MedSurg HURST
What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit? select all that apply 1. Asymmetrical chest expansion 2. Night sweats 3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus
3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 6. Increased tactile fremitus
Which nursing intervention will be most helpful to a middle-aged client experiencing insomnia? 1. Instruct the client to initiate an exercise routine during the day. 2. Educate the client on ways to adjust the sleep environment. 3. Instruct the client on progressive relaxation techniques to be used just before bedtime. 4. Instruct the client to decrease caffeine intake.
3. Instruct the client on progressive relaxation techniques to be used just before bedtime.
A middle-aged client has a strong positive family history of type 2 diabetes mellitus. What should the nurse teach the client regarding the best method to prevent or delay the development of this disease? 1. Test serum glucose values monthly. 2. Avoid starches and sugars in the diet. 3. Obtain a normal body weight and exercise regularly. 4. Maintain a normal serum lipid panel.
3. Obtain a normal body weight and exercise regularly.
A client admitted to a long-term care facility is legally blind and partially deaf. How would the nurse best provide for the client's safety in the event of an emergency? select all that apply 1. Have roommate lead client out of the room to safety area. 2. Assign a specific UAP every shift to escort client to safety. 3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family. 5. Plan for the supervisor to be responsible for evacuating the client.
3. Research established protocols utilized by emergency groups. 4. Discuss best communication methods with client and family.
The nurse is reviewing morning laboratory results on four clients. Which lab finding should the nurse report to the primary healthcare provider immediately? 1. aPTT 2. WBC 3. Sed rate 4. K+
4. K+
Twelve hours post coronary artery bypass surgery (CABG), the nurse notes the client's level of consciousness has decreased from alert to somnolent. BP 88/50, HR 130 and thready, resp 32, urinary output (UOP) has dropped from 100 mL one hour earlier to 20 mL this hour. What would be the nurse's first action? 1. Administer 100% oxygen per mask. 2. Lower the head of the bed. 3. Give furosemide STAT. 4. Re-check the BP in the other arm.
1. Administer 100% oxygen per mask.
What signs/symptoms would the nurse expect to find in a client diagnosed with osteoarthritis (OA) in the knee? Select all that apply 1. Sjogren's syndrome 2. Clicking sound when knee bends 3. Fever 4. Pain that is worse after activity 5. Severe fatigue
2. Clicking sound when knee bends 4. Pain that is worse after activity
What should the nurse include in the teaching plan for a client who has iron deficiency anemia?Select all that apply 1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 3. Iron is needed for white blood cell development. 4. Educate about ferrous sulfate supplement. 5. After drinking liquid iron, follow immediately by water.
1. Consume iron rich foods such as dried lentils, peas, and beans. 2. Notify primary healthcare provider of glossitis, anorexia, and paresthesia. 4. Educate about ferrous sulfate supplement.
A client has been admitted to the med-surg floor with lower abdominal pain and bloating, fever, chills, and vomiting. Following a Cat scan, a diagnosis of diverticulitis is made. What action by the nurse is most appropriate after the initial assessment? 1. Obtain a stool specimen for ova and parasites. 2. Prepare client for emergency exploratory surgery. 3. Notify dietary the client will need a clear liquid diet. 4. Give client a heating pad to ease abdominal pain.
3. Notify dietary the client will need a clear liquid diet.
What assessment data would a nurse expect to find in a client diagnosed with a severe episode of acute inflammatory bowel disease? select all that apply 1. Dark yellow urine 2. Fever 3. Frequent, hard stools 4. Lower abdominal cramping 5. Tachycardia
1. dark yellow urine 2. fever 4. lower abdominal cramping 5. tachycardia
A client is curious about visible appearance changes related to menopause. What menopausal changes, in general, would the nurse explain to the client? 1. Bone loss and fractures. 2. Loss of muscle mass. 3. Improved skin turgor and elasticity. 4. A reduction in waist size.
2. Loss of muscle mass.
The homecare nurse is visiting a newly diagnosed diabetic being treated for a small left foot wound. What is the nurse's priority assessment on this first home visit? 1. Determine stage and drainage of foot wound. 2. Assess the client's ability to prepare and administer insulin. 3. Check home environment for potential hazards. 4. Assess client's knowledge of signs of hypoglycemia.
3. Check home environment for potential hazards.
A client is to be discharged following treatment for hepatitis A. The nurse knows teaching was successful when the client makes what statement? 1. "I should never eat fresh salad in a restaurant." 2. "I must wait two years before traveling abroad." 3. "I will need blood work once a month for a year." 4. "I will be able to donate blood when I am well."
