, such as coffee and soda. Coffee can cause excretion of calcium through diuretic effects.

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

"I will limit my daily intake of protein." Rationale: The client should decrease their intake of protein to slow the progression of kidney failure. Therefore, the nurse should identify this statement as an understanding of the teaching.

A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure." Rationale: The nurse should instruct the client to notify their dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk for endocardial infection.

A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

"I will set the suction pressure dial between 80 and 120"

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet." Rationale: The nurse should instruct the client to maintain a low-fiber, low-residue diet, which helps control pain and inflammation in the small intestine and reduces episodes of diarrhea.

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?

"My food tastes bland even after I add seasoning." Rationale: As clients age, there is a decrease in the number of taste buds of the tongue due to tongue atrophy.

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

"Perform testicular self-examination after taking a warm shower." Rationale: The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes.

A nurse is providing information regarding transmission-based precautions for a client who has Clostridium dicile to an assistive personnel (AP). Which of the following instructions should the nurse include? (Select all that apply.)

"Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution." Rationale: Clients who have C. difficile require contact precautions, which include using disposable utensils and dishes during meals to prevent exposure to contaminants by others. When using contact precautions, the health care staff should dedicate equipment to single-client use to prevent transmission of the pathogen. The health care staff should use a bleach solution to clean equipment to prevent transmission of the pathogen.

A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"Pursed-lip breathing works best for activities like walking up stairs." Rationale: The nurse should acknowledge that performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain.

A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

"Sitting quietly near the bedside can provide comfort and support"

A nurse is reinforcing teaching with a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

"Take calcium supplements with meals." Rationale: The nurse should instruct the client to take calcium carbonate supplements with or following meals to increase absorption and effectiveness.

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning." Rationale: The nurse should instruct the client to take levothyroxine at the same time each day, preferably 1 hr before breakfast.

A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make?

"The removal of a single testicle will not prevent you from having an erection"

A nurse is caring for a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make?

"The tumor causes obstruction of urine from the urethra." Rationale: As a prostate tumor grows, it compresses the urethra, resulting in obstructed urine flow.

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?

"The virus can be transmitted without lesions being present." Rationale: The nurse should inform the client that viral shedding and spreading of the infection can occur even when lesions are not present.

A home health nurse is caring for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?

"Use a bronchodilator 30 minutes before your meal." Rationale: The client should use a bronchodilator 30 min before meals to prevent shortness of breath while eating.

A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include?

"Use rapid-acting insulin in the infusion device." Rationale: The nurse should instruct the client to use rapid-acting insulin with an insulin pump.

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

"You are at risk for infertility with this infection, regardless of treatment." Rationale: The nurse should inform the client that there is a risk for infertility as a result of this infection.

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make?

"You feel like you want to discontinue treatment?" Rationale: The nurse is clarifying and acknowledging the client's feelings by establishing a trusting relationship. This question encourages the client to expand on their feelings.

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?

"You should have a pneumococcal immunization every 10 years." Rationale: The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia.

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide." Rationale: Clients who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection.

A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following instructions should the nurse include?

"You should receive one dose of the pneumococcal vaccine"

A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching?

"Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." Rationale: The provider will give specific instructions concerning the CPM machine's flexion and extension motion each day. Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity.

A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select?

(first picture, clear tube ending with blue tube) Rationale: When using a double-lumen gastric sump tube, the clear portion of the tube allows for aspiration of stomach contents. The blue portion of the tube, or the "pigtail", vents the tube to the atmosphere, which prevents the tube from becoming lodged against the wall of the stomach and protects the stomach from damage.

what does it mean to have high creatinine levels

-kidney dysfunction -s/s: dehydration, fatigue, swelling, SOB, confusion, n/v causes: high blood pressure, diabetes

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.7 Rationale: desired/have x mL

A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching?

1 cup of boiled broccoli Rationale: The nurse should recommend boiled broccoli to the client because 1 cup contains 115 mg of vitamin C per serving.

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans Rationale: The nurse should recommend kidney beans as the best source of fiber because 1/2 cup contains 6.5 g of fiber per serving.

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 ml. How many ml should the nurse administer?

10 ml

BUN levels

10-20 mg/dL

A nurse is caring for a client who a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD?

2 fingers

A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

864

A nurse is receiving change-of-shift report about the care of four clients. Which of the following clients should the nurse see first?

