NCLEX Challenge FINAL
A nurse is caring for a client who has had a myocardial infarction. Upon his first visit to cardiac rehabilitation, he tells the nurse that he doesn't understand why he needs to be there because there is nothing more to do, as the damage is done. Which of the following is the correct nursing response? -"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." -"It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it." -"Exercise is good for you and good for your heart." -"Your doctor is the expert here, and I'm sure he would only recommend what is best for you."
"Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely." With this response, the nurse uses the therapeutic communication technique of presenting reality by indicating her perception of the situation for the client.
A nurse is caring for a client who has difficulty swallowing medications and is prescribed entericcoated aspirin PO once daily. The client asks if the medication can be crushed to make it easier to swallow. Which of the following responses should the nurse provide? -"Crushing the medication might cause you to have a stomachache or indigestion." -"Crushing the medication is a good idea, and I can mix it in some ice cream for you." -"Crushing the medication would release all the medication at once, rather than over time." -"Crushing is unsafe, as it destroys the ingredients in the medication."
"Crushing the medication might cause you to have a stomachache or indigestion." The pill is enteric-coated to prevent breakdown in the stomach and decrease the possibility of GI distress. Crushing the pill destroys that protection.
A charge nurse notes that a staff nurse delegates an unfair share of tasks to the assistive personnel (AP) and the nurses on next shift report the staff nurse frequently leaves tasks uncompleted. Which of the following statements should the charge nurse make to resolve this conflict? "I need to talk to you about unit expectations regarding delegating and completing tasks." "Several staff members have commented that you don't do your fair share of the work." "If you don't do your share of the work, I will have to inform the nurse manager." "You have been very inconsiderate of others by not completing your share of the work."
"I need to talk to you about unit expectations regarding delegating and completing tasks." This statement opens the conversation in a nonthreatening way. The focus is on the issue of the equity of the assignment rather than on any personal characteristic of the individual.
A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make? "We will call your family in time for them to get here." "I wonder if you are fearful of dying alone." "I will make sure a staff member is in your room at all times." "I will tell your family of your concern so that they can be here."
"I wonder if you are fearful of dying alone." The nurse is verbalizing the client's implied concerns and seeks to validate if this is the client's concern.
A nurse is admitting a client who is about to undergo surgery for benign prostatic hypertrophy. The client states, "I don't know what I will do if they find I have cancer." Which of the following responses should the nurse make? "Why do you think you might have cancer when your diagnosis is a benign condition?" "I'm looking at your chart here and I don't see any reason for you to worry about that." "I think that's something you need to discuss with your provider." "I'm hearing that you are concerned that it might turn out that you have cancer."
"I'm hearing that you are concerned that it might turn out that you have cancer." This response illustrates the therapeutic communication techniques of seeking clarification and restating. It demonstrates the nurse's willingness to explore the client's fears and encourages communication.
A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching? -"Expect the foot to be numb for several days postoperatively." -"Rest frequently with your foot elevated." -"Expect the foot to take at least 3 weeks to heal." -"Walk primarily on the heel to relieve pressure on the toes."
"Rest frequently with your foot elevated." The client should rest and elevate the foot to help reduce discomfort and prevent edema.
A nurse is teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include? -"Sit upright or stand for at least 30 minutes after taking this medication." -"Take this medication with food." -"Take this medication with orange juice." -"Chew or suck on the tablet."
"Sit upright or stand for at least 30 minutes after taking this medication." The nurse should instruct the client to sit or stand for 30 minutes after administration of this medication to reduce prolonged contact of the medication with the esophageal mucosa that can cause esophagitis.
An assistive personnel (AP) comes to work with a new set of artificial nails. The nurse takes the AP to a private location to discuss the issue. Which of the following statements by the nurse is appropriate? "There is a higher risk of infection for our clients associated with artificial nails." "You should know that artificial nails have a very unprofessional appearance." "I want you to review the facility's policy on personal attire before you begin the shift." "Why would you wear artificial nails to work when you know it's against the rules?"
"There is a higher risk of infection for our clients associated with artificial nails." Short, natural nails are less likely to harbor pathogens that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting.
A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? "You will do special exercises in advance of getting your prosthesis." "You will be fitted for your prosthesis at the time of surgery." "A special pressure dressing will remain on to cushion your prosthesis." "The prosthesis will be adjustable depending on what shoe you are wearing."
"You will do special exercises in advance of getting your prosthesis." The physical therapist will teach muscle strengthening exercises to prepare the client for prosthesis use.
