MedSurg Final - Practice Questions
The client with chronic renal failure tells then nurse that he takes magnesium hydroxide (milk of magnesia) at home for constipation. The nurse suggests that the client switch to psyllium hydrophilic mucilloid (Metamucil) because: A. Milk of magnesium can cause magnesium intoxication B. Milk of magnesia is too harsh on the bowel C. Metamucil is more palatable D. Milk of magnesia is high in sodium
A. Milk of magnesium can cause magnesium intoxication.
A client with severe arthritis has been receiving maintenance therapy of prednisone (Deltasone) 10mg/day for the past 6 weeks. The nurse should instruct the client to immediately report symptoms of: A. Respiratory infection B. Joint pain C. Constipation D. Joint swelling
A. Respiratory infection Immunosuppressant = increased risk for infection
A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature
A. Unequal pupil size
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should focus the assessment for: A. Limited motion of joints B. Deformed joints of the hands C. Early morning stiffness D. Rheumatoid nodules
C. Early morning stiffness
After teaching the client with severe rheumatoid arthritis about prescribed methotestrate (Rheumatrex), which of the following statement indicates the need for further teaching? A. "I will take my vitamins while I'm on this drug" B. "I must not drink any alcohol while I'm taking this drug." C. "I should brush my teeth after every meal." D. "I will continue taking my birth control pill"
A. "I will take my vitamins while I'm on this drug"
Which of the following meals would be appropriate for the child with osteomyelitis to choose? A. Beef and bean burrito with cheese, carrot and celery sticks, and an orange. B. Buttered wheat bread, cream of broccoli soup, tossed salad with dressing, and an apple C. Potato soup; bacon, lettuce, and tomato sandwich; and an orange D. Tomato soup, grilled cheese sandwich, and a banana
A. Beef and bean burrito with cheese, carrot and celery sticks, and an orange Protein & vitamin C (Zinc, vitamin A), high calorie
Which of the following nursing measures is most useful in preventing the development of osteoporosis in a client who is immobilized? A. Beginning weight-bearing activities as soon as possible B. Increasing the client's calcium intake in the diet C. Performing passive ROM exercises four times a day D. Teaching the client to perform isometric exercises
A. Beginning weight-bearing activities as soon as possible
Which foods should the nurse encourage a client with diverticulosis to incorporate into a diet? Select all that apply. A. Bran cereal B. Broccoli C. Tomato juice D. Navy beans E. Cheese
A. Bran cereal B. Broccoli D. Navy beans
Which of the following outcomes is most appropriate for a nursing diagnosis of ineffective tissue perfusion R/T interruption of arterial flow? Select all that apply. A. Extremities warm to the touch B. Improved respiratory status C. Decreased muscle pain with activity D. Participation in self-care measures E. Lungs clear to auscultation
A. Extremities warm to the touch C. Decreased muscle pain with activity
The client attends two sessions with the dietician to learn about diet modifications to minimize gastroesophageal reflux (GERD). The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods? A. Fats B. High-Sodium Foods C. Carbohydrates D. High-Calcium Foods
A. Fats
The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage? A. Numbness B. Bleeding C. Dislocation D. Pinkness
A. Numbness
A client is in the advanced stages of osteoarthritis. Which of the following best describes the pain that occurs in the advanced stage of the disease? A. Pain occurs with minimal activity B. Crepitation develops and intensifies C. Joints are symmetrically affected by pain D. Fatigue accompanies pain
A. Pain occurs with minimal activity
A client with a T2-toT3 spinal cord injury suddenly complains of a throbbing headache and blurred vision. The nurse assesses that he is flushed and sweating on his upper trunk an face, and the hairs on his arms are raised. What should the nurse do first? A. Raise the head of the bed B. Assess for hypotension C. Check the client for a distended bladder D. Logroll the client to see if he is lying on a foreign object.
