Nclex - Adult Health
A client with a terminal illness, asks the nurse about palliative care. What would be the nurse's best response?
Palliative care prevents and treats symptoms and side effects of disease and treatments.
A client has returned to the unit following an upper gastrointestinal series (Upper GI). What is the nurse's priority action?
3. Administer 30 mLs milk of magnesia orally.
A hospitalized client diagnosed with rheumatoid arthritis is receiving IV methylprednisolone every six hours. What is the best method for the nurse to provide client safety? 1. Place "fall precautions" sign above client's bed. 2. Change the intravenous site for steroids daily. 3. Restrict any visitors with visible illnesses. 4. Put client on full contact precautions.
3. Restrict any visitors with visible illnesses.
Which signs and symptoms indicates a tension pneumothorax?
3. Tracheal deviation and dyspnea
16. A client has been diagnosed with genital herpes. Which comment indicates understanding of the disease and prevention of the spread of the disease?
4. "My sex partner should be tested because we have not always used condoms."
A client presenting at the clinic has a history of systemic lupus erythematosus (SLE). Which finding would indicate to the nurse that the client is having a flare-up of the disease?
4. Fever 28
A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? 1. Elevate the leg. 2. Check distal pulses. 3. Increase the IV rate. 4. Notify the primary healthcare provider.
4. Notify the primary healthcare provider.
The nurse is caring for a client diagnosed with heat exhaustion. Which finding by the nurse suggests a problem?
Hot, dry skin
A client has recently been diagnosed with systemic scleroderma. Which of the following client complaints would be of most concern to the homecare nurse?
1. "I feel like food gets stuck in my throat when I eat."
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?
1. Admission to the hospital. 2. Amount of physical pain. 3. Current bed confinement. 5. Response to analgesic.
A client who is at high risk for developing a stroke has been advised to follow a Mediterranean type diet by the primary healthcare provider. Which food choices, if selected by the client, would indicate to the nurse that the client understands this diet.
1. Grilled eggplant 2. Purple grape juice 4. Cashews 5. Skim milk 6. Salmon
A client with a history of eczema has been admitted with cellulitis of the left forearm. Which admission order should the nurse question immediately?
2. Apply ice packs to affected area every shift.
A client who has had a stroke presents with lethargy, facial droop, and slurred speech. The client has a history of gastroesophageal reflux disease (GERD). From this history, what does the nurse recognize as an increased risk for this client? 1. Diminished colonic motility 2. Esophageal hemorrhage 3. Aspiration pneumonia 4. Stress ulcers
3. Aspiration pneumonia
What food should the nurse include when reinforcing teaching to an older adult about increasing vitamin B12 intake? 1. Calf liver 2. Feta cheese 3. Fresh spinach 4. Shrimp 5. Tuna 6. Tofu
1. Calf liver 2. Feta cheese 4. Shrimp 5. Tuna
What potential contributing factors for stress urinary incontinence should a nurse collect data for in an elderly female client?
1. Lack of estrogen 2. Rising abdominal pressure 3. Multiparous vaginal births
Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response?
1. Remove the dressing and elevate the head of bed.
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?
2. Calcium channel blockers 3. Digoxin 4. Diuretics 5. Oxygen 6. Vasodilators
Following nasal surgery, the nurse suspects a client has developed diabetes insipidus. The nurse knows what laboratory results provide evidence of diabetes insipidus?
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 admitted with a diagnosis of cirrhosis of the liver. What signs/symptoms would the nurse anticipate in this client?
1. Firm, nodular liver 2. Ascites 4. Abdominal pain 5. Bleeding from the GI tract
Which independent nursing actions should the nurse initiate for a client admitted with heart failure? Select all that apply 1. Monitor for distended neck veins 2. Measure abdominal girth 3. Monitor urine output from diuretic therapy 4. Inform client regarding signs and symptoms of heart failure 5. Administer medications as prescribed
1. Monitor for distended neck veins 2. Measure abdominal girth 3. Monitor urine output from diuretic therapy 4. Inform client regarding signs and symptoms of heart failure
The nurse is sharing best practice for preventing pressure injuries in clients. What should the nurse include?
1. Use moisturizer daily on dry skin. 5. Position client at 30 degree tilt when placed on side.
The nurse is caring for a client with myasthenia gravis. What teaching is essential for the nurse to reinforce with this client regarding treatment?
