medsurg 3

Merperidine has been prescribed for a client to treat pain. Which side and adverse effects should the nurse monitor for? (SATA) A. Diarrhea B. Tremors C. Drowsiness D. Hypotension E. Urinary frequency F. Increased respiratory rate

2, 3, 4

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. A. Keep the cast clean and dry. B. Allow the cast 24 to 72 hours to dry. C. Keep the cast and extremity elevated. D. Expect tingling and numbness in the extremity. E. Use a hair dryer set on a warm to hot setting to dry the cast. F. Use a soft, padded object that will fit under the cast to scratch the skin under the cast.

A, B, C

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

A, B, C, D

The nurse is planning to teach a client with GERD about substances to avoid. Which items should the nurse include on this list? (SATA) A. Coffee B. Chocolate C. Peppermint D. Nonfat milk E. Fried chicken F. Scrambled eggs

A, B, C, E

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? (SATA) A. Keeping the linen wrinkle-free under the client B. Preventing unnecessary pressure on the lower limbs C. Limiting bladder catheterization to once every 12 hours D. Turning and repositioning the client at least every 2 hours E. Ensuring that the client has a bowel movement at least once a week

A, B, D

The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? (SATA) A. I should not use someone else's crutches B. I need to remove any scatter rugs at home C. I can use crutch tips even when they are wet D. I need to have spare crutches and tips available E. When i'm using the crutches, my arms need to be completely straight

A, B, D

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke. Which characteristics are associated with this condition? (SATA) A. The client is aphasic B. The client has weakness on the right side of the body C. The client has complete bilateral paralysis of the arms and legs D. The client has weakness on the right side of the face and tongue E. The client has lost the ability to move the right arm but is able to walk independently F. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance

A,B,D

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? (SATA) A. Maintain NPO B. Encourage coughing and deep breathing C. Give small, frequent high-calorie feedings D. Maintain the client in a supine and flat position E. Give hydromorphone intravenously as prescribed for pain F. Maintain intravenous fluids at 10 mL.hr to keep the vein open

A,B,E

The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? (SATA) A. Padding the side rails of the bed B. Placing an airway at the bedside C. Placing the bed in the high position D. Putting a padded tongue blade at the head of the bed E. Placing oxygen and suction equipment at the bedside F. Flushing the intravenous catheter to ensure that the site is patient

A,B,E,F

A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? (SATA) A. Administer stool softeners as prescribed B. Instruct the client to limit fluid intake to avoid urinary retention C. Encourage a high-fiber diet to promote bowel movements without straining D. Apply cold packs to the anal-rectal area over the dressing until the packing is removed E. Help the client to a Fowler's position to place pressure on the rectal area and decrease bleeding

A,C,D

The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take? (SATA) A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and restraining padded side rails D. Positioning the client to the side, if possible, with the head flexed forward E. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist

A,C,D

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? (SATA) A. Fever B. Positive Cullen's sign C. Complaints of indigestion D. Palpable mass in the left upper quadrant E. Pain in the upper right quadrant after a fatty meal F. Vague lower right quadrant abdominal discomfort

A,C,E

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? A. Clear mentation B. Minimal dyspnea C. Oxygen saturation of 85% D. Arterial oxygen saturation of 75 mm Hg

A. Clear mentation

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? A. Drink 3,000 mL of fluid a day B. Take the medication on an empty stomach C. The effect of the medication will occur immediately D. Any swelling of the lips is a normal expected response

A. Drink 3,000 mL of fluid a day

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration fo this medication? A. Glaucoma B. Emphysema C. Hypothyroidism D. Diabetes mellitus

A. Glaucoma

A client is being discharged to home after application of a plaster leg cast. Which statement indicates that the client understands proper care of the cast? A. I need to avoid getting the cast wet B. I need to cover the casted leg with warm blankets C. I need to use my fingertips to lift and move my leg D. I need to use something like a padded coat hanger end to scratch under the cast if it itches