A. Raise the head of the bed
The nurse is teaching the client to administer enoxaparin (Lovenox_ following a total hip arthroplasty. The nurse should instruct the client about which of the following? Select all that apply. A. Report promptly any difficulty breathing, rash, or itching B. Notify the health care provider of unusual bruising C. Avoid all aspirin-containing medications D. Wear or carry medical identification E. Expel the air bubble from the syringe before the injection F. Remove the needle immediately after medication is injected
A. Report promptly any difficulty breathing, rash, or itching B. Notify the health care provider of unusual bruising C. Avoid all aspirin-containing medications D. Wear or carry medical identification
The nurse is developing a plan to teach a client deep breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply A. Splint or support the incision to promote maximal comfort B. Inhale slowly through the nostrils; exhale through pursed lips C. Hold the breath for about 5 seconds to expand the alveoli D. Repeat this breathing method 5 to 10 times hourly E. Close one nostril while inhaling
A. Splint or support the incision to promote maximal comfort B. Inhale slowly through the nostrils; exhale through pursed lips C. Hold the breath for about 5 seconds to expand the alveoli D. Repeat this breathing method 5-10 times hourly
Which of the following is an appropriate outcome for a client with rheumatoid arthritis? A. The client will manage joint pain and fatigue to perform activities of daily living B. The client will maintain full range of motion in joints C. The client will prevent the development of further pain and joint deformity D. The client will take anti-inflammatory medications as indicated by the presence of disease symptoms.
A. The client will manage joint pain and fatigue to perform activities of daily living
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that: A. There is a strong link between alcohol use and acute pancreatitis B. Alcohol intake can interfere with the tests used to diagnose pancreatitis C. Alcoholism is a major health problem, all clients are questioned about alcohol intake D. The physician must obtain the pertinent facts, regardless of religious beliefs.
A. There is a strong link between alcohol us and acute pancreatitis
What should the nurse teach the client to do to prevent stress incontinence? Select all that apply. A. Use techniques that strengthen the sphincter and structural supports of the bladder, such as kegel exercises. B. Avoid dietary irritants (i.e. caffeine, alcoholic beverages) C. Not to laugh when at social gatherings D. Carry an extra incontinence pad when away from home E. Obtain a fluid intake of 500mL/day
A. Use techniques that strengthen the spinster and structural supports of the bladder, such as Kegel exercise. B. Avoid dietary irritants (i.e. caffeine, alcoholic beverages)
To prevent recurrence of cystitis, the nurse should plan to encourage the fame client to include which of the following measures in her daily routine? A. Wearing cotton underpants B. Increasing citrus juice intake C. Douching regularly with 0.25% acetic acid D. Using vaginal sprays
A. Wearing cotton underpants
A 24 y/o client has been diagnosed with acute osteomyelitis int he left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101 and a reddened, warm area in the mid calf region over the shaft of the tibia. Based on this information , which of the following nursing diagnoses would be most appropriate for the client? A. Grieving R/T possible lower leg amputation B. Activity intolerance R/T severe left leg pain C. Disturbed body image R/T left leg swelling and inflammation D. Deficient fluid volume R/T elevated temperature of 101
B. Activity intolerance R/T severe left leg pain
The nurse prepares a teaching plan for a client about crutch walking using a two-point gait pattern. Which of the following should the nurse include? A. Advance a crutch on one side and then advance the opposite foot; repeat on the opposite side B. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side C. Advance both crutches together and then follow by lifting both lower extremities to the level of the crutches. D. Advance both crutches together and then follow by lifting both lower extremities pas the level of the crutches
B. Advance a crutch on one side and simultaneously advance and bear weight on the opposite foot; repeat not the opposite side
Four hours after a cast has been applied for a fracture ulna, the nurse assesses that the client's fingers are pale and cool and capillary refill is delayed for 4 seconds. How should the nurse interpret these findings? A. Nerve impairment is developing to the fingers B. Arterial blood supply to the fingers is decreased C. Venous stasis is occurring in the fingers D. The finding is normal for this recovery period
B. Arterial blood supply to the fingers is decreased
The nurse teaches the client with osteoporosis that food products high in calcium include: A. Rice B. Broccoli C. Apples D. Meat
B. Broccoli Dairy & green leafy vegetables
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after they cystoscopy? A. Dizziness B. Chills C. Pink-tinged urine D. Bladder Spasms
B. Chills (from a fever)
After the application of an arm cast, the client complains of pain on passive stretching of his fingers, finger swelling and tightness, and loss of function. Based on these data, the nurse anticipates that the elcoinet may be developing which of the following? A. Delayed bone union B. Compartment syndrome C. Fat embolism D. Osteomyelitis
B. Compartment syndrome Nurse can't take the cast off; call MD
The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism? A. Respiratory distress B. Confusion C. Petechiae D. Fever
B. Confusion Fever occurs later on
A client with peptic ulcer disease (PUD) tells the nurse he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping R/T fear of diagnosis of chronic illness B. Deficient knowledge R/T unfamiliarity with significant signs and symptoms C. Constipation R/T decreased gastric motility D. Imbalanced nutrition: less than body requirements R/T gastric bleeding
B. Deficient knowledge R/T unfamiliarity with significant signs and symptoms