4. "I will be able to donate blood when I am well."
A community health nurse is assessing a migrant farmer who raises chickens. The nurse notes the client has developed a cough, fever, dyspnea, and hemoptysis. What infection should the nurse suspect? 1. Lyme disease 2. Toxoplasmosis 3. Tuberculosis 4. Histoplasmosis
4. Histoplasmosis
The nurse is assessing a client admitted with acute gastritis. Which client information is most significant? 1. Takes ibuprofen for arthritis pain. 2. Had an upper respiratory infection two weeks ago. 3. Has a stressful job. 4. Enjoys spicy food.
1. Takes ibuprofen for arthritis pain.
A nurse is planning a teaching session for a group of clients diagnosed with irritable bowel syndrome. What points should the nurse include to help the clients control symptom flare-ups? Select all that apply 1. If you are constipated, try to make sure you have breakfast. 2. Avoid low fat foods. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms. 5. Foods such as broccoli and cabbage are good sources of fiber.
1. If you are constipated, try to make sure you have breakfast. 3. If you think a certain food is a problem, try cutting it out of your diet for about 12 weeks. 4. Drinks containing caffeine are likely to contribute to symptoms.
An alert elderly client has been admitted to the hospital and placed on bedrest following a fall at home. During evening medication rounds, the nurse notes the client has become disoriented to time and place. The nurse is aware a new onset of confusion could be the result of what factors? Select all that apply 1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 4. Advanced age. 5. Response to analgesic.
1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic.
What symptoms of meningeal irritation would the nurse anticipate when performing an assessment on a newly admitted client with a diagnosis of bacterial meningitis? Select all that apply 1. Positive Kernig's sign 2. Positive Brudzinski's sign 3. Presence of Babinski's reflex 4. Photophobia 5. Severe headache 6. Nuchal rigidity
1. Positive Kernig's sign 2. Positive Brudzinski's sign 4. Photophobia 5. Severe headache 6. Nuchal rigidity
The nurse is providing teaching for a client who is being scheduled for outpatient 24 hour electrocardiogram monitoring using a Holter monitor. What should the nurse tell the client to avoid while monitoring is in progress? Select all that apply 1. Taking a shower or bath 2. Performing daily exercises 3. Working around high voltage equipment 4. Being screened at airport security 5. Eating foods that are sources of potassium
1. Taking a shower or bath 3. Working around high voltage equipment 4. Being screened at airport security
What assessment data is the priority nursing concern in a client receiving prednisolone for the treatment of nephrotic syndrome? 1. Weight gain of 2 lbs (0.907 kg) in 24 hours 2. Temperature 99.6°F (37.5° C) 3. Blood glucose 116 mg/dL 4. Blood pressure 138/88
1. Weight gain of 2 lbs (0.907 kg) in 24 hours
Which food items, if chosen by a new unlicensed assistive personnel (UAP), would indicate to the nurse that the UAP understands a clear liquid diet? select all that apply 1. White grape juice 2. Gelatin 3. Vanilla pudding 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey
1. White grape juice 2. Gelatin 4. Lemon Popsicle 5. Fat free Broth 6. Tea with honey
A client presents in the emergency department with acute onset of fever, headache, stiff neck, nausea/vomiting, and mental status changes. What interventions should the nurse initiate? Select all that apply 1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 4. Initiate airborne isolation precautions 5. Darken room
1. Elevate HOB 30 degrees 2. Pad side rails 3. Provide sponge bath if temperature greater than 101°F (38.3°C) 5. Darken room
In what position should the nurse place a client post intracranial surgery? 1. Head of bed elevated 30 degrees 2. Supine 3. Dorsal recumbent 4. Recovery position
1. Head of bed elevated 30 degrees
Following a motor vehicle accident, a client is brought to the emergency room with shallow, labored respirations. The client is intubated and placed on a ventilator. What is the nurse's priority action immediately after the intubation? 1. Suction to clear all secretions 2. Listen for bilateral breath sounds 3. Secure the endotracheal tube 4. Obtain x-ray to verify tube placement
2. Listen for bilateral breath sounds
The nurse is preparing to discharge four clients from the unit. Which client is most likely to warrant a referral to other agencies or community outreach programs? 1. 45 year-old client who had nasal surgery. 2. 50 year-old client postop mastectomy. 3. 72 year-old client with diabetes and obesity. 4. 80 year-old client with a diagnosis of delirium caused by dehydration.
3. 72 year-old client with diabetes and obesity.