Setting the alarm clock for medication times
Which symptom identified in a client diagnosed with Guillain-Barre Syndrome would indicate that the nurse needs to notify the primary healthcare provider?
2. Breathlessness while talking.
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?
3. "Please describe your bowel habits and stool."
The nurse is preparing to administer scheduled medications for a client. Which medication would require clarification prior to administration? Exhibit - Diagnosis - Heart failure Current vital signs - BP 110/64, HR 70, R 18 Allergies - Sulfonamides Medical history -Hypertension Lab results - Glucose- 98 mg/dl (5.4 mmol/L) Sodium- 142 mEq/L (142 mmol/L) Potassium- 3.8 mEq/L (3.8 mmol/L) Digoxin level - 0.8 ng/mL (1.02 nmol/L) Diet - 2 gm Sodium Scheduled procedures - Echocardiogram Chest x-ray 1. Digoxin 2. Sacubitril/valsartan 3. Bumetanide 4. Potassium chloride
3. Bumetanide
he nurse is assigned to bathe a client diagnosed with dementia. Which nursing intervention should the nurse implement? 1. Increase the volume of the television. 2. Finish the bath as soon as possible. 3. Clean the face and hair at the end of the bath. 4. Delegate another nurse to distract the client.
3. Clean the face and hair at the end of the bath.
A client arrives at the emergency department (ED) in obvious emotional distress, reporting numbness around the mouth and tingling of the fingers and toes. The nurse notes a respiratory rate of 56/min. What should be the initial intervention performed by the nurse? 1. Send the client for a CT of the head. 2. Place on 100% O2 per non-rebreathing face mask. 3. Have the client breathe into a paper bag. 4. Administer diazepam 5 mg po.
3. Have the client breathe into a paper bag.
After administering an oral analgesic, the client states that the pain is better but continues to report a backache. Which action may directly help the client's backache? Select all that apply 2. Assisting the client into a side lying position.
3. Providing a back massage. 4. Provide heat therapy.
Bottom of Form The nurse collects data on a client post thyroidectomy for complications by performing which action?
Chovostek's
The nurse has been trained to work in a decontamination station for hazardous exposure victims. What should the nurse tell the victim about the process?
1. First you will remove clothing and dispose of it in hazardous material containment area. 2. You will be placed in a warm shower for decontamination. 3. You will spend a minute or so using soap over the entire body before rinsing. 5. You will apply soap from head to toe and then rinse for a few minutes.
The nurse is preparing to reinforce teaching to a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include? Select all that apply 1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week. 5. Reduce sodium intake to less than 2700 mg/day.
1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3.Diaphragmatic breathing exercises. 4. Brisk walking for 30 minutes 3-4 times/week.
A client with an automated internal cardiac defibrillator (AICD) was successfully defibrillated. The telemetry technician shouts out that the client was in ventricular fibrillation (VF). What should the nurse do first? 1. Go to the client to collect data for signs and symptoms of decreased cardiac output. 2. Call the primary healthcare provider to report that the client had an episode of VF so medication adjustments can be made. 3. Notify the "on call" person in the cath lab to re-charge the ICD in the event that the client has a recurrence. 4. Document the incident on the code report form and follow up regularly.
1. Go to the client to collect data for signs and symptoms of decreased cardiac output.
A client returns to the unit after a liver biopsy. Which nursing interventions would the nurse implement? Select all that apply 1. Put a pillow under the costal margin. 2. Place in the right side lying position. 3. Perform passive range of motion exercises to right shoulder. 4. Take vital signs every 10 - 15 minutes for first hour. 5. Instruct the client to avoid strenuous exercise for 1 month.
1. Put a pillow under the costal margin. 2. Place in the right side lying position. 4. Take vital signs every 10 - 15 minutes for first hour.
What information should the nurse include when reinforcing teaching about decreasing the risk of developing skin cancer?
2. A self-tanning product containing dihydroxyacetone (DHA) is safe to use. 3. Put on sunscreen every day, even on days when it is cloudy. 4. Stay in the shade between 9 AM and 4 PM.