A. I need to avoid getting the cast wet

The nurse provides instructions to a client about measures to treat inflammatory bowel syndrome (IBS). Which statement by the client indicates a need for further teaching? A. I need to limit my intake of dietary fiber B. I need to drink plenty, at least 8 to 10 cups daily C. I need to eat regular meals and chew my food well D. I will take the prescribed medications because they will regulate my bowel patterns

A. I need to limit my intake of dietary fiber

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further information. A. I should increase the fiber in my diet B. I will need to avoid caffeinated beverages C. Im going to learn some stress reduction techniques D. I can have exacerbations and remissions with Crohn's disease

A. I should increase the fiber in my diet

The client with hiatal hernia chronically experiences heartburn following meals. The nurses plans to teach the client to avoid which action because it is contraindicated with a hiatal hernia? A. Lying recumbent following meals B. Consuming small, frequent, bland meals C. Taking H2-receptor antagonist medication D. Raising the head of bed on 6-inch blocks

A. Lying recumbent following meals

A client has developed hepatitis A after eating contaminated oysters. The nurse assess the client for which expected assessment finding? A. Malaise B. Dark stools C. Weight gain D. Left upper quadrant discomfort

A. Malaise

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence? A. Sweating and pallor B. Bradycardia and indigestion C. Double vision and chest pain D. Abdominal cramping and pain

A. Sweating and pallor

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? A. Taking medications as scheduled B. Eating large, well-balanced meals C. Doing muscle-strengthening exercises D. Doing all chores early in the day while less fatigued

A. Taking medications as scheduled

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? A. Temperature of 101.6 F orally B. Complaints of discomfort during repositioning C. Old bloody drainage outlines on the surgical dressing D. Discomfort during coughing and deep-breathing exercises

A. Temperature of 101.6 F orally

A client has a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? A. The is normal, expected event B. The client is experiencing early signs of ischemic bowel C. The client should not have the nasogastric tube removed D. This indicated inadequate preoperative bowel preparation

A. The is normal, expected event

The client arrives at the emergency department complaining of back spasms. The client states, I have been taking 2 to 3 aspirin every 4 hours for the last week, and it hasn't helped my back. Since acetylsalicylic acid intoxication is suspected, the nurse should assess the client for which manifestation? A. Tinnitus B. Diarrhea C. Constipation D. Photosensitivity

A. Tinnitus

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? A. Sternal rub B. Nailbed pressure C. Pressure on the orbital rim D. Squeezing of the sternocleidomastoid muscle

B Nailbed pressure

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

B. Affect is flat, with periods of emotional lability

The nurse is preparing discharge instructions for a client who has sustained a skeletal muscle injury and is receiving baclofen. Which instruction should be included in the teaching plan? A. Restrict fluid intake B. Avoid the use of alcohol C. Stop the medication if diarrhea occurs D. Notify the primary health care provider if fatigue occurs

B. Avoid the use of alcohol

The nurse has given medication instructions to a client receiving phenytoin. Which statement indicates that the client has an adequate understanding of the instructions? A. Alcohol is not contraindicated while taking this medication B. Good oral hygiene is needed, including brushing and flossing C. The medication dose may be self-adjusted, depending on side effects D. The morning dose of the medication should be taken before a serum medication level is drawn

B. Good oral hygiene is needed, including brushing and flossing

The primary health care provider has determines that a client has contracted hepatitis A based on the flu-like symptoms and jaundice. Which statement by the client supports this medical diagnosis? A. I have had unprotected sex with multiple partners B. I ate shellfish about 2 weeks ago at a local restaurant C. I was an intravenous drug abuser in the past and shared needles D. I had a blood transfusion 30 years ago after major abdominal surgery

B. I ate shellfish about 2 weeks ago at a local restaurant

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicated that the client needs further clarification of the instructions? A. I will use a straw for drinking B. I will drive only during the daytime C. I will be careful because the device alters balance D. I will wash the skin daily under the lamb's wool liner of the vest

B. I will drive only during the daytime

A client is diagnosed with viral hepatitis, complaining of no appetite and losing my taste for food. What instruction should the nurse give the client to provide adequate nutrition? A. Select foods high in fat B. Increase intake of fluids, including juices C. Eat a good supper when anorexia is not as severe D. Eat less often, preferably only 3 large meals daily