A client who displays increased confusion over the past 4 hr

A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that a client who has mental confusion and is getting out of bed without assistance is the first client the nurse should see. This client is experiencing manifestations of dehydration, which increases the risk for falls.

A nurse is prioritizing care for four clients following a change of shift report. Which of the following clients should the nurse attend to first?

A client who sustained a head injury 2 days ago and has a decreased level of consciousness

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain?

A is correct. Rationale: Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully.

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication?

Abdominal cramps Rationale: Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication.

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen Rationale: Acetaminophen is a nonopioid analgesic that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics. However, clients should be advised that acetaminophen toxicity can cause liver damage.

A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include?

Add a weight-bearing exercise regimen

A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care?

Administer an antiemetic to the client Rationale: The nurse should plan to administer an antiemetic to a client who has Ménière's disease to reduce the duration and severity of the attack.

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine. Rationale: The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula. Rationale: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed.

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?

Allow for 30 min of rest before meals. Rationale: The nurse should allow the client to rest for 30 min before meals to prevent aspiration.

A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?

Allow the weights to hang freely. Rationale: The nurse should instruct the AP to allow the weights to hang freely and to refrain from bumping the weights. Skeletal traction maintains alignment of fractured bones through the use of counterweights. If these weights rest on the floor or another object, they do not maintain the counterbalance necessary to maintain the alignment of the fracture, which can result in client injury or pain.

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?

Apply a mask on the client if transport is needed. Rationale: The nurse should apply a mask to a client who has manifestations of pertussis during transport to prevent exposure to others.

A nurse is working the night shift and is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Apply a motion sensor mat to the client's bed

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Apply cold packs to the inflamed joints.

A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?

Apply foam handles to the client' s eating utensils Rationale: The nurse should instruct the client to use both warm and cold packs on inflamed joints to decrease pain.

A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?

Assist the client to change positions at least every 2 hr. Rationale: The nurse should assist the client to change positions at least every 2 hr to promote return of respiratory function following anesthesia and prevent atelectasis and pneumonia.

A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching?

Avoid eating red meat for 3 days prior to the test.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?

Avoid stopping this medication suddenly. Rationale: The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.

A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the cast using a blow dryer on a cool setting. Rationale: Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin.

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?

Bradycardia Rationale: The nurse should identify that bradycardia is a manifestation of hypothyroidism that is caused by a decrease in the client's metabolic rate.

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will nd hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C Rationale: The nurse should identify that the V1 electrode should be placed in the fourth intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart.

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Ceftriaxone Rationale: Clients who have a severe sensitivity to penicillin can have a cross-sensitivity reaction to ceftriaxone, a cephalosporin. Therefore, the nurse should contact the provider to clarify the prescription.

A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?

Change the sheepskin liner weekly. Rationale: The nurse should provide instruction regarding the care and maintenance of the vest. The instruction should include changing the sheepskin liner either when soiled or at least once per week to prevent skin irritation.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client. Therefore, the priority action is to check the NG tube to determine if the tube is kinked, which can interfere with the suctioning function and result in nausea.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse. Rationale: The first action the nurse should take when using the nursing process is to check the IV site for infiltration. If infiltration is found, the next step the nurse should take is to stop the infusion to prevent vein and tissue damage. Once the infusion is stopped, the nurse should remove the IV catheter. The nurse should elevate the affected extremity to decrease swelling. The nurse should notify the charge nurse about the client's condition.

A nurse is caring for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first?

Check the incisional dressing Rationale: The greatest risk to the client is hemorrhage following an amputation of the lower extremity. Therefore, the first action the nurse should take is to check the client's incisional dressing for excessive bleeding.

A nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider?

Chest drainage is greater than 70 mL/hr. Rationale: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider.

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?

Cleanse the client's skin prior to electrode placement. Rationale: The nurse should cleanse the client's skin prior to electrode placement to improve electrode conduction.

A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm3. Which of the following actions should the nurse take?

Cleanse the client's toothbrush with hydrogen peroxide.

A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take?

Cleanse the drainage plug with alcohol swabs. Rationale: The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system.

A nurse is caring for a client who is postoperative following an above-the-knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take?