The nurse is caring for a hypertensive client who has been taking a loop diuretic while hospitalized. Which foods should the nurse reinforce that are appropriate for the client? 1. Cereals and breads 2. Avocados and apricots 3. Table salt and spinach 4. Blueberries and strawberries
2. Avocados and apricots
The nurse is preparing to discharge four clients from the unit. Which client is most likely to receive a referral to other agencies or community outreach programs?
3. 72 year-old client with diabetes and obesity
A client diagnosed with hypothyroidism has received dietary education from the nurse. Which snack selection chosen by the client would indicate that education has been successful? 1. Cup of almonds 2. Cheese and crackers 3. Popcorn 4. Sweet potato fries
3. Popcorn
Which intervention should the nurse recommend to the adult child who is caring for an elderly parent diagnosed with Alzheimer's disease (AD)? 1. Give parent a small dog for company and comfort. 2. Reset the water heater to 125 degrees Fahrenheit (51.67 degree Celsius) to prevent burns. 3. Place mirrors in multiple locations so parent sees images of self. 4. Make floors and walls different colors.
4. Make floors and walls different colors.
Which victim would the nurse decontaminate first in a biological terrorist event? 1. Client who was exposed but is exhibiting no symptoms 2. Client who has an open leg fracture and head injury 3. Client who is not breathing and has no palpable pulse 4. Client with minor cuts and abrasions
1. Client who was exposed but is exhibiting no symptoms
The nurse is caring for a client who receives furosemide 40 mg PO twice daily, as well as 20 meq of potassium chloride twice daily. The client's lab work reveals that the potassium level is 2.4 mEq/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 is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? 1. Promotes the return of venous blood to the heart and assists in preventing blood clots. 2. Stabilizes any clots to prevent embolization. 3. To increase the blood pressure in the venous system in the legs to promote perfusion. 4. Promotes lymphatic drainage to prevent swelling and arterial congestion.
1. Promotes the return of venous blood to the heart and assists in preventing blood clots.
A hiker that was lost in the mountains for 3 days experienced exposure to below freezing temperatures. Upon arrival to the emergency department (ED), the client presents with hard, mottled, bluish-white toes bilaterally and reports being unable to feel the toes. Which actions should the nurse take initially? Select all that apply 1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze. 4. Encourage the client to walk. 5. Apply a heating pad to the feet. 6. Massage the frozen digits.
1. Remove any wet or constricting clothing. 2. Initiate a controlled and rapid rewarming process with warm water. 3. Wrap each toe individually with sterile gauze.
The nurse is providing morning care to a client who has pneumonia. The client has shortness of breath on exertion and fatigues easily. What alterations in routine may be needed to complete the hygienic needs of the client? 1. Perform all of the hygiene needs for the client. 2. Allow periods for rest as the care is provided. 3. Leave equipment at the bedside to allow client to go at his own pace. 4. Omit the morning hygiene routine for the present time.
2. Allow periods for rest as the care is provided.
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."
When planning post procedure care for a client who is having a barium enema, what must the nurse include?
3. Administration of a laxative or enema after the procedure
A client has been on the nursing unit for two hours following a retropubic prostatectomy for the treatment of prostate cancer. The client is receiving a continuous bladder irrigation of normal saline infusing at 1000 mL/hr. The client's urine output for the past two hours is 410 mL. What is the nurse's first action?
Stop the irrigation flow.
A client has been admitted to the unit with recurrent nephrotic syndrome. Which signs and symptoms does the nurse expect to find when examining the client?
1. Anasarca 2. Foamy urine 4. Periorbital edema 5. Proteinuria
A client is being admitted with a diagnosis of cirrhosis of the liver. What signs/symptoms would the nurse anticipate in this client? Select all that apply 1. Firm, nodular liver 2. Ascites 3. Hematuria 4. Abdominal pain 5. Bleeding from the GI tract
1. Firm, nodular liver 2. Ascites 4. Abdominal pain 5. Bleeding from the GI tract
When explaining to caregivers how to reduce the risk of falls in their elderly parent, the nurse should educate about which measure? Select all that apply 1. Allow the parent to wear shoes that are most comfortable. 2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet. 5. Encourage the parent to have an inside pet for comfort. 6. Rearrange the furniture for the parent to prevent stagnation.
2. Assure there is adequate lighting with minimal glare. 3. Use sharply contrasting colors at edges of stairs. 4. Install grab bars beside the shower, tub, and toilet.