The nurse is discharging a client post right radial percutaneous transluminal coronarey angioplasty (PTCA) with stent insertion. Which instructions should the nurse give the client to reduce the risk of complications? Select all that apply 1. Do not use the wrist to lift more than 5 pounds (2.27 kg) for 24 hours. 2. Stop taking aspirin in one week. 3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 5. Do not shower or soak in a tub for one week. 6. Take short walks around your house.
3. Drink at least 8 glasses of water a day. 4. Wear loose fitting sleeves. 6. Take short walks around your house.
What signs/symptoms would the nurse expect to assess in a client diagnosed with Guillain-Barre' Syndrome? select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia
3. Paresthesia 5. Hypotonia 6. Muscle aches
A client admitted to ICU has a prescription for an arterial line insertion to the right radial artery. What assessment findings by the nurse would be of concern? Select all that apply 1. Right sided mastectomy 2. Inability to abduct fingers of right hand 3. Negative Allen's test 4. Radial pulse 3+/4+ 5. Presence of A-V shunt to right forearm
1. Right sided mastectomy 3. Negative Allen's test 5. Presence of A-V shunt to right forearm
The nurse is working with a group of elderly clients to promote better nutrition. Prior to developing the health promotion plan, the nurse assesses individual members of the group. Which assessment findings are expected as the nurse works with this group? Select all that apply 1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels. 4. Access to fresh foods is adequate. 5. The desire and interest in cooking is increased.
1. Some clients may have dental issues, making chewing difficult. 2. There may be a decreased appetite in clients. 3. Caloric and nutritional needs may vary somewhat depending on activity levels.
What signs of cannula displacement should the nurse monitor for at an arterial line insertion site? Select all that apply 1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform 5. Pyrexia 6. Purulent drainage
1. Swelling 2. Fluid leakage 3. Blanching 4. Poor arterial waveform
The nurse is planning to teach a group of senior citizens about modifiable risk factors for developing a stroke. Which factors should the nurse include? Select all that apply 1. Diabetes mellitus 2. Hypertension 3. Hispanic ethnicity 4. Atrial fibrillation 5. Sleep apnea 6. Smoking
1. Diabetes mellitus 2. Hypertension 4. Atrial fibrillation 5. Sleep apnea 6. Smoking
Which signs/symptoms should the nurse assess for in the client admitted with a diagnosis of myasthenia gravis? select all that apply 1. Difficulty holding head erect 2. Limited facial expressions 3. Ptosis 4. Hemiparesis 5. Writhing, twisting movements of the body 6. Pill rolling
1. Difficulty holding head erect 2. Limited facial expressions 3. Ptosis
A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will prevent further chemical exposure? 1. Don appropriate personal protective equipment (PPE). 2. Remove only contaminated clothes. 3. Avoid decontaminating the eyes. 4. Use hot water during decontamination.
1. Don appropriate personal protective equipment (PPE).
The nurse is caring for a client who has an active herpes simplex 1 lesion on the lip. What measures should be implemented by the nurse? Select all that apply 1. Tell the client to avoid touching the lesion. 2. Scrub the lesion gently with soap and water prior to meals. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 4. Wear sterile gloves when applying medication to lesion. 5. Ask client to discard lip balm until lesion is resolved.
1. Tell the client to avoid touching the lesion. 3. Apply a thin layer of acyclovir to the lesion 5 times a day. 5. Ask client to discard lip balm until lesion is resolved.
The homecare nurse is instructing the family of a client recently diagnosed with Parkinson's disease about potential neurologic changes. During the discussion, what signs should the nurse include? Select all that apply 1. Unsteady gait 2. Muscle rigidity 3. Hyperactive reflexes 4. Bradykinesia (slowed movements) 5. Expressive aphasia
1. Unsteady gait 2. Muscle rigidity 4. Bradykinesia (slowed movements)
A client is preparing to be discharged after a total colectomy with the creation of an ileoanal reservoir for ulcerative colitis. The nurse recognizes that education has been successful if the client makes which statement? 1. "Ulcerative colitis cannot be cured." 2. "I look forward to having the ileostomy closed." 3. "I am going to eat a hamburger and fries for dinner." 4. "Because of this surgery, I am at a higher risk of developing colon cancer."
2. "I look forward to having the ileostomy closed."