Following a total hip replacement, the nurse should do which of the following? Select all that apply A. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours B. Encourage the client to use the overhead trapeze to assist with position changes C. For meals, elevate the head of the bed to 90 degrees D. Use a fracture bedpan when needed by the client E. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises
B. Encourage the client to use the overhead trapeze to assist with position changes D. Use a fracture bedpan when needed by the client E. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises
A client is admitted with numbness and tingling of the feet and toes after having an upper respiratory infection and flu for the past 5 days. Within 1 hour of admission, the client states that his legs are numb all the way up to his hips. The nurse should do which of the following next? Select all that apply. A. Call his family to come in to visit with him B. Notify his health care provider of the change C. Place respiratory resuscitation equipment int he client's room D. Check for advancing levels of paresthesia E. Perform ankle pumps to increase circulation and relieve numbness
B. Notify his health care provider of the change C. Place respiratory resuscitation equipment in the client's room D. Check for advancing levels of paresthesia A = implies death E. Won't go away, this would be considered a waste of time
A client with Crohn's Disease has concentrated urine, decreased urinary output, dry skin with decreased turgor, hypotension, and weak, thready pulses. The nurse should do which of the following? A. Encourage the client to drink at least 1000 mL per day B. Provide parenteral rehydration therapy ordered by the physician C. Turn and reposition every 2 hours D. Monitor vital signs every shift
B. Provide parenteral rehydration therapy ordered by the physician
In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for sings of: A. Nephritis B. Referred pain C. Urine retention D. Additional stone formation
B. Referred pain
The nurse in instructing the UAP about the correct technique for obtaining a clean-catch urine culture from a female client. Which of the following statements indicates that the assistant has understood the instructions? A. "I will have the client completely empty her bladder into the specimen cup." B. "I will need to catheterize the client to get the urine specimen." C. "I will ask the client to clean her labia, void into the toilet, and then into the specimen cup." D. "I will obtain the specimen in the afternoon after the client has had plenty of fluids."
C. "I will ask the client to clean her labia, void into the toilet, and then into the specimen cup."
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, "Why can't I stop talking about these things? I know those days are gone forever." Which of the following responses by the nurse conveys the best understanding of the client's behavior? A. "Be patient. It takes time to adjust to such a massive loss." B. "Talking about the past is a form of denial. We have to help you focus on today." C. "Reviewing your losses is a way to help you work through your grief and loss" D. "It's a simple escape mechanism to go back and live again in happier times."
C. "Reviewing your losses is a way to help you work through your grief and loss."
What is the priority nursing intervention in the postictal phase of seizure A. Reorient the client to time, person, and place B. Determine the client's level of sleepiness C. Assess the client's breathing pattern D. Position the client comfortably
C. Assess the client's breathing patter
Which of the following is contraindicated for a client with seizure precautions? A. Encouraging him to perform his own personal hygiene B. Allowing him to wear his own clothing C. Assessing oral temperature with a glass thermometer D. Encouraging him to be out of bed
C. Assessing oral temperature with a glass thermometer
A healthcare provider has ordered carbidopa-levidopa (Sinemet) four times per day for a client with Parkinson's Disease. The client states that he wants "to end it all now that the Parkinson's disease has progressed." What should the nurse do? Select all the apply. A. Explain that the new prescription for Sinemet will treat his depression B. Encourage the client to discuss his feelings as the Sinemet is being administered C. Contact the healthcare provider before administering the Sinemet D. Determine if the client is on antidepressants or monoamine oxidase inhibitors E. Determine if the client is at risk for suicide
C. Contact the healthcare provider before administering the Sinemet (This can cause suicidal thoughts) D. Determine if the client is on antidepressants or monoamine oxidase inhibitors E. Determine if the client is at risk for suicide
Which clinical manifestation is a typical reaction to long-term phenytoin sodium (Dilantin) therapy? A. Weight gain B. Insomnia C. Excessive growth of gum tissue D. Deteriorating eyesight
C. Excessive growth of gum tissue
A client is taking phenytoin (Dilantin) as an anti epileptic medication. The nurse should instruct the client to obtain: A. Increased iron B. Increased calcium C. Frequent dental examinations D. Frequent eye examinations
C. Frequent dental examinations
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? A. Compress the nares B. Tilt the head back C. Give the client tissues to collect the fluid D. Administer an antihistamine for post nasal drip
C. Give the client tissues to collect the fluid
When planning to move a person with a possible spinal cord injury, the nurse should direct the team to: A. Limit movement of the arms by wrapping them next to the body B. Move the person gently to help reduce pain C. Immobilize the head and neck to prevent further injury D. Cushion the back with pillows to ensure comfort
C. Immobilize the head and neck to prevent further injury
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statement best indicates that the client understands how to correctly take the antacid? A. " I should take my antacid before I take my other medications." B. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacids." C. "My antacid will be most effective if I take it whenever I experience my stomach pains." D. "It is best for me to take my antacid 1 to 3 hours after meals."