A nurse is observing an unlicensed nursing personnel (UAP) feed a client who is on aspiration precautions. Which action by the UAP would require the nurse to intervene? 1. Elevating the head of the bed to a 90 degree angle 2. Instructing the client to lean the head back slightly when swallowing. 3. Adding a thickening agent to liquids. 4. Feeding the client small amounts of food per bite.
2. Instructing the client to lean the head back slightly when swallowing.
A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? 1. PT of 13 seconds 2. PTT of 22 seconds 3. INR of 1.0 4. Hemoglobin of 11 g/dL (6.8266 mmol/L)
2. PTT of 22 seconds
What interventions should the LPN/VN include when reinforcing teaching with a client on how to prevent and treat fungal infections of the feet? Select all that apply 1. Apply cornstarch to the feet after bathing. 2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 3. Wear socks at all times until infection has cleared up. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.
2. Put terbinafine hydrochloride cream 1% on affected areas twice a day for two weeks. 4. Wash feet daily with soap and water. 5. Wear shower sandals when showering in public places. 6. Wear shoes that allow the feet to breathe.
What is the only acceptable use of restraints by the nurse? 1. An elderly male client had a chest restraint applied after crawling over the 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 is in a Geri-chair with lap belt at nurse's station at night.
3. A confused client with a closed head injury had hand mitts applied after pulling out IV.
The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? 1. Clots in urine 2. Bladder pressure 3. Clear urine 4. Bladder spasms
3. Clear urine
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? 1. Apply skin protectant and allow drying. 2. Cut center of new flange to fit stoma. 3. Remove ostomy bag and old flange. 4. Wash stoma with warm soapy water. 5. Press flange into place and attach bag. 6. Place stoma adhesive onto new flange.
3. Remove ostomy bag and old flange. 4. Wash stoma with warm soapy water. 1. Apply skin protectant and allow drying. 2. Cut center of new flange to fit stoma. 6. Place stoma adhesive onto new flange. 5. Press flange into place and attach bag.
What electrolyte imbalance should the nurse monitor for in a client diagnosed with hyperosmolar hyperglycemic state (HHS)? 1. Hypocalcemia 2. Hypermagnesemia 3. Hyperkalemia 4. Hyponatremia
4. Hyponatremia
A client had an open cholecystectomy several days ago. What finding by the nurse should be reported to the primary healthcare provider immediately? 1. Respiratory rate of 30 2. Blood pressure reading of 104/50 3. Incisional pain with foul, green drainage 4. Urinary output of 75 mL straw colored urine
3. Incisional pain with foul, green drainage
A client is being discharged with halo traction. What instructions should the nurse reinforce regarding home care of this traction?
3. Never pull on any part of the halo traction. 4. Clean around pins at least twice a day using sterile technique.
What signs/symptoms would the nurse expect to be manifested in a client diagnosed with Guillain-Barre' Syndrome? Select all that apply 1. Opisthotonos 2. Seizures 3. Paresthesia 4. Hemiplegia 5. Hypotonia 6. Muscle aches
3. Paresthesia 5. Hypotonia 6. Muscle aches
A nurse is caring for a client who was brought into the ED with a gunshot wound to the chest. There is an occlusive dressing in place and the client is receiving high flow oxygen. The nurse notes a deviated trachea, asymmetrical chest wall movement and decreased breath sounds bilaterally. What action should the nurse take first? 1. Elevate the head of the bed. 2. Initiate CPR. 3. Remove the occlusive dressing. 4. Notify the primary healthcare provider.
3. Remove the occlusive dressing.
A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client? 1. I will ask the dietician to add more meat with dinner. 2. Protein must be limited because of elevated ammonia levels. 3. You need to drink more fluids because of your dehydration. 4. We can ask for between meal snacks with more carbohydrates.
2. Protein must be limited because of elevated ammonia levels.
The nurse is caring for a client on the skilled nursing unit. The client has lost 8 pounds (3.6 kg) since admission 3 months ago. Which strategy may help to improve the client's caloric intake? 1. Encourage the client to eat meals in the room. 2. Take the client to the dining room for meals. 3. Provide a high protein supplement 30 minutes before meals. 4. Ask the nursing tech to feed the client at each meal.
2. Take the client to the dining room for meals.
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?