A nurse is providing teaching to a client who has a new diagnosis of testicular cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.) Close male relatives are at an increased risk of developing testicular cancer. Testicular cancer typically occurs between ages 15 and 35. Testicular cancer occurs in both testicles equally. Sperm are no longer viable after diagnosis. An early manifestation is a painful scrotal lump.
*Close male relatives are at an increased risk of developing testicular cancer is correct.* Testicular cancers are more common in clients who have a family history of testicular cancer. Therefore, close male relatives are at increased risk.T *Testicular cancer typically occurs between ages 15 and 35 is correct.* Testicular cancer typically occurs in the productive years and has significant economic, social, and psychological impact clients and their families. Testicular cancer occurs in both testicles equally is incorrect. Testicular cancer is rarely bilateral. Sperm are no longer viable after diagnosis is incorrect. Sperm might be absent or low in number but remain viable after diagnosis. An early manifestation is a painful scrotal lump is incorrect. A painless scrotal swelling is an early manifestation.
A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) Excessive laxative use Ignoring the urge to defecate Inadequate fluid intake Increased fiber in the diet Increased activity
*Excessive laxative use is correct.* Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. *Ignoring the urge to defecate is correct.* Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits, such as constipation. *Inadequate fluid intake is correct.* Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool. Increased fiber in the diet is incorrect. Increased fiber promotes more efficient bowel emptying. Increased activity is incorrect. Increased activity promotes bowel emptying.
A nurse in an emergency department is caring for a client who has abdominal pain. Nurses' Notes 0800: Client reports abdominal pain that began the previous evening. Client is two weeks postoperative from a right knee replacement. Reports taking 3 to 4 hydrocodone tablets daily for postoperative pain. Has not had bowel movement in 4 days. Reports not drinking many fluids to avoid having "to get up and go to the bathroom so often because it hurts to walk." 0830: Client taken for abdominal x-ray. Partner reports that client has not been following physical therapist's exercise regimen of walking several times daily. 0915: Fecal mass of hard, dry stool removed digitally from client per provider's order. 1015: Provided teaching to client and partner about constipation and methods to avoid further impaction. Diagnostic Results 0900:Abdominal x-ray: Large amount of fecal material throughout the colon with rectal impaction. No evidence of small bowel obstruction. A nurse is providing teaching to a client who has constipation. Which of the following information should the nurse include?
*Increase fluid intake to 1500 mL daily is correct.* Drinking at least 1500 mL of fluid daily will help to soften the stool. *Include probiotic foods in the daily diet is correct.* Probiotic foods, such as yogurt, contain live bacterial cultures that aid in digestion by promoting regularity in bowel elimination. Increase intake of low fiber foods is incorrect. The nurse should instruct the client to increase the intake of high fiber foods, such whole-grain breads and cereals, fruits, and vegetables because these foods give bulk to stools and help promote passage through the digestive tract. *Increase daily exercise is correct.* Lack of exercise decreases the muscle tone of the lower digestive tract. Even minimal exercise can increase peristalsis. Avoid drinking hot liquids is incorrect. Drinking hot liquids can stimulate peristalsis and promote bowel elimination.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) -Report of feeling pressure -Tenderness over the symphysis pubis -Distended bladder -Voiding 30 mL frequently -Dysuria
*Report of feeling pressure is correct.* Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. *Tenderness over the symphysis pubis is correct.* Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. *Distended bladder is correct.* Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder. *Voiding 30 mL frequently is correct.* Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. Dysuria is incorrect. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Dysuria, or painful burning with urination, is not a finding associated with urinary retention.
An occupational health nurse is instructing workers at an industrial facility in emergency procedures in the event of a traumatic amputation. Which of the following guidelines should the nurse include for emergency care? (Select all that apply.) -Wrap the part in dry sterile gauze. -Place the severed end of the part into crushed ice. -Put the severed part in a dry, waterproof plastic bag. -Elevate the extremity. -Prevent contact of the severed part with water.
*Wrap the part in dry sterile gauze is correct.* The person at the scene should wrap the severed part in dry, sterile gauze or a clean cloth. Place the severed end of the part into crushed ice is incorrect. The person at the scene should not allow direct contact between the part and ice. The person should use ice water that is 1 part ice and 3 parts water. *Put the severed part in a dry, waterproof plastic bag is correct.* The person at the scene should place the covered part in a sealed, waterproof plastic bag and then put the bag in ice water. *Elevate the extremity is correct.* This action reduces blood loss. *Prevent contact of the severed part with water is correct.* The person at the scene should not allow the severed part to become wet but should keep it dry.