The nursing supervisor is reviewing several instances in which restraints have been used. The nurse is aware the only acceptable use of restraints is what? 1. An elderly male had a chest restraint applied after crawling over bed rails several times. 2. An Alzheimer client's room door is closed to prevent wandering during shift change. 3. A confused client with a closed head injury had hand mitts applied after pulling out IV 4. A dementia client with sundowners is placed in Geri-chair with lap belt at nurse's station.
3. A confused client with a closed head injury had hand mitts applied after pulling out IV
A client is to be discharged following cataract removal with lens implantation. What statement by the client indicates to the nurse that teaching has been successful? 1. "I must keep both eyes covered till my check-up." 2. "I should only have pain for about two days." 3. "I will no longer have to wear reading glasses." 4. "My vision will be blurry for a couple weeks."
4. "My vision will be blurry for a couple weeks."
The nurse walks into a client's room and discovers the radioactive uterine implant lying on the bed. In what order should the nurse properly dispose of the implant? Place implant in lead lined container Pick up implant with tongs Call radiation department to take the implant out of the room Put on gloves
Put on gloves Pick up implant with tongs Place implant in lead lined container Call radiation department to take the implant out of the room
The nurse is demonstrating ostomy care to a client with a new stoma in the sigmoid area of the colon. The nurse knows teaching is successful when the client completes care in what order? Cut center of new flange to fit stoma. Press flange into place and attach bag. Place stoma adhesive onto new flange. Wash stoma with warm soapy water. Apply skin protectant and allow drying. Remove ostomy bag and old flange.
Remove ostomy bag and old flange. Wash stoma with warm soapy water. Apply skin protectant and allow drying. Cut center of new flange to fit stoma. Place stoma adhesive onto new flange. Press flange into place and attach bag.
Which statements by an older adult indicate that teaching about adequate nutrition and hydration have been effective? Select all that apply 1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 3. "I am less likely to become constipated if I increase my fiber intake to 20 grams a day." 4. "Drinking 1 liter of water a day will keep me hydrated." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."
1. "Taking a multivitamin every day will help me get enough calcium and vitamin C." 2. "Enrolling in Meals on Wheels will provide me with a nutritious meal every day." 5. "I will strive to eat at least 5 servings of fruits and vegetables a day."
A nurse is planning to educate diabetic clients on how to decrease their risk for developing renal failure. What educational points should the nurse include? Select all that apply 1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%. 4. Have estimated glomerular filtration rate measured every five years. 5. Increase protein intake to 30% of total calories eaten per day.
1. Avoid daily use of non-steroidal antiinflammatory medications. 2. Aggressive blood pressure management is necessary. 3. Aim to keep Glycosylated Hemoglobin (HgbA1c) less than 7%.
The nurse is monitoring the infection risk in a client that is to begin chemotherapy. Which activity should alert the nurse that the client is at a higher risk for infection? Select all that apply 1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 4. Selects steamed vegetables as part of routine dietary intake. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.
1. Enjoys getting manicures and pedicures every two weeks. 2. Loves to go with the children to the local water park. 3. Relaxes in hot tubs when traveling. 5. Prefers to go barefooted when at home. 6. Keeps cats in the home and cleans the litter boxes once a week.
An elderly, bed-bound client receiving G-tube feeding at home is transported to the emergency department after onset of behavioral changes and hallucinations. Which nursing action is priority while diagnostic testing is underway? 1. Initiate seizure precautions 2. Discontinue G-tube feeding 3. Administer oxygen 4. Obtain blood work for troponin level
1. Initiate seizure precautions
A client is admitted to the critical care unit after suffering from a massive cerebral vascular accident. The client's vital signs include BP 160/110, HR42, Cheyne-Stokes respirations. Based on this assessment the nurse anticipates the client to be in which acid/base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
1. Respiratory acidosis
What risk factors should the nurse include when teaching a group of clients about osteoarthritis? Select all that apply 1. Sports injury to joint 2. Genetic predisposition 3. Obesity 4. Male sex 5. Repetitive joint stress
1. Sports injury to joint 2. Genetic predisposition 3. Obesity 5. Repetitive joint stress
Which health promotion instructions should the nurse provide to a client diagnosed with cirrhosis? select all that apply 1. Use a shower chair when performing hygiene. 2. Limit alcohol intake. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.
1. Use a shower chair when performing hygiene. 3. Stop any activity that causes dizziness. 4. Calculate daily sodium intake. 5. Proper hand hygiene.