Collaborate with the physical therapist to initiate alternative pain therapies Rationale: Phantom limb pain does not usually respond to routine postoperative analgesia. The nurse should collaborate with the physical therapist to initiate alternative pain therapies, such as heat, massage, and transcutaneous electrical nerve stimulation.

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?

Combination oral contraceptives Rationale: The nurse should identify that combination oral contraceptives are contraindicated for this client because they increase estrogen levels, which can stimulate the growth of any remaining cancerous breast cells.

A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?

Compartment Syndrome Rationale:

A nurse is caring for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take?

Compress the bulb reservoir and then close the drainage valve Rationale: The nurse should fully compress the bulb reservoir and then replace the valve plug using aseptic technique to establish suction after emptying or activating a portable wound bulb suction device.

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough Rationale: Enalapril is an ACE inhibitor, which can cause a dry, nonproductive cough. Therefore, the nurse should monitor the client for this adverse effect.

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL Rationale: Creatinine 1.9 mg/dL is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.

A nurse is collecting data from a client who has mitral valve regurgitation. Which of the following areas should the nurse place the stethoscope to auscultate a murmur?

D

A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include?

Dangle the extremities o the side of the bed. Rationale: The nurse should include in the plan of care to have the client dangle their lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.

A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?

Decrease in exertional dyspnea Rationale: A decrease in exertional dyspnea indicates the antibiotics are resolving the infection and the albuterol treatments are facilitating effective ventilation. Therefore, the nurse should evaluate the therapeutic regimen as effective for the client.

A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?

Decreased blood pressure Rationale: Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?

Decreased potassium Rationale: The nurse should notify the provider immediately about a decreased potassium level because potassium is lost when a diuretic, such as furosemide, is administered, which can cause hypokalemia.

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?

Decreased shortness of breath Rationale: The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

Encourage the client to complete ADLs. Rationale: The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

Decreases pain during urination Rationale: Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.

A nurse in a dermatology clinic is reviewing the medical records of a group of clients. Which of the following prescriptions for a client who has psoriasis should the nurse clarify with the provider?

Dermabrasion Rationale: The nurse should identify that dermabrasion is a treatment for acne that could trigger further irritation in a client who has psoriasis. Therefore, the nurse should clarify this prescription with the provider.

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Determine the client's daily elimination habits. Rationale: The first action the nurse should take when using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority?

Determine the client's understanding of the procedure.

A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes mellitus Rationale: Clients who have diabetes mellitus are at increased risk for developing cardiovascular and peripheral vascular disease because of the changes in the microvasculature resulting from elevated levels of glucose.

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath sounds Rationale: Diminished breath sounds might indicate a pneumothorax or laryngeal edema. The nurse should report this finding to the provider for further evaluation of the client.

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache Rationale: Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor the client for a diminished headache as an expected outcome of the medication.

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of radiation implants in a lead container. Rationale: Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol.

A nurse is caring for a client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes Rationale: Macular degeneration results in a distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center.

A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include?

Drink carbonated beverages with meals

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?

Dyspnea Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is dyspnea, which is a complication of the epidural infusion.

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?

Dysrhythmia Rationale: When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority finding for a client who has hypokalemia is dysrhythmia.

A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

Eat several, small-portioned meals daily. Rationale: Clients who have difficulty eating because of pain or anorexia can usually tolerate small amounts of food at one time. Eating several small meals daily can increase the client's caloric intake.

A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?

Elevated serum amylase level Rationale: The nurse should anticipate an elevation in the client's serum amylase level due to injury of the pancreatic cells.

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?

Elevated troponin Rationale: Laboratory evaluation of troponin is used specifically to detect cardiac muscle injury. Therefore, the nurse should identify an elevated troponin level as an indication that the client is experiencing a myocardial infarction.

A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan?

Encourage abdominal breathing. Rationale: The nurse should encourage abdominal breathing, which reduces the workload on the accessory muscles of respiration during dyspneic episodes.

A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?

Encourage reminiscence of past experiences. Rationale: The nurse should encourage reminiscence of past experiences to reduce the client's confusion.

A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises. Rationale: Weight-bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis.

A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?

Escharotomy Rationale: The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible, and the client's oxygenation should improve.

A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care?

Face the client while speaking. Rationale: The nurse should face the client, which allows the client to see who is speaking, read the nurse's lips, and obtain visual cues by observing facial expressions.