2. Weight gain of 4 pounds in one week 5. Serum potassium of 3.2 mEq
When providing instructions, the nurse asks the client to repeat the techniques for crutch walking. The nurse is aware that further action is needed when the client makes which statement?
1. "The elbows should be flexed at 10 degrees."
The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?
3. Check blood pressure
What signs/symptoms would the nurse expect to find in a client diagnosed with late stage rheumatoid arthritis?
1. Effusion to knees. 3. Swan neck deformity. 4. Peripheral neuropathy. 5. Subcutaneous nodules on elbows.
A client with distended and tortuous veins along the inner aspects of both legs asks the nurse how to decrease the development of these veins. What should the nurse advise? Select all that apply 1. Exercise 2. Follow a low protein diet 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs
1. Exercise 3. Wear low heeled shoes 4. Elevate legs above heart several times per day 5. Do not cross legs
The nurse is preparing to reinforce teaching to a client diagnosed with essential hypertension on how to decrease the risk of developing complications. What topics should the nurse include?
1. Following the DASH dietary plan. 2. Use of blood pressure monitoring device. 3. Diaphragmatic breathing exercises. 3. Brisk walking for 30 minutes 3-4 times/week
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?
3. Check that identification band is in place.
What signs and symptoms does the nurse expect a client diagnosed with bacterial pneumonia to exhibit?
3. Dyspnea 4. Tachypnea 5. Pleuritic chest discomfort 7. Increased tactile fremitus
Which comment made by a client scheduled for a lumbar laminectomy and discectomy indicates to the nurse that the client needs further teaching?
3. I can turn by myself after surgery, but I will need help to get out of bed.
A client diagnosed with gout has received instruction on maintaining a low-purine diet. Which statements, if made by the client, would indicate to the nurse that instructions were successful? Select all that apply 1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 2. "Rather than drinking a glass of wine, I should drink a glass of beer." 3. "Losing weight can help reduce the uric acid levels in my blood." 4. "Potatoes, rice, and barley are high in purine and should be eliminated from my diet." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."
1. "I will eliminate foods from my diet that contain 150 mg or more of purine per serving." 3. "Losing weight can help reduce the uric acid levels in my blood." 5. "Vegetables that should be limited to 2 times/week include cauliflower, spinach, and mushrooms." 6. "Increasing fluid intake to 8-10 cups/day will help to eliminate purines through my urine."
When assessing the client with acute myeloid leukemia the nurse notes the client has pain from mucositis, fatigue from slight activity, pulse rate 100, respiratory rate 22, blood pressure 130/64 mmHg, temperature 98.9 F, and petechiae on the arms. What action should the nurse take first?
1. Administer pain medicine.
A client is admitted to the hospital due to a left-sided cerebrovascular accident. Which interventions should the nurse initiate? Select all that apply 1. Apply splint nightly to affected extremities. 2. Approach client from the right side. 3. Provide full range of motion once a shift. 4. Elevate left extremities on a pillow. 5. Place pillow in the right axilla. 6. Wrap affected hand into a fist.
1. Apply splint nightly to affected extremities. 5. Place pillow in the right axilla.
A client who underwent a laparoscopic cholecystectomy is being discharged from an outpatient surgical center. Which statement by the client shows the LPN/VN that the RN's discharge teaching has been effective? 1. I will need to eat a low fat diet since I no longer have a gallbladder. 2. I can expect drainage from the incisions for a few days. 3. I may have some mild pain from the procedure. 4. I should plan to limit my activities and not return to work for several weeks.
3. I may have some mild pain from the procedure.
The nurse is reinforcing dietary teaching with a client who has been diagnosed with iron deficiency anemia. Which food selections by the client would indicate a correct understanding of foods that should be increased in the diet?
1. Chickpeas 3. Oysters 4. Raisins 5. Spinach 6. Tuna
The nurse is reinforcing teaching with a client, recovering from a myocardial infarction (MI), about the prescribed diet of low sodium, low saturated fat, and low cholesterol. Which statements, if made by the client, would indicate to the nurse that instructions have been successful? Select all that apply 1. "I should drink fruit juices rather than soft drinks." 2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 4. "I should use 2% milk when cooking." 5. "There is no restriction on egg white consumption."