B. Increase intake of fluids, including juices

The nurse is caring for the client with increased intracranial pressure as a result of a head injury. The nurse would note which trend in vital signs if the intracranial pressure is rising? A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

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

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds knowing that which would most likely result from this improper crutch measurement? A. A fall and further injury B. Injury to the brachial plexus nerves C. Skin breakdown in the area of the axilla D. Impaired range of motion while the client ambulates

B. Injury to the brachial plexus nerves

The nurse is caring for a client with chronic back pain. Codeine has been prescribed for the client. Specific to this medication, which intervention should the nurse include in the plan of care while the client is taking this medication? A. Monitor radial pulse B. Monitor bowel activity C. Monitor apical heart rate D. Monitor peripheral pulses

B. Monitor bowel activity

The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which is the most appropriate nursing intervention? A. Administer the prescribed pain medication B. Notify the primary health care provider C. Call and ask the operating room team to perform surgery as soon as possible D. Reposition the client and apply a heating pad on the warm setting to the client's abdomen

B. Notify the primary health care provider

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? A. Cold, bluish-colored fingers B. Numbness and tingling in the fingers C. Pain that increases when the arm is dependent D. Pain that is out of proportion to the severity of the fracture

B. Numbness and tingling in the fingers

The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the PCP? A. Stoma is beefy red and shiny B. Purple discoloration of the stoma C. Skin excoriation around the stoma D. Semiformed stool noted in the ostomy pouch

B. Purple discoloration of the stoma

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

B. The white blood cell counts and platelet counts

The nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? A. Calcium level of 9.0 mg/dL B. Uric acid level of 9.0 mg/dL C. Potassium level of 4.1 mEq/L D. Phosphorus level of 3.1 mg/dL

B. Uric acid level of 9.0 mg/dL

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. Which assessment finding would indicate that the client is developing meningitis as a complication of surgery? A. A negative Kernig's sign B. Absence of nuchal rigidity C. A positive Brudzinski's sign D. A Glasgow Coma Scale score of 15

C. A positive Brudzinski's sign

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presences of asterixis. How should the nurse assess for its presence? A. Dorsiflex the client's foot B. Measure the abdominal girth C. Ask the client to extend the arms D. Instruct the client to learn forward

C. Ask the client to extend the arms

A client is complaining of low back pain that radiates down the left posterior thigh. The nurse should ask the client if the pain is worsened or aggravated by which factor? A. Bed rest B. Ibuprofen C. Bending or lifting D. Application of heat

C. Bending or lifting

The nurse is administering an intravenous dose of methocarbamol to a client with a muscle skeletal injury. For which adverse effect should the nurse monitor? A. Tachycardia B. Rapid pulse C. Bradycardia D. Hypertension

C. Bradycardia

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate? A. Clamp the T-tube B. Irrigate the T-tube C. Document the findings D. Notify the primary health care provider

C. Document the findings

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicated that spinal shock persists? A. Hyperreflexia B. Positive reflexes C. Flaccid paralysis D. Reflex emptying of the bladder

C. Flaccid paralysis

The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography procedure. The nurse determines that the client needs further information if the client makes which statement? A. I know I must sign the consent form B. I hope the throat spray keeps me from gagging C. I'm glad I don't have to lie still for this procedure D. I'm glad some intravenous medication will be given to relax me

C. I'm glad I don't have to lie still for this procedure

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse evaluates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? A. Infection under the cast B. The anxiety of the client C. Impaired tissue perfusion D. The recent occurrence of the fracture

C. Impaired tissue perfusion

The nurse is caring for a client following a gastrojejunostomy. Which postoperative prescription should the nurse question and verify? A. Leg exercises B. Early ambulation C. Irrigating the nasogastric tube D. Coughing and deep-breathing exercises

C. Irrigating the nasogastric tube

The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to take which measure to assist in preventing dumping syndrome? A. Ambulate following a meal B. Eat high-carbohydrate foods C. Limit the fluids taken with meals D. Sit in a high-Fowlers position during meals