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamphlet?

Females have a higher risk for contracting STIs than males. Rationale: The nurse should include that oral contraceptive use, prolonged contact with male secretions, and increased cervical permeability during hormone fluctuations increase a female's risk for acquiring STIs.

A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?

Frequent colds Rationale: The nurse should inform the client that corticosteroids can increase susceptibility to infection by suppressing the immune response. The nurse should instruct the client about infection prevention measures to implement while taking a corticosteroid.

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosemide Rationale: The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity.

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?

Give the client liquids with increased viscosity. Rationale: Thickened liquids are easier for the client to swallow and can prevent aspiration.

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take?

Have a designated stethoscope in the client's room. Rationale: The nurse should designate equipment to leave in the client's room to avoid cross-contamination. The designated equipment should be disposed of or decontaminated before leaving the client's room.

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months. Rationale: HbA1c testing reflects average overall glucose control over a 3-month period. The nurse should inform the client that HbA1c testing is the best measure of long-term glucose control.

A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heart rate 120/min Rationale: The client's heart rate of 120/min is above the expected reference range and indicates that the client's hypovolemia has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement.

A nurse is collecting data who has gastroenteritis with diarrhea and vomiting. Which of the following laboratory values should alert the nurse the client is at risk for fluid volume deficit?

Hematocrit 56 mg/dl

A nurse is caring for a client who is 8 hr postoperative following left hip arthroplasty. Which of the following laboratory values indicates the nurse should notify the provider?

Hemoglobin 8.6 g/dL

A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group?

Herpes zoster Rationale: The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older.

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hgb 11 g/dL Rationale: Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective.

A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot ashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?

History of treatment for blood clots Rationale: Estrogen increases the risk for blood clots. Therefore, a female client who has a history of blood clots should not receive HRT.

A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?

Household family members should be tested for TB. Rationale: The nurse should instruct the client that family members or others who have been in close contact with the client should schedule testing for TB.

A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following?

Hyperactive bowel sounds Rationale: A mechanical bowel obstruction prevents a portion or all of the bowel contents from moving forward through the bowel. The nurse should expect to auscultate high-pitched, hyperactive bowel sounds above the point of the intestinal obstruction as the intestines attempt to propel the blockage forward.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first?

Implement recommendations from the speech-language pathologist. Rationale: The greatest risk to the client following a stroke is injury from aspiration. Therefore, the first intervention the nurse should include in the plan of care is to implement recommendations from the speech language pathologist. A speech language pathologist can conduct a swallow study to determine the client's risk for aspiration, provide teaching to the client regarding swallowing techniques, and recommend the consistency of foods and liquids for the client.

A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include?

Incontinence of the bowel and bladder Rationale: The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin.

A nurse is reinforcing teaching about the management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching?

Increase intake of fiber-rich foods. Rationale: The nurse should instruct the client to increase the amount of fiber-rich foods in their diet. Dried beans and brown rice are examples of fiber-rich foods.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula Rationale: When using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body.

A nurse is caring for a client who has dysphagia and left sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding?

Instruct the client to place their chin when swallowing

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?

Instruct the client to swish the medication in their mouth. Rationale:

A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factors for falls?

Instructs the client to wear their own socks to the bathroom

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?

Intra-abdominal bleeding Rationale: Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?

Irregular borders Rationale: The nurse should report irregular borders of a skin lesion to the provider because it can indicate malignant melanoma.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride. Rationale: The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow.

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the client's extremity and the CPM machine. Rationale: The nurse should plan to keep a sheepskin pad between the client's extremity and the CPM machine to protect the client's skin. The nurse should check the client's skin condition frequently while the client is using the CPM machine.

A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow between the client's legs. Rationale: The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off of the affected areas. Rationale: The nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions.

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side-lying position. Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity.

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown?

Keep the skin dry and free of perspiration. Rationale: The nurse should not leave moisture on the skin for prolonged periods of time because it can cause skin breakdown.

A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend?

Lemon juice Rationale: The nurse should recommend that the client use lemon juice to flavor their food because it is low in sodium.

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults. Rationale: The nurse should limit visitors to healthy adults to minimize the client's risk for exposure to infection.

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep?

Listen to soft music before sleeping. Rationale: Listening to soft music can help the client to relax and reduces environmental stressors.