2. "A good snack to eat would be unsalted popcorn." 3. "When making homemade tomato sauce, I should not add salt." 5. "There is no restriction on egg white consumption."
The nurse is contributing to an educational seminar on ophthalmic health. Which risk factors for cataract formation should the nurse recommend? Select all that apply 1. Diabetes mellitus. 2. Cigarette smoking. 3. Family history of glaucoma. 4. Long-term use of corticosteroids. 5. Thin cornea.
1. Diabetes mellitus. 2. Cigarette smoking. 4. Long-term use of corticosteroids.
Which signs/symptoms would the nurse anticipate 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
Which signs/symptoms would the nurse anticipate in the client admitted with a diagnosis of myasthenia gravis?
1. Difficulty holding head erect 2. Limited facial expressions 3. Ptosis A client is admitted for management of ulcerative colitis.
Which signs/symptoms does the nurse expect to see in a client diagnosed with Bell's Palsy?
1. Drooping of one side of the face. 2. Inability to wrinkle forehead. 3. Excessive tearing. 5. Decrease inability to taste. 6. Numbness of affected side of face.
The family of a bedfast 80 year old is providing care in the home. Which reports by the family indicate adequate understanding of interventions that will reduce the risk for skin breakdown? Select all that apply 1. I make sure that the sheets and the foam pad in the chair stay dry. 2. I will not encourage my parent to turn in the bed at night. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.
1. I make sure that the sheets and the foam pad in the chair stay dry. 3. The perineal area should be kept dry and clean. 4. My parent eats 2 meals per day and drinks a supplement. 5. I may reposition my parent more than every 2 hours if their perception of pressure is intact.
A client who needs to have a stool specimen for an occult blood test is guided by the nurse to avoid which substance 2 hours prior to testing.
1. Liver 3. Ibuprofen 4. Sardines 5. Ascorbic acid
The nurse enters the client's room and finds the client having a seizure on the floor. Which nursing interventions should the nurse implement? Select all that apply 1. Loosen tight shirt or jacket. 2. Move the client to the couch. 3. Place a pillow under the head. 4. Position the head tilted forward. 5. Insert a wash cloth between the teeth
1. Loosen tight shirt or jacket. 4. Position the head tilted forward.
A client diagnosed with advanced cirrhosis is admitted with dehydration and elevated ammonia levels. While discussing dietary issues, the client requests larger portions of meat with meals. Which response by the nurse provides the most accurate information to the client?
2. Protein must be limited because of elevated ammonia levels.
What actions should the nurse include when providing care for a client admitted with Guillain-Barre' Syndrome? Select all that apply 1. Monitor for contractures. 2. Place prone for 30 minutes, 4 times per day. 3. Provide therapeutic massage for pain relief. 4. Reinforce teaching for range of motion exercises. 5. Provide high protein meals 3 times a day. 6. Refer to physical therapist.
1. Monitor for contractures. 3. Provide therapeutic massage for pain relief. 4. Reinforce teaching for range of motion exercises. 6. Refer to physical therapist.
The nurse, caring for a client who has terminal cancer, finds that the client is extremely restless. In response to this data, what would be the appropriate nursing action? Select all that apply 1. Play soothing music. 2. Use chamomile aromatherapy. 3. Place soft restraints on arms. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.
1. Play soothing music. 2. Use chamomile aromatherapy. 4. Dim room lights. 5. Keep conversations quiet. 6. Massage forehead.
Following a thyroidectomy, a client reports shortness of breath and neck pressure. Which nursing action is the best response? 1. Remove the dressing and elevate the head of bed. 2. Call a code, open the trach set, and position the client supine. 3. Obtain vital signs. 4. Immediately go to the nurse's station and call the primary healthcare provider.
1. Remove the dressing and elevate the head of bed.
A client with chronic obstructive pulmonary disease (COPD) learns about the importance of a nutritious diet to avoid weight loss. Which food selections for a breakfast menu show understanding by the client? Select all that apply 1. Scrambled eggs 2. Cheese omelet 3. Sliced banana 4. Orange juice 5. Whole milk 6. Dry toast
1. Scrambled eggs 2. Cheese omelet 3. Sliced banana
Which intervention would the nurse recognize as in best helping to relieve joint stiffness in a client with rheumatoid arthritis? 1. Take a warm shower prior to performing activities of daily living. 2. Take an aspirin after activity to help decrease inflammation. 3. Lose 10 pounds of weight. 4. Apply cold compresses to joints for 30-45 minutes.