C. Limit the fluids taken with meals

The nurse is analyzing the laboratory studies on a client receiving dantrolene to treat muscle spasms from an injury. Which laboratory test would identify an adverse effect associated with the administration of this medication? A. Platelet count B. Creatinine level C. Liver function tests D. Blood urea nitrogen level

C. Liver function tests

The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse should assess the client for which manifestation of duodenal ulcer? A. Weight loss B. Nausea and vomiting C. Pain relieved by food intake D. Pain radiating down the right arm

C. Pain relieved by food intake

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL. Which dietary selection does the nurse suggest to the client? A. Roast pork B. Cheese omelet C. Pasta with sauce D. Tuna fish sandwich

C. Pasta with sauce

The nurse is assessing the casted extremity of a client. Which sign is indicative of infection? A. Dependent edema B. Diminished distal pulse C. Presence of a hot spot on the cast D. Coolness and pallor of the extremity

C. Presence of a hot spot on the cast

A client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? A. Giving the client full control over care decisions and restricting visitors B. Providing positive feedback and encouraging active range of motion C. Providing information, giving positive feedback, and encouraging relaxation D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

C. Providing information, giving positive feedback, and encouraging relaxation

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? A. Apply ice to the site B. Call the primary health care provider C. Rewrap the residual limb with an elastic compression bandage D. Apply a dry, sterile dressing and elevate the residual limb on 1 pillow

C. Rewrap the residual limb with an elastic compression bandage

A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35mcg/mL (140 mcmcl/L). Which finding would be expected as a result of this laboratory result? A. Hypotension B. Tachycardia C. Slurred speech D. No abnormal finding

C. Slurred speech

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? A. Blowing the nose B. Isometric exercises C. Coughing vigorously D. Exhaling during repositioning

D. Exhaling during repositioning

The home health nurse visits a client who is taking phenytoin for control for seizures. During the assessment, the nurse notes that the client is taking birth control pills. Which information should the nurse include in the teaching plan? A. Pregnancy must be avoided while taking phenytoin B. The client may stop the medication if it is causing severe gastrointestinal effects C. There is the potential of decreased effectiveness of birth control pills while taking phenytoin D. There is the increased risk of thrombophlebitis while taking phenytoin and birth control pills together

C. There is the potential of decreased effectiveness of birth control pills while taking phenytoin

The nurse is evaluating a client in a skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding? A. Redness around the pin sites B. Pain on palpation at the pin sites C. Thick, yellow drainage at the pin sites D. Clear, watery drainage from the pin sites

C. Thick, yellow drainage at the pin sites

A client with trigeminal neuralgia is being treated with carbamazepine, 400mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? A. Sodium level, 140 mEq/L (140 mmol/L) B. Uric acid level, 4.0 mg/dL (240 mmol/L) C. White blood cell count, 3000 mm^3 (3.0 X 10^9/L) D. Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

C. White blood cell count, 3000 mm^3 (3.0 X 10^9/L)

The nurse is caring for a client who begins to experienc seizure activity while in bed. Which actions should the nurse take? (SATA) A. Loosening restrictive clothing B. Restraining the client's limbs C. Removing the pillow and restraining padded side rails D. Positioning the client to the side, if possible, with the head flexed forward E.

D

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (SATA) A. Diarrhea B. Black, tarry stools C. Hyperactive bowel sounds D. Gray-blue color at the flank E. Abdominal guarding and tenderness F. Left upper quadrant pain with radiation to the back

D, E, F

The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation fo the ulcer. A. Bradycardia B. Numbness in the legs C. Nausea and vomiting D. A rigid, board-like abdomen

D. A rigid, board-like abdomen

The nurse is conducting health screening for osteoporosis. Which client is at greatest risk for developing this problem? A. A 25-year old woman who runs B. A 36-year old woman who has asthma C. A 70-year old woman who consumes excess alcohol D. A sedentary 65-year old woman who smokes cigarettes

D. A sedentary 65-year old woman who smokes cigarettes

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate that the client is in cholinergic crisis? A. No change in the condition B. Complaints of muscle spasms C. An improvement of the weakness D. A temporary worsening of the condition