A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck. Rationale: The nurse should loosen clothing around the client's neck to maintain an open airway and prevent aspiration.

A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client. Rationale: The nurse should lower the client to the floor to prevent the client from falling. The nurse should place a pad beneath the client's head to protect the client from injury. The nurse should loosen clothing around the client's neck to allow for easier ventilation. The nurse should note the time the seizure began for accurate reporting. The nurse should reorient and reassure the client because confusion and embarrassment are common following a seizure.

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed. Rationale: The nurse should maintain abduction of the client's right leg to prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Maintain hip flexion at 90° or less when sitting. Rationale: A client who had a cemented total hip arthroplasty should maintain hip flexion at 90° or less when sitting to prevent hip dislocation.

A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take?

Minimize the time the head of the bed is elevated. Rationale: The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?

Mohs surgery is a horizontal shaving of thin layers of the tumor. Rationale: Mohs surgery is performed to treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high success rate.

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications?

Monitor the insertion site for bleeding. Maintain the pressure dressing Check the client's peripheral pulses Rationale: The nurse should monitor the client's insertion site for manifestations of hemorrhaging. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.

A nurse is caring for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?

Muscle spasticity Rationale: Muscle spasticity is a manifestation of multiple sclerosis.

A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching Rationale: A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth.

A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take?

Notify the charge nurse of the client's BUN level. Rationale: The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which can indicate impaired renal function. The nurse should anticipate interventions to restore the client's fluid volume.

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?

Obtain a raised toilet seat. Rationale: The nurse should instruct the client to use a raised toilet seat to avoid flexing the hip more than 90°, which increases the risk for dislocation.

A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?

Obtain the client's blood pressure. Rationale: The greatest risk to the client is postural hypotension due to decreased blood volume following surgery. Therefore, the first action the nurse should take is to obtain the client's baseline blood pressure to determine whether it is safe to have the client get out of bed.

A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral?

Occupational Therapist

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime. Rationale: The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep.

A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light Rationale: The nurse should instruct the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight.

A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?

Oxygen saturation of 88% Rationale: When using the airway, breathing, circulation approach to client care, the nurse should determine that the finding that requires immediate attention is an oxygen saturation of 88%. This finding is below the expected reference range of 95% to 100% and requires intervention to restore oxygenation to the client's tissues.

A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider?

PaCO2 55 mm Hg

A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first?

Palpate the abdomen. Rationale: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

Perform pin site care daily. Rationale: The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration?

Pinch the NG tube. Rationale: The nurse should pinch the NG tube to prevent secretions from draining into the client's throat, which can cause aspiration.

A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?

Place the client in a negative-pressure airflow room. Rationale: The nurse should place the client in a negative-pressure airflow room to filter the air and prevent the transmission of micro-organisms.

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals. Rationale: The nurse should encourage the client to lie in the supine position for a short time following meals to decrease rapid gastric emptying.

A nurse is caring for a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take?

Position pillows between the bony prominences. Rationale: The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure injury development.

A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report?

Potassium level 6.2 mEq/L

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Prealbumin 12 mg/dL Rationale: This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that they are at risk for delayed wound healing due to malnutrition.

A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?

Withhold the medication if the systolic blood pressure is less than 90 mm Hg

A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?

Prednisone Rationale: Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis.

nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism Rationale: Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.

A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching their feet when walking. Rationale: The nurse should instruct the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their feet when walking.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood. Rationale: When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood.

A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching?

Report purulent drainage to the provider. Rationale: The nurse should remind the caregiver to report manifestations of infection, including purulent drainage, to the provider.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client Rationale: When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed.

A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify that which of the following medications can cause this adverse effect?

Rifampin

A nurse is repositioning a client who has low back pain. Which of the following positions is should the nurse place the client in?

Semi-Fowler's with knees flexed Rationale: Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back and relieve pressure on the nerves.

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

Sildenafil

A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress. Rationale: A firm mattress or a bed board helps the client maintain joint alignment while sleeping.

A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist Rationale: The nurse should recommend a referral for a speech-language pathologist to evaluate the client's ability to safely swallow. A client who had a stroke is at increased risk for dysphagia and aspiration of fluids, food, and medications. The speech-language pathologist should conduct a swallowing study to determine the client's risk for aspiration and provide teaching to the client regarding swallowing techniques.