The nurse is reviewing the Centers for Disease Control and Prevention's (CDC's) guidelines for immunization recommendations with a group of parents whose children are preparing to attend college in the fall. Which immunization recommendations should the nurse include? Select all that apply 1. Rotavirus 2. Meningococcal 3. Herpes zoster 4. Seasonal influenza 5. Human papilloma virus
2. Meningococcal 4. Seasonal influenza 5. Human papilloma virus
A client with a deep partial-thickness burn to the right forearm has returned from surgery with a skin graft to the burned area. Which graft site intervention would the nurse implement within the first 24 hours? 1. Monitor temperature every 12 hours. 2. Position arm to prevent pressure to the graft site. 3. Prepare to change the 1st dressing within 24 hours. 4. Perform passive range of motion exercises to the right arm.
2. Position arm to prevent pressure to the graft site.
The medical surgical nurse is admitting a client diagnosed with deep vein thrombosis (DVT) of the right leg. The client suddenly begins to report shortness of breath. Which additional early signs/symptoms indicative of a complication would the nurse need to report to the primary healthcare provider immediately? 1. Tachycardia with tachypnea. 2. Restlessness and dizziness. 3. Pain in the lower right leg. 4. A positive Homan's sign.
2. Restlessness and dizziness.
A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological
3. Airway
A client is admitted to the emergency department after sustaining burns to the chest and legs during a house fire. Which assessment should the nurse perform immediately? 1. Respiratory 2. Cardiac 3. Airway 4. Neurological
3. Airway
The nurse is performing sterile wound care for partial thickness burns on a client's lower right leg. Prior to initiating this procedure, what action should the nurse complete first? 1. Position client upright with right leg elevated. 2. Obtain wound culture before cleaning wound. 3. Assess current pain level and medicate. 4. Encourage client to verbalize concerns.
3. Assess current pain level and medicate.
A client being prepared for surgery is to be given a pre-operative medication. What is the nurse's priority action when administering the medication? 1. Verify client has signed all consent forms. 2. Escort the client to the bathroom to void. 3. Check that identification band is in place. 4. Raise side rails and put call bell in place.
3. Check that identification band is in place.
A client buzzes the nurses' station to report chest pain. The nurse looks at the client's cardiac rhythm strip, then hurries into the client's room to find the client unresponsive and without a pulse. What initial action should the nurse take? 1. Administer Epinephrine 1mg IV push. 2. Begin cardiopulmonary resuscitation (CPR) for 2 minutes. 3. Defibrillate at 120 joules. 4. Insert supraglottic airway device.
3. Defibrillate at 120 joules.
The nurse evaluates an electrocardiogram (EKG) and notices a U-wave. The nurse suspects that this occurrence is caused by which electrolyte imbalance? 1. Hypermagnesemia 2. Hypocalcemia 3. Hypokalemia 4. Hyponatremia
3. Hypokalemia
What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)? Select all that apply 1. Monitor Central venous pressure (CVP) 2. Administer diuretic 3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities
3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities
A client reporting right thigh pain is admitted to a local hospital with a diagnosis of deep vein thrombosis (DVT). During the admission assessment, the client develops new signs/symptoms. The nurse would be most concerned about what sign/symptom? 1. Swelling along vein of leg 2. Right foot begins to tingle 3. Restlessness 4. Warmth over affected area
3. Restlessness
A client is admitted to the hospital due to a deep vein thrombosis (DVT). Which intervention should the nurse initiate? 1. Ambulate client around room every 2 hours. 2. Assess Homans' sign every 8 hours. 3. Place sequential compression device on both legs. 4. Apply intermittent warm, moist soaks to affected area.
4. Apply intermittent warm, moist soaks to affected area.
The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find? 1. Increased white blood cells 2. Presence of protein 3. Presence of ketones 4. Increased specific gravity
4. Increased specific gravity
An elderly client with a history of congestive heart failure has been admitted to the Telemetry Unit with new-onset chest pain and palpitations. The healthcare provider decides to change the client's hydralazine to metoprolol. In preparing to teach the client about changes related to the new medication, the nurse is aware that metoprolol will likely decrease chest pain episodes secondary to what known side effect of hydralazine? 1. Dizziness 2. Hypotension 3. Sodium retention 4. Reflex tachycardia
4. Reflex tachycardia
The nurse is supervising the care of a client on bedrest with a skull fracture from head trauma. Which action, when performed by an unlicensed assistive personnel (UAP), should the nurse interrupt? select all that apply 1. Assisting with turn, cough, and deep breathing (TCDB) 2. Elevating the head of the bed to 30 degrees. 3. Measuring urinary output every hour. 4. Turning off room lights.