D. "It is best to take my antacid 1 to 3 hours after meals."
While visiting a client with multiple sclerosis, the community health nurse observes that the client looks untidy and sad. The client suddenly says, "I can't even find the strength to comb my hair," and bursts into tears. Which of the following responses by the nurse is best? A. "It must be frustrating not to be able to care for yourself" B. "How many days have you been unable to comb your hair?" C. "Why hasn't your husband been helping you?" D. "Tell me more about how you're feeling"
D. "Tell me more about how you're feeling"
A client with osteoarthritis purchased a copper bracelet to wear, he tells the nurse that he feels better since he started wearing it. Which response by the nurse is most appropriate? A. Tell the client to remove the bracelet because it does not have any therapeutic value B. Warn the client not to spend any more money on quackery such as bracelets C. Instruct the client to remove the bracelet because the copper in it can interfere with salicylate metabolism D. Acknowledge that the client feels better, but encourage the client to continue with prescribed therapy
D. Acknowledge that the client feels better, but encourage the client to continue with prescribed therapy
The client tells the preoperative nurse that she cannot hear without her hearing aid and ask s to wear it to surgery and recovery. What is the nurse's best response? A. Explain to the client hat tit is policy not to take personal items to surgery because they may be lost or broken B. Tell the client that she will bring the hearing aid to the postanestheisa care unit so that she can have it as soon as she wakes up C. Explain to the client that she will have pre-medication the that will make her sleepy before she goes down to surgery and she won't need to hear D. Call the surgery unit to explain the client's request and ask if she can wear them to surgery
D. Call the surgery unit to explain the client's request and ask if she can wear them to surgery
The primary goal of nursing care for a client with stress incontinence is to: A. Help the client adjust to the frequent episodes of incontinence B. Eliminate all episodes of incontinence C. Prevent the development of urinary tract infections D. Decrease the number of incontinence episodes
D. Decrease the number of incontinence episodes
Two days after being placed in a cast for a fractured femur, the client suddenly complains of chest pain and dyspnea. The client is confused and has an elevated temperature. The nurse should assess the client for: A. Osteomyelitis B. Compartment syndrome C. Venous thrombosis D. Fat embolism syndrome
D. Fat embolism syndrome
When using crutches, the client should be instructed to bear weight primarily on the: A. Axillae B. Elbows C. Upper arms D. Hands
D. Hands
Following a total hp replacement, the nurse should position the client in which of the following ways? A. Place weights alongside of the affected extremity to keep the extremity from rotating B. Elevate both feet on two pillows C. Keep the lower extremities adducted by use of an immobilization binder around both legs D. Keep the extremity in slight abduction using an abduction split or pillows paced between thighs
D. Keep the extremity in slight abduction using an abduction split or pillows paced between thighs
A client with peptic ulcer disease (PUD) is taking ranitidine (Zantac). What is the expected outcome of this drug? A. Heal the ulcer B. Protect the ulcer surface from acids C. Reduce acid concentrations D. Limit gastric acid secretions
D. Limit gastric acid secretions
The nurse is assessing a child's skeletal traction and notices that the weights are on the floor. Which of the following should the nurse do next? A. Raise the weights so that the child can move up in bed B. Notify the physician immediately C. Put the foot of the bed not blocks D. Move the child up in the bed
D. Move the child up in bed
To assess the client's renal status, the nurse should monitor which of the following laboratory tests? Select all that apply. A. Serum Sodium B. Potassium levels C. Arterial blood gasses D. Hemoglobin E. Serum blood urea nitrogen F. Creatinine levels G. Urinalysis
E. Serum blood urea nitrogen F. Creatinine levels (Only two that have to do with the kidney's specifically)
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations? A. Inappropriate laughter B. An exaggerated sense of well-being C. Slurring of words when excited D. Visual hallucinations
B. an exaggerated sense of well-being
Which of the following is not a typical clinical manifestation of multiple sclerosis (MS) A. Double vision B. Sudden bursts of energy C. Weakness in the extremities D. Muscle tremors