A nurse is providing nutritional teaching to a client who has osteoporosis. Which of the following foods should the nurse recommend as being the highest in calcium? -1 cup carrot strips -3 oz canned salmon -1 cup chopped chicken breast -1 plain baked potato
3 oz canned salmon The nurse should recommend canned salmon as a food to increase calcium intake. A 3 oz serving of canned salmon contains 197 mg of calcium.
A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A reddened area over the sacrum Stiffness in the lower extremities Difficulty moving the upper extremities Difficulty hearing some types of sounds
A reddened area over the sacrum A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.
A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? Ability to achieve independent transfer from bed to wheelchair Independent control of bowel and bladder function Use of a wheelchair with a chin or mouth stick Ability to self-feed with the use of adaptive equipment
Ability to self-feed with the use of adaptive equipment A client who has a spinal cord transection at the level of the fifth cervical vertebrae should have full neck, partial shoulder, back, biceps, and gross elbow movements. A realistic rehabilitation goal for the client is the ability to feed himself with the use of adaptive equipment.
A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications? -Fat embolism syndrome -Acute compartment syndrome -Pulmonary embolism -Osteomyelitis
Acute compartment syndrome Edema is an early manifestation of acute compartment syndrome, which is a complication that involves increased pressure within the fascia that leads to reduced circulation to the affected area.
A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications? Fat embolism syndrome Acute compartment syndrome Pulmonary embolism Malignant hypothermia
Acute compartment syndrome Increasing edema is a manifestation of acute compartment syndrome, which is a complication that occurs when excessive pressure reduces circulation.
A nurse is caring for a client who has acute osteomyelitis. Which of the following interventions is the nurse's priority? ] Provide the client with antipyretic therapy. Administer antibiotics to the client. Increase the client's protein intake. Teach relaxation breathing to reduce the client's pain.
Administer antibiotics to the client. The greatest risk to this client is bacteremia caused by the infection which can lead to septic shock; therefore, the priority intervention is antibiotic therapy. The client might require multiple antibiotics for an extended time.
A nurse is caring for a client with a new diagnosis of Paget's disease. The nurse anticipates the provider will prescribe which of the following medications for this client? Alendronate Colchicine Prednisone Allopurinol
Alendronate Alendronate, a bisphosphonate, decreases bone resorption and minimizes loss of bone density.
A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? Auscultate breath sounds at least every 2 hr. Perform range-of-motion (ROM) exercises at least two to three times daily. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. Apply antiembolic stockings
Auscultate breath sounds at least every 2 hr. The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.
A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders? Scoliosis Kyphosis Lordosis Ankylosis
Kyphosis
A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? Identity crisis Body image changes Feelings of displacement Loss of privacy
Body image changes Body image changes are the most common behaviors observed in adolescents who have scoliosis and require surgery.
A nurse is teaching an older adult client who has an intracapsular fracture of the right hip following a fall about the purpose of Buck's extension traction. The nurse should include which of the following information in the teaching? Buck's extension traction will reduce the fracture. Buck's extension traction will relieve muscle spasms. Buck's extension traction will maintain alignment of the pins. Buck's extension traction will allow supported movement of the extremity.
Buck's extension traction will relieve muscle spasms. Buck's extension traction immobilizes the fractured bone to relieve associated muscle spasms and thereby relieve pain. Any movement of the fractured extremity will aggravate severe muscle spasm and trigger pain.
A nurse is planning care for a client who has pelvic fractures and will require bed rest and traction for 4 to 6 weeks. The client is a stay-at-home mother and her husband travels extensively for his job. Which of the following effects should the nurse consider when planning care for the family? -Loss of privacy -Decrease in income -Changes in family members' roles and tasks -Loss of autonomy for the children
Changes in family members' roles and tasks Since the client will require extensive bedrest and be immobile, a significant change in roles and responsibilities of the family members will need to occur. The nurse should include this in the plan of care.
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.
Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.
A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include? Decreased muscle mass Thickened vertebral disks Reduced chest width Increased force of isometric contraction
Decreased muscle mass A decrease in muscle mass and strength occurs with aging.
A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings? -Urge incontinence -Critically elevated prostate-specic antigen (PSA) level -Difficulty starting the flow of urine -Painful urination
Difficulty starting the flow of urine Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.
A nurse is caring for a client who has metastatic bone cancer. The client states, "I want to go home to die." The family is concerned about meeting the client's care needs at home. Which of the following actions should the nurse take? Discuss initiating hospice care with the client and family. Write a referral to place the client in a nursing home. Talk with the provider about extending the client's hospital stay. Inform the client's family that they are responsible for providing palliative care.