1. Assisting with turn, cough, and deep breathing (TCDB)
The nurse is assessing a 70 year old client who was admitted several hours ago for IV hydration with lactated ringers solution after being diagnosed with dehydration. What findings would be of concern to the nurse? select all that apply 1. BP 142/88 2. Bounding pulse 3. CVP 7 mmHg 4. S3 heart sound 5. Urinary output 220 mL over 4 hours
1. BP 142/88 2. Bounding pulse 3. CVP 7 mmHg 4. S3 heart sound
A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair? Select all that apply 1. Blood pressure screening 2. Glucose monitoring 3. Influenza vaccination 4. BMI calculation 5. Test urine for protein. 6. Pneumococcal vaccination
1. Blood pressure screening 2. Glucose monitoring 3. Influenza vaccination 4. BMI calculation 5. Test urine for protein.
Which interventions should be included in the nutritional teaching plan to accomplish the goal of a diet lower in fat? Select all that apply 1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 3. Eat more red meat instead of fish. 4. Incorporate plant sources of protein. 5. Use olive oil instead of vegetable oil when frying.
1. Use 2% milk instead of whole milk. 2. Eat air-popped popcorn instead of potato chips. 4. Incorporate plant sources of protein.
The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? 1. I'll have to take a strong laxative the morning of the test. 2. I'll have to drink contrast while x-rays are taken. 3. I'll have a CT scan after I'm injected with a radiopaque contrast dye. 4. I'll have an instrument passed through my mouth to my stomach.
2. I'll have to drink contrast while x-rays are taken.
A client who must use crutches, is being taught by the nurse how to perform a three-point gait. What information should the nurse provide? 1. Move right crutch forward, then left foot. Next move left crutch forward, then right foot. 2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward. 3. Move left crutch and right foot forward together, then move the right crutch and left foot forward together. 4. Move both crutches ahead together, then lift body weight by the arms and swing both legs to the crutches.
2. Move both crutches forward without bearing weight on the affected leg, then move the unaffected leg forward.
A client admitted for debridement of a leg wound has been diagnosed with vancomycin-resistant enterococci (VRE). What is the nurse's priority action? 1. Place with another client in contact isolation for methicillin-resistant staphylococcus aureus (MRSA). 2. Move the client to a private room with contact precautions. 3. Alert staff to use masks, goggles and gown to provide care. 4. Notify family members to gown and glove before entering room.
2. Move the client to a private room with contact precautions.
A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately? 1. Start IV of normal saline at 100 mL per hour. 2. Keep left arm elevated on pillow at all times. 3. Apply ice packs to affected area every shift. 4. Ibuprophen 800 mg po every 6 hours prn pain.
3. Apply ice packs to affected area every shift.
The nurse is caring for a client who has been receiving treatment for systolic heart failure. What assessment findings would indicate to the nurse that further treatment is necessary? Select all that apply 1. 3+ pedal edema 2. CVP of 6 mm Hg 3. One day weight loss of 2 pounds (0.9 kg) 4. Purse-lip breathing 5. Pale nail beds 6. Urine output at 50 mL/hr
1. 3+ pedal edema 4. Purse-lip breathing 5. Pale nail beds
Which sign/symptom would the nurse expect when assessing a client diagnosed with aortic valve stenosis? Select all that apply 1. Angina 2. Prominent S4 3. Reports being light-headed 4. Systolic murmur 5. Ventricular gallope
1. Angina 2. Prominent S4 3. Reports being light-headed 4. Systolic murmur
A long-term care nurse is planning care for a newly admitted client diagnosed with alzheimer's disease. What should the nurse include in the plan of care? Select all that apply 1. Assess client's ability to perform self care. 2. Educate nursing staff to help client in all activities of daily living. 3. Separate tasks into small manageable steps. 4. Relieve family members of stress by advising them to visit 1 time per week. 5. Have nursing staff spend time talking and listening to client.
1. Assess client's ability to perform self care. 3. Separate tasks into small manageable steps. 5. Have nursing staff spend time talking and listening to client.