B. Sudden bursts of energy
A 30 y/o client is hospitalized with a fractured femur, which is being treated with skeletal traction. He states that he has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time? A. Administer a tap water enema B. Place the client on the bedpan every 2-3 hours C. Increase the client's fluid intake to 3000 mL/day D. Perform ROM movement to all extremities
C. Increase the clint's fluid intake to 3000 mL/day
Which of the following statements by the client would indicate that she is at risk for recurrence of cystitis? A. "I can usually go 8-10 hours without needing to empty my bladder" B. "I take a tub bath every evening." C. "I wipe from front to back after voiding" D. "I drink a lot of water during the day"
A. "I can usually go 8-10 hours without needing to empty my bladder"
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which of the following snacks is most appropriate? A. A gelatin dessert B. Yogurt C. An orange D. Peanuts
A. A gelatin dessert The other options had too many nutrients in them for it to be the correct choice
A client has been hospitalized with diagnosis of myasthenia graves. A friend is visiting the client during lunch. Th nurse entered the room after the client recovered from choking on lunch. What should the nurse do next? A. Instruct the client to sit at a 30-degree-angle in bed when eating B. Tell the client to swallow when her chin is tipped down to her chest C. Remind the client to rest after eating D. Encourage the client to eat alone
B. Tell the client to swallow when her chin is tipped down on her chest "Chin tuck"
Which of the following is an initial sign of Parkinson's disease? A. Rigidity B. Tremor C. Bradykinesia D. Akinesia
B. Tremor
When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? A. Renal status B. Vascular status C. Gastrointestinal status D. Biliary function
B. Vascular status
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6. Which of the following would be a priority outcome for this client? A. Prevention of urinary tract complications B. Alleviation of nausea C. Alleviation of pain D. Maintenance of fluid and electrolyte balance
C. Alleviation of pain
A client is admitted to the hospital with a diagnosis of cholecystitis from cholelithiasis. The client has severe abdominal pain, nausea, and has vomited several times. Based on these data, which nursing diagnosis would have the highest priority for intervention at this time? A. Anxiety R/T severe abdominal discomfort B. Deficient fluid volume R/T vomiting C. Pain R/T gallbladder inflammation D. Imbalanced nutrition: less than body requirements R/T vomiting
C. Pain R/T gallbladder inflammation
The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication? A. Presence of crusts around the pin insertion site B. A serious drainage on the dressing C. Pin moves slightly at insertion site D. Client does not feel pain at insertion site
C. Pin moves slightly at insertion site
A client with rheumatoid arthritis tells the nurse that she feels "quite alone" in adjusting to changes in her lifestyle. Which of the following nursing actions is most appropriate in response to this statement? A. Refer the client and her husband for counseling to decrease her sense of isolation B. Suggest that the client develop a hobby to occupy her time C. Tell the client about her community's arthritis support groups D. Suggest that the client discuss her feelings with her minister
C. Tell the client about her community's arthritis support group
When admitting a client with a fractured extremity, the nurse should first focus the assessment on which of the following? A. The are proximal to the fracture B. The actual fracture site C. The areal distal to the fracture D. The opposite extremity for baseline comparison
C. The area distal to the fracture
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? Select all that apply. A. Epigastric pain at night B. Relief of epigastric pain after eating C. Vomiting D. Weight loss E. Melena (Blood in stools)
C. Vomiting D. Weight loss E. Melena (blood in stools)
A client refuses to look at or care for her colostomy. Which of the following statements made by the nurse would be most appropriate? A. "It has been 4 days since your surgery and you will soon be discharged. You have to learn to care for your colostomy before you leave the hospital." B. "I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it." C. "I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness." D. "I can see that you are upset. Would you like to share your concerns with me?"