1. Take a warm shower prior to performing activities of daily living.
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
A client has been admitted to the medical unit after sustaining a stroke. The nurse notes a decrease in visual field and hemianopia from cerebrovascular problems because the client shows consistent inattention to stimuli on the affected side. What nursing actions would the nurse expect to be included on the plan of care for this client?
1. Tell client to scan from left to right to visualize the entire environment. 3. Position bed in room so that individuals approach the client on the unaffected side. 5. Touch unaffected shoulder when initiating conversation with client. 6. Position personal items within view on the unaffected side.
The nurse is caring for a client on the medical unit who has hematemesis. What data is most important for the nurse to collect? Select all that apply 1. Vital signs 2. History of prior bleeding episodes 3. Medications the client is taking 4. Urinary output 5. Level of consciousness
1. Vital signs 4. Urinary output 5. Level of consciousness
A client who has diabetes calls the nurse at the clinic reporting shakiness, nervousness, and palpitations. Which questions would yield information that would assist the nurse to gather data to share with the primary healthcare provider?
1. What have you eaten today and at what times? 2. Are you using insulin as a treatment of diabetes, and if so, what kind? 3. Do you feel hungry? 4. Do you have access to a glucose monitor to check your current glucose level?
A client with tuberculosis (TB) has been coming to the health department for directly observed therapy (DOT) for the past month. Today, the client states, "I don't think I need to come back anymore. I am feeling much better now." What should the nurse tell the client? 1. "You have taken your medication long enough so, the primary healthcare provider should discontinue it today." 2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured." 3. "I will be required to have you arrested if you do not come back for further treatment." 4. "Just let us decide when you should stop taking the medication."
2. "If you stop taking your medication now, your disease could become resistant to this medication, making it harder for you to be cured."
After administering an oral analgesic, the client states that the pain is better but continues to report a backache. Which action may directly help the client's backache? Select all that apply 1. Educating the client regarding pain and pain control. 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Provide heat therapy. 5. Reporting to the primary healthcare provider the client's report of pain.
2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Provide heat therapy.
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
A client with diabetes has a history of ignoring the primary healthcare provider's prescription for daily medication management of the illness. The client has been working toward increased adherence to prescribed medication regimen. Which finding suggests that the client has increased adherence to the regimen?
2. Client takes medication as prescribed.
The nurse is reinforcing discharge teaching for a client with thrombocytopenia. Which should the nurse include?
2. Eat soft foods. 3. Take docusate sodium daily to prevent straining 4. Wear well fitting shoes while ambulating. 5. Apply a cool compress to site with any soft tissue trauma.
What should the nurse include when reinforcing teaching to a client following a right knee arthroscopy?
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.
What should the nurse include when reinforcing teaching to a 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.
Which strategies should the nurse suggest for the prevention of constipation in older clients? Select all that apply 1. Mild laxatives are appropriate if a bowel movement is not achieved daily. 2. Emphasize the importance of establishing a bowel routine. 3. Introduce abdominal toning exercises. 4. Encourage foods low in bulk. 5. Drink 6-8 glasses of water per day.
2. Emphasize the importance of establishing a bowel routine. 3. Introduce abdominal toning exercises. 5. Drink 6-8 glasses of water per day.
The LPN/VN is reinforcing teaching in a community health class for cancer prevention and screening. Which individual does the nurse recognize as having the highest risk for colon cancer?
2. Has a family history of colon polyps
What electrolyte imbalance should the nurse monitor for when caring for a client diagnosed with chronic alcoholism?
2. Hypokalemia 3.Hypophosphatemia 4.Hypomagnesemia
A nurse prepares a client for a colonoscopy and presents the consent form to the client. The client states, "I don't know what a colonoscopy is." Which is the best action for the nurse to take?
2. Inform the primary healthcare provider that the client requests additional information related to the procedure.
The nurse is caring for a client with multiple episodes of diarrhea and suspected Clostridium Difficile (C. diff). Which actions should be included when caring for this client? Select all that apply 1. Institute contact precautions only after confirmation of stool culture. 2. Instituting contact precautions for all who enter the client's room 3. Use alcohol based foam for hand hygiene. 4. Dedicating equipment for use only in the client's room. 5. Requesting antidiarrheal medication for the client.