Discuss initiating hospice care with the client and family. The nurse should discuss the availability of resources that can assist with the care of the client. Home health and hospice care are both resources that can provide support for the care of a client at home.
A nurse is talking with a young adult client who has a family history of osteoporosis. Which health promotion activity should the nurse recommend as a possible preventive measure? Increase sodium intake. Have a bone-density scan each year. Engage in weight-bearing exercise regularly. Drink a cup of coffee each morning.
Engage in weight-bearing exercise regularly. Regular weight-bearing exercise, such as walking and stair-climbing, increases bone density and can reduce the risk for osteoporosis.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? Inform the client that privileges are related to participation in therapy. Limit visiting hours until the client begins to participate in therapy. Allow the client to control the timing and frequency of the therapy. Establish a plan of care with the client that sets attainable goals.
Establish a plan of care with the client that sets attainable goals. The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.
A nurse is teaching a group of male adolescents about testicular self-examination. Which of the following information should the nurse include? -Perform testicular self-examination twice per year. -Pinch the testicles to feel for abnormalities. -Examine the testicles after a bath or shower. -Expect a moderate amount of swelling.
Examine the testicles after a bath or shower. The nurse should inform the adolescents to perform testicular self-examinations when the scrotal skin is relaxed.
A nurse is caring for a client who reports bilateral knee pain after hiking this past weekend in the mountains on rough ground. He says he is concerned because his cousin died from bone cancer recently. Which of the following actions should the nurse take? -Tell the client that it is unlikely that he has bone cancer. -Ask the client why he thinks the pain isn't a result of hiking. -Suggest genetic testing so the client can understand his risks. -Explain that the provider will see him and determine a course of action.
Explain that the provider will see him and determine a course of action. This response illustrates the therapeutic communication technique of focusing the client on the usual course of action that must precede drawing any conclusions about the cause of the client's pain.
A nurse is instructing a group of clients about nutrition. The nurse should include that which of the following is a trigger for the formation of vitamin D in the body? -Calcium -Vitamin A depletion -Exposure to sunlight -Weight-bearing exercise
Exposure to sunlight Exposure to sunlight triggers the formation of vitamin D in the body.
A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications? Hypovolemic shock Fat embolism syndrome Compartment syndrome Venous thromboembolism
Fat embolism syndrome A client who has multiple long bone fractures is at high risk for developing a fat embolism syndrome. The nurse should assess the client for additional manifestations—such as an altered mental status, tachypnea, and tachycardia—and report the findings to the provider.
A nurse is caring for a client who is 3 days postoperative following an above-the-knee amputation. Which of the following actions should the nurse take? Elevate the foot of the bed. Encourage the client to sit up as much as possible. Elevate the stump on a pillow. Have the client lie prone several times per day.
Have the client lie prone several times per day. The nurse should encourage the client to lie prone for 20 to 30 min every 3 to 4 hr to help prevent hip flexion contractures.
A nurse is providing an education program about dietary interventions to reduce the risk for prostate cancer. Which of the following information should the nurse include? Increase animal fat in the diet. Increase fatty fish in the diet. Reduce dietary fiber intake. Increase complex carbohydrates in the diet.
Increase fatty fish in the diet. The client should increase intake of fish and increase omega-3 fatty acids to reduce the risk for prostate cancer.
A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? Increased respiratory rate from 18 to 44/min. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F). Increased blood pressure from 112/68 to 120/72 mm Hg. Increased heart rate from 68 to 72/min.
Increased respiratory rate from 18 to 44/min. This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F).This change in temperature is not significant, as both values are within the expected reference range. A client who has a fat embolism may develop a high temperature, usually 39.5º C (103 Fº).
A nurse is caring for a client who is prescribed bedrest. The plan of care indicates that the client should perform isometric exercises every 2 hr. Which of the following actions should the nurse take as directed by the plan of care? Ask the client to move her arms and legs while applying slight resistance. Move the client's limbs through their complete range of motion. Have the client move each limb independently through its complete range of motion. Instruct the client to tighten muscle groups for a short period, and then relax.
Instruct the client to tighten muscle groups for a short period, and then relax. Isometric exercises involves static (no movement) contraction of a muscle without any movement of the joint. Isometrics promote increased muscle mass, strength, and tone for clients who are on bedrest.
A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? Measure the circumference of the thigh. Palpate the femoral pulse. Monitor the client's calf for edema. Instruct the client to wiggle his toes.
Instruct the client to wiggle his toes. The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.
A nurse in a provider's clinic is caring for a