D. "I can see that you are upset. Would you like to share your concerns with me?
A client with a fracture develops compartment syndrome. Which of the following signs should alert the nurse to impending organ failure? A. Crackles B. Jaundice C. Generalized edema D. Dark, scanty urine
D. Dark, scanty urine This indicates kidney function is diminished (usually this is the first thing to go)
The nurse should teach the client with diverticulitis to integrate which of the following into a daily routine at home? A. Using enemas to relieve constipation B. Decreasing fluid intake to increase the formed consistency of the stool C. Eating a high-fiber diet when symptomatic with diverticulitis D. Refraining from straining and lifting activities.
D. Refraining from straining and lifting activities
After a cholecystectomy, the client is to follow a low-fat diet. Which of the following foods would be most appropriate to include in a low-fat diet? A. Cheese omelet B. Peanut Butter C. Ham salad sandwich D. Roast Beef
D. Roast Beef
Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing GERD? A. Limit caffeine intake to two cups of coffee per day B. Do not lie down for 2 hours after eating C. Follow a low-protein diet D. Take medication with milk to decrease irritation
B. Do not lie down for 2 hours after eating
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence? A. Limit fluid intake ot 1,000 mL/day B. Insert an indwelling urinary catheter C. Establish a regular voiding schedule D. Administer prophylactic antibiotics, as ordered
C. Establish a regular voiding schedule
The nurse is document care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurses's documentation should include which of the following? Select all that apply. A. Nutrition and hydration needs B. Capillary refill C. Continued need for restraints D. Need for medication E. Skin Integrity
A. Nutrition and hydration needs B. Capillary refill C. Continued need for restraints E. Skin integrity
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment? A. Presence of a distal pulse B. Pain with a pain rating scale C. Vital sign changes D. Potential for drug tolerance
A. Presence of a distal pulse
At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain second to osteoarthritis, to minimize gastric mucous irritation? A. At bedtime B. On arising C. Immediately after a meal D. On an empty stomach
C. Immediately after a meal
A postmenopausal woman is scheduled for a bone-density scan. To pan for the client's test, what should the nurse communicate to the client? A. Request that the client remove all metal objects on the day of the scan B. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test C. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test D. Tell the client that she should report any significant pain to her physician at least 2 days before the test.
A. Request that the client remove all metal objects on the day of the scan
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assess her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability? A. "I won't be able to have sexual intercourse until the urinary catheter is removed." B. "I can participate in sexual activity but might not experience orgasms." C. "I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay." D. "I should be able to participate in sexual activity, but I will be infertile."
B. "I can participate in sexual activity but might not experience orgasms."
A client has a total hip replacement. Which of the following client statements indicates a need for further teaching before discharge? A. "I will implement my exercise program as soon as I get home" B. "I will be careful not to cross my legs" C. "I will need an elevated toilet seat" D. "I can't wait to take a tub bath when I get home"
D. "I can't wait to take a tub bath when I get home"
A client has had a total hip replacement. Which of the following signs most likely indicates that the hip has dislocated? A. Abduction of the affected leg B. Loosening of the prosthesis C. External rotation of the affected leg D. Shortening of the affected leg
D. Shortening of the affected leg
Non steroidal anti-inflammatory drugs (NSAIDs) are commonly used in the treatment of musculoskeletal conditions. It is important for the nurse to remind the client to: A. Take NSAIDs at least three times per day B. Exercise the joints at least 1 hour after taking the medication C. Take antacids 1 hour after taking NSAIDs D. Take NSAIDs with food
D. Take NSAIDs with food
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the midepigatric region along with a rigid, boardlike abdomen. These clinical manifestations most likely indicated which of the following? A. An intestinal obstruction has developed B. Additional ulcers have developed C. The esophagus has become inflamed D. The ulcer has perforated
D. The ulcer has perforated
A client has his leg immobilized in a long leg cast. Which of the following assessments indicates the early beginning of circulatory impairment? A. Inability to move toes B. Cyanosis of toes C. Complaining of cast tightness D. Tingling of toes
D. Tingling of toes
Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's Disease? A. To cure the disease B. To stop the progression of the disease C. To begin preparations for terminal care D. To maintain optimal body function
D. To maintain optimal body function