2. Instituting contact precautions for all who enter the client's room 4. Dedicating equipment for use only in the client's room.
What actions would the nurse expect to see in the care plan of a client admitted with Guillain-Barre syndrome?
2. Keep a sterile tracheostomy at the bedside. 3. Monitor for heart rate above 120/min.
The nurse is teaching a group of adults how to check skin lesions for signs of melanoma. What should the nurse include?
2. Multiple colors with a lesion 3. Odd looking lesion 4. Poorly defined border of lesion 5. Diameter of lesion 6 mm
After reinforcing dietary teaching to a client diagnosed with Crohn's Disease, the nurse recognizes client understanding when the client selects which low-residue foods? Select all that apply 1. Broccoli 2. Oatmeal 3. Green peas 4. Spaghetti 5. Cantaloupe 6. Raisins
2. Oatmeal 4. Spaghetti 5. Cantaloupe
A client returns to the unit post scleral buckling of the right eye. Which nursing interventions should the nurse include?
2. Place personal items within easy reach. 3. Maintain eye patch over right eye. 4. Administer antiemetic for reports of nausea.
A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what nursing meaasures are appropriate? Select all that apply
2. Place the client's meal on the right side of the over bed table. 5. Have client look at the left side of the body.
The nurse is caring for an elderly client who is approaching death and expressing intense despair and anxiety. Based on Erikson's theory, the nurse recognizes that this client's despair and anxiety would most likely be based on what? 1. An inappropriate desire for youthfulness and staying young. 2. The decision to never marry. 3. The lack of a sense of wholeness, purpose, and a life well lived. 4. The fear of experiencing a painful death
3. The lack of a sense of wholeness, purpose, and a life well lived.
An LPN/VN is reinforcing instructions for the spouse of a home care client recently diagnosed with Alzheimer's Disease. The LPN/VN acknowledges that previous teaching was successful when the spouse makes what statement? 1. "Activities that provide stimulation will help to reorient my spouse". 2. "With medications and therapy, my spouse will begin to improve". 3. "Keeping the rooms dark and quiet will be calming for my spouse". 4. "As the disease progresses, I need to review safety issues at home".
4. "As the disease progresses, I need to review safety issues at home".
What sign/symptom would be of immediate concern to the nurse?
4. Abdominal guarding
An 18 year old football player is admitted to the ortho unit after a femur fracture. He is scheduled for a rod to be placed in the morning, but suddenly develops severe shortness of breath, a petechial rash on his chest, and unstable vital signs. What should the nurse do first?
4. Call the active response team.
The nurse checks the results of a urinalysis performed on a client with dehydration. Which results should the nurse expect to find?
4. Increased specific gravity
Two days after a client has a chest tube inserted, the nurse notes constant bubbling in the water seal chamber. What action should the nurse take?
4. Notify healthcare provider
To reduce the risk of developing a hematoma post-balloon angioplasty, the nurse should implement which measure?
4. Prevent flexion of the affected leg. 30.
Which finding should take priority when the nurse is collecting data about 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
Four clients are admitted to the medical-surgical unit. The nurse is aware that what client will need standard precautions only? 1. The client with chicken pox. 2. The client with rubeola. 3. The client with impetigo. 4. The client with pancreatitis.
4. The client with pancreatitis.
A nurse is caring for a client who complains of fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. The nurse immediately puts the client in isolation. The nurse suspects that the client is suffering from which condition? 1. Bronchitis 2. Pneumonia 3. Pneumothorax 4. Tuberculosis
4. Tuberculosis
The nurse is caring for a client experiencing difficulty urinating. Which finding should the nurse report to the primary healthcare provider?
4. Urinary output of less than 30 ml per hour.
The nurse is caring for a client experiencing difficulty urinating. Which finding should the nurse report to the primary healthcare provider? 1. Urinary output of 90 ml per hour. 2. Daily weight increase from 140 lbs. (63.6 kg) to 141 lbs. (64 kg). 3. Client statement of "I don't know if today is Tuesday or Wednesday". 4. Urinary output of less than 30 ml per hour.
Urinary output of less than 30 ml per hour.
A nurse is collecting data on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather at this time?
The client's description of the pain