D. A temporary worsening of the condition

The nurse is caring for a client in the emergency department who has been diagnosed with Bell's palsy. The client has been taking acetaminophen, and acetaminophen overdose is suspected. Which antidote should the nurse prepare for administration if prescribed? A. Penostatin B. Auranofin C. Fludarabine D. Acetylcysteine

D. Acetylcysteine

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

D. Assessing for the return of the gag reflex

The nurse is assessing the adaptation of a client to changes in functional status after a stroke. Which observation indicated to the nurse that the client is adapting most successfully? A. Gets angry with family if they interrupt a task B. Experiences bouts of depression and irritability C. Has difficulty with using modified feeding utensils D. Consistently uses adaptive equipment in dressing self

D. Consistently uses adaptive equipment in dressing self

A client with trigeminal neuralgia tells the nurse that acetaminophen is taken daily for the relief of generalized discomfort. Which laboratory value would indicate toxicity associated with the medication? A. Sodium level of 140 mEq/L B. Platelet count of 400,000 mmm^3 C. Prothrombin time of 12 seconds D. Direct bilirubin level of 2 mg/dL

D. Direct bilirubin level of 2 mg/dL

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client had complaints of inability to move both legs and reports the complications of the disorder, the nurse should bring which most essential items into the client's room? A. Nebulizer and pulse oximeter B. Blood pressure cuff and flashlight C. Nasal cannula and incentive spirometer D. Electrocardiographic monitoring electrodes and intubation tray

D. Electrocardiographic monitoring electrodes and intubation tray

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

D. Elevated on pillows continuously for 24 to 48 hours

A client has just has surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery? A. Folate deficiency B. Malabsorption of fat C. Intestinal obstruction D. Fluid and electrolyte imbalance

D. Fluid and electrolyte imbalance

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? A. Fluid is clear and test negative for glucose B. Fluid is grossly bloody in appearance and has a pH of 6 C. Fluid clumps together on the dressing and has a pH of 7 D. Fluid separates into concentric rings and tests positive for glucose

D. Fluid separates into concentric rings and tests positive for glucose

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? A. I can sit down to put on my pants and shoes B. I try to exercise every day and rest when I'm tired. C. My son removed all loose rugs from my bedroom D. I don't need to use my walker to get to the bathroom

D. I don't need to use my walker to get to the bathroom

The nurse has given instructions to a client returning home after knee arthroscopy. Which statement by the client indicates that the instructions are understood? A. I can resume regular exercise tomorrow B. I can't eat food for the remainder of the day C. I need to stay off the leg entirely for the rest of the day D. I need to report a fever or swelling to my health care provider

D. I need to report a fever or swelling to my health care provider

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

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

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? A. Pruritus B. Tachycardia C. Hypertension D. Impaired voluntary movements

D. Impaired voluntary movements

A client with a hip fracture asks the nurse about Buck's extension traction that is being applied before surgery and what is involved. The nurse should provide which information to the client? A. Allows bony healing to begin before surgery and involves pins and screws B. Provides rigid immobilization of the fracture site and involves pulleys and wheels C. Lengthens the fractured leg to prevent severing of blood vessels and involves pins and screws D. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

D. Provides comfort by reducing muscle spasms, provides fracture immobilization, and involves pulleys and wheels

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

D. Respiratory or gastrointestinal infection during the previous month

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery? A. Hemorrhage B. Edema of the residual limb C. Slight redness of the incision D. Separation of the wound edges

D. Separation of the wound edges

The nurse witnessed a vehicle hit a pedestrian. The victim is dazed and tries to get up. A leg appears fractured. Which intervention should the nurse take? A. Try to reduce the fracture manually B. Assist the victim to get up and walk to the sidewalk C. Leave the victim for a few moments to call an ambulance D. Stay with the victim and encourage him or her to remain still

D. Stay with the victim and encourage him or her to remain still

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

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

The nurse has instructed the family of a client with stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client? A. "We need to discourage him from wearing eyeglasses" B. We need to place objects in his impaired field of vision C. We need to approach him from the impaired field of vision D. We need to remind him to turn his head to scan the lost visual field

D. We need to remind him to turn his head to scan the lost visual field