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion. Rationale: The greatest risk to the client is injury from an allergic response to the medication. Therefore, the first action the nurse should take is to stop the medication infusion.

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next?

Take the client's vital signs. Rationale: The first action the nurse should take when using the nursing process is to collect data from the client to determine what actions should be taken next.

A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent pacemaker. Which of the following findings should the nurse report to the provider?

The client experiences hiccups when sitting. Rationale: The nurse should monitor clients who have a newly-inserted permanent pacemaker for hiccups because this finding can indicate that the pacemaker wires are displaced or that the pacemaker is not firing properly. Therefore, the nurse should report this finding to the provider.

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication. Rationale: The nurse should identify that a client who is in pain will not be able to concentrate, which can interfere with their ability to learn.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?

This type of insulin should be given at the same time every day. Rationale: Insulin glargine is released in the body over a 24-hr period. The nurse should instruct the client to administer the insulin at the same time each day to maintain consistent serum levels for optimal therapeutic effect.

A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?

Thrombophlebitis Rationale: The nurse should identify pain, warmth, and a red streak up the arm as indications of thrombophlebitis.

A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

Truncal obesity Rationale: Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns.

A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?

Upright, leaning forward Rationale: The nurse should plan to place a client who has pericarditis in an upright position, leaning forward, to facilitate breathing and decrease pain.

A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?

Urine output is 50 mL/hr. Rationale: The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client. Rationale: The nurse should change the client's position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client provides the nurse with the ability to better control the client's movement and alignment. The nurse should instruct the client to exhale during the position change to prevent an increase in ICP.

A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?

Use simple verbal cues when directing tasks Rationale: The nurse should expect a client who had a left hemispheric stroke to manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication.

A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?

Ventilate the client with 100% oxygen Rationale: According to evidence-based practice, the first action the nurse should take is to ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway.

A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first?

Verify the client has given informed consent. Rationale: The greatest risk to the client in this situation is performing an unauthorized invasive procedure. Therefore, the first action the nurse should take is to verify that the client has given informed consent. If documentation of informed consent is not on the client's medical record, the nurse should withhold medications, which can alter the client's consciousness, until consent is obtained.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?

Visitors must don a gown and gloves prior to entering the client's room. Rationale: The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRSA to prevent the spread of infection.

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3 Rationale: The nurse should monitor laboratory findings for indications of a postoperative complication. This WBC count is above the expected reference range and indicates the presence of infection.

A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? (Click on the audio button to listen to the clip.)

Wheezes Rationale: The nurse should identify the breath sound auscultated as wheezes. These are high-pitched, musical sounds that occur as air passes through narrowed airways, such as when a client is experiencing an asthma attack.

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin. Rationale: The nurse should instruct the client to withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

Withhold the dose. Rationale: The nurse should withhold the digoxin dose for an apical pulse of less than 60/min and notify the provider. Digoxin slows the heart rate, so administering the dose can cause harm to the client.

A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take?

cover the pad prior to use

A nurse is collecting data from a client who is 2 days postoperative following a colon resection. Which of the following indicates the need for nursing intervention?

dark brown drainage in the NG tube

A nurse in a long term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?

encourage the client to ambulate with a staff member

A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?

ensure weights hang freely from the client's bed

A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching?

fever

A nurse is caring for a client who has been admitted with Addison's disease. For which of the following laboratory findings should the nurse plan to monitor and report to the provider?

glucose 55 mg/dL

A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider?

glycosylated hemoglobin 5.2%

A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care?

heat food before serving

A nurse is collecting data about immunizations from a 65yr old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations?

herpes zoster

hemoglobin A1c levels

high: 6.5%< normal: below 5.7% prediabetic: 5.7% - 6.4%

A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching?

history of diabetes mellitus family history of colorectal cancer age over 50 years

A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take?

hold the client's finger in a dependent position

A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?

hypertension

A nurse is reinforcing teaching about environmental modification in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

install locks at the top of doors

A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure?

intermittent straight catheter (clear tube with blue top) Rationale: This is an intermittent straight catheter and is the correct catheter for the nurse to use.

A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan?

keep a stethoscope at the client's bedside for the duration of her hospital stay

A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse expect to report to the provider immediately?

lip swelling

prealbumin levels

low: 5.0- 10.9 pre-risk: 11.0-15.0 normal: 15-35

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?

mask Rationale: The nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client.