What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)? select all that apply 1. Fatigue 2. Ptosis 3. Blurry vision 4. Leg weakness 5. Limited facial expression 6. Electric shock sensation when bending neck forward
1. Fatigue 3. Blurry vision 4. Leg weakness 6. Electric shock sensation when bending neck forward
The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client's condition. Which intervention is most important for the nurse to initiate? 1. Suggest that the family seek an appointment with the primary healthcare provider. 2. Ask the dietician to visit the client and discuss food preferences. 3. Note any weight loss over the next month. 4. Continue to monitor intake over the next couple of weeks
2. Ask the dietician to visit the client and discuss food preferences.
A client diagnosed with primary pulmonary hypertension is admitted to the hospital. What does the nurse expect the client to mention when reviewing the client's current treatment regimen? Select all that apply 1. Aminoglycosides 2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators
2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators
The nurse is preparing to administer a dose of ondansetron 0.15 mg/kg. The nurse has not administered this medication before and is using a drug reference to review information about the medication. Which client and drug reference information supports the nurse's decision to withhold the ondansetron? select all that apply 1. Nystagmus 2. Concurrent use of apomorphine 3. Pill rolling movement 4. Tachycardia 5. Maximum dose 16 mg 6. Elevated liver enzymes
2. Concurrent use of apomorphine 6. Elevated liver enzymes
A client with a history of intolerance to fatty foods is admitted to the hospital with a sudden onset of severe right upper quadrant pain radiating to the right shoulder. What should be included in the nurse's initial focused assessment of this client? 1. "Do you have pain in the middle of your stomach that is relieved by vomiting?" 2. "Have you noticed any red splotches on your skin?" 3. "Please describe your bowel habits and stool." 4. "Tell me how often you eat high fat meals."
3. "Please describe your bowel habits and stool."
The client has been diagnosed with cutaneous anthrax in a cut on the right hand. What measure should be implemented by the nurse to prevent further spread of the disease? 1. Wear mask only. 2. There are no precautions necessary. 3. Standard precautions. 4. Limit interactions with client.
3. Standard precautions.
A nurse is caring for a client who had a total hip replacement 2 days ago. What assessment finding would be a priority concern for the nurse? 1. Small amount of red drainage on the surgical dressing. 2. Continues to report pain in hip when being repositioned. 3. Temperature of 101.8°F (38.7°C). 4. Slight swelling in the leg on the affected side.
3. Temperature of 101.8°F (38.7°C).
Which finding should take priority when the nurse is assessing the skin of a client diagnosed with diabetes? 1. Vitiligo of the chest. 2. Scleroderma to scapula and posterior neck region. 3. Redness of face and upper chest. 4. Small abrasion on great toe.
4. Small abrasion on great toe.
A client with cervical cancer received an internal cervical radiation implant. What should be the initial nursing action if the radiation implant becomes dislodged and is found lying in the bed? 1. Call the client's primary healthcare provider. 2. Pick up the implant immediately with gloved hands and place it in double biohazard bags. 3. Notify the radiology department. 4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.
4. Utilize long-handled forceps to pick up the implant and dispose of it in a lead container.
A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive tuberculin skin test reaction? Select all that apply 1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 3. Client working at a nursing home with an induration of 8 millimeters. 4. 3 year old client with an induration of 12 millimeters. 5. Healthy client with no known TB exposure who has an induration of 5 millimeters.
1. HIV+ client with an induration of 6 millimeters. 2. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. 4. 3 year old client with an induration of 12 millimeters.
What potential contributing factors for stress urinary incontinence should a nurse assess for in an elderly female client? Select all that apply 1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births 4. Spinal cord injury 5. Dementia
1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births
The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement? Select all that apply 1. Oily skin 2. Weight gain of 4 pounds in one week 3. Loss of muscle mass in extremities 4. Blood glucose of 58 mg/dL 5. Serum potassium of 3.2 mEq
2. Weight gain of 4 pounds in one week 5. Serum potassium of 3.2 mEq
The pathology report on a client diagnosed with urolithiasis reveals calcium oxalate stones. Which food selections by the client would indicate to the nurse that the client understands the prescribed low oxalate diet? Select all that apply 1. Spinach 2. Raspberries 3. Almonds 4. 100% bran cereal 5. Bananas 6. Raisins
5. Bananas 6. Raisins
A client with a history of alcoholism arrives at the clinic reporting severe abdominal pain with nausea and vomiting. What additional findings would make the nurse suspect the client may have pancreatitis? select all that apply 1. Bruising at the umbilicus. 2. Fever with tachycardia. 3. Positive Trousseau sign. 4. Pain radiating to back. 5. Vague pain at night.
1. Bruising at the umbilicus. 2. Fever with tachycardia. 4. Pain radiating to back.
Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus? select all that apply 1. White blood cells of 9,500 mm3 (9.5 x 10^9/L) 2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L) 5. Glucose of 100 mg/dL (5.6 mmol/L)
2. Urine specific gravity of 1.004 3. Serum sodium level of 149 mEq/L (149 mmol/L) 4. Hemoglobin of 20 g/dL (200 g/L)
A client is being evaluated for possible Rheumatoid Arthritis (RA). Which lab data and assessment findings by the nurse would be indicative of RA? Select all that apply 1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 4. Presence of Dupuytren's contractures. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.
1. Joint pain, swelling, and warmth. 2. Decreased movement in joints. 3. Presence of Rheumatoid factor on lab analysis. 5. Elevated erythrocyte sedimentation rate (ESR). 6. Presence of Cyclic Citrullinated Peptide Antibody.
The nurse is caring for a client who is scheduled to receive furosemide 40 mg IVP twice daily, as well as 20 meq (20 mmol/l) of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/L (2.4 mmol/L) this morning. How should the nurse proceed? 1. Notify the primary healthcare provider of the potassium level immediately. 2. Administer the medications as scheduled and notify the primary healthcare provider on rounds. 3. Give the potassium, but hold the furosemide until primary healthcare provider rounds. 4. Assess the client for muscle cramps.
1. Notify the primary healthcare provider of the potassium level immediately.
The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents? Select all that apply 1. Limit TV viewing and video game playing to 4 hours a day 2. At least 60 minutes of moderate-intensity activity daily 3. Exercise should be structured 4. A strict diet should be followed avoiding all junk food and drinking water only 5. Set a goal of at least 11,000 to 13,000 steps each day
2. At least 60 minutes of moderate-intensity activity daily 5. Set a goal of at least 11,000 to 13,000 steps each day
What signs/symptoms would the nurse expect to find in a client diagnosed with pernicious anemia? Select all that apply 1. Pain 2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion
2. Smooth, red tongue 3. Burning feeling in feet 4. Lightheadedness 5. Dyspnea on exertion
Which statement by a client diagnosed with infectious mononucleosis indicates to the nurse that education has been successful? 1. "I should let my primary healthcare provider know if I start having pain in the side of my stomach" 2. "I can return to my normal activities in 5 days." 3. "I will not let others drink from my glass." 4. "My immediate family needs to get vaccinated against mononucleosis."
3. "I will not let others drink from my glass."
A client is being discharged with halo traction. What should the nurse teach about home care of this traction? Select all that apply 1. Showering is permitted. 2. Apply baby powder under the halo vest to prevent irritation. 3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique. 5. Driving is allowed after discharge.
3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique.
Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible."
1. "I would like to have my serum creatinine checked at this visit."
A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide? Select all that apply 1. Administer furosemide. 2. Maintain fluid replacement at 150 ml per hour for 8 hours. 3. Measure abdominal girth every 24 hours. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.
1. Administer furosemide. 4. Weigh daily. 5. Measure urine output every 30 - 60 minutes.
What should the nurse teach the client following a right knee arthroscopy? Select all that apply 1. Apply ice to right knee continuously for the first 24 hours. 2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.
2. Elevate the right knee when sitting. 3. Notify the primary healthcare provider of tingling in the right leg. 4. Gradually start an exercise program to prevent scarring. 5. Place a plastic bag over wound when showering.
The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. The client asks the nurse to clarify foods that can be eaten with ulcerative colitis. What foods should the nurse suggest? Select all that apply 1. Dried beans 2. Fish 3. Apples 4. Yogurt 5. Scrambled eggs
2. Fish 5. Scrambled eggs
A client has just had a bone marrow biopsy. What is the nurse's priority intervention post procedure? 1. Apply ice pack to needle site. 2. Hold pressure on needle site for at least 5 minutes. 3. Observe needle insertion site every 2 hours. 4. Advise client to avoid activities that may result in trauma to the site for 48 hours.
2. Hold pressure on needle site for at least 5 minutes.
What signs/symptoms would the nurse expect to assess in an elderly client diagnosed with acute decompensated heart failure (ADHF)? Select all that apply 1. Thick, white sputum 2. Crackles that clear with coughing 3. Wheezing 4. Orthopnea 5. Apical pulse 88/min 6. S3 gallop
3. Wheezing 4. Orthopnea 6. S3 gallop
The head nurse on a busy surgical unit is evaluating several fresh post-operative clients. Which observation should the nurse report immediately to the primary healthcare provider? 1. A post transurethral resection client with cherry colored urine 2. A post mastectomy client drains 40 mL of bloody drainage within 3 hours of the surgery 3. A post ileostomy client with a beefy red stoma and mucus drainage 4. A post thyroidectomy client reporting tingling in toes and fingers
4. A post thyroidectomy client reporting tingling in toes and fingers