A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions?

monitor blood glucose while taking this medication

hyponatremia

normal levels: <135 mEq/L clinical manifestations: fatigue, abdominal cramps, diarrhea, weakness, hypotension, cool clammy skin causes: excessive sweating, excess intake of water, diuretics, adrenal insufficiency, renal failure

ABG levels

normal: 12-16

hemoglobin levels

normal: 12-16

cholesterol levels

normal: 125 mg/dl

sodium levels

normal: 135-145

platelet count

normal: 150,000 - 300,000 low: unable to heal regularly, prone to bleeding

HCO3 levels

normal: 21-28 mmHg

CO2 levels

normal: 35-45 mmHg

RBC levels

normal: 37-47

WBC levels

normal: 5,000 to 10,000/mm3 low: prone to infection, avoid those that are high in bacteria

troponin levels

normal: <0.03 mg/ml

blood sugar levels

normal: <140 mg/dl high: >200 mg/dl prediabetic: 140 and 199 mg/dl

hypernatremia

normal: >145 mEq/L clinical manifestations: thirst; dry, sticky mucous membranes; dry tongue and skin; flushed skin; increased temperature causes: diarrhea, decreased water intake, salt water ingestion, impaired renal function, febrile illness, inability to swallow, burn, diabetes insipidus

A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

observe the skin 10 min after start of treatment

A nurse is contributing to the plan of care for a client who has disuse syndrome following a cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

occupational therapist

A nurse is caring for a client who has returned to the unit following a cardiac catherization using a femoral approach. Which of the following methods should the nurse use to monitor complications?

palpate the client's pedal pulses and compare bilaterally

A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

participates in performing ostomy care

A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat?

pears

A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include?

plan to shampoo hair in 1 week

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

platelets 60,000/mm3

A nurse is collecting data from a client prior to administering hydrocholorothiazide for mild hypertension. Which of the following findings should the nurse identify as a contraindication to administering medication?

potassium 2.8 mEq/L

A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which of the following laboratory values should indicate to the nurse that the client is experiencing malnutrition?

prealbumin 10.5 mg/dl

A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation?

primary health problem scheduled times for dressing changes current medication prescriptions

A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take?

provide regular oral care for the client with a moist swab

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The client received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take?

reposition the client

A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take?

rinse the client's mouth twice daily with an alcohol based mouthwash

A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

sealant

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction?

small liquid stools Rationale: Small liquid stools can be the result of fecal material being expelled around an impaction.

A nurse is caring for a client who has bladder cancer and is 1 day postoperative following placement of an ileal conduit. Which of the following information should the nurse report to the provider?

stoma color

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result?

the client takes ibuprofen for headaches

A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure?

tingling of the fingers

creatinine test purpose

to measure how well your kidneys are performing at filtering waste from your blood

A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following risk factors should the nurse include?

ulcerative colitis

A nurse is reinforcing teaching with a client who has a history of urinary tract infections. Which of the following instructions should the nurse include?

urinate before and after sexual intercourse

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine?

urticaria

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

use clean technique to collect urine specimens from the drainage system

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

use the client's left arm to obtain blood samples

hypokalemia

values: <3.5 mEq/L clinical manifestations: weakness, fatigue, anorexia, abdominal distention, cardiac arrhythmias causes: acute/chronic renal failure, burns, heat stress, ulcerative colitis, potassium-free IV fluids, metabolic acidosis

hypocalcemia

values: <4.5 mg/dl clinical manifestations: abdominal cramps, tingling, muscle spasm, convulsions causes: parathyroid dysfunction, vitamin D deficiency, pancreatitis

hyperkalemia

values: >5.0 mEq/L clinical manifestations: cardiac arrhythmias, anxiety, increased bowel sounds, abdominal cramps Causes: acute/chronic renal failure, burns crush injuries, metabolic acidosis, potassium-sparring diuretics

hypercalcemia

values: >5.6 mg/dl clinical manifestations: bone pain, vomiting, constipation causes: parathyroid tumor, bone cancer/metastasis, osteoporosis

A nurse is assisting with the care of a client who has closed-chest tube drainage system. Which of the following actions should the nurse take?

watch for 150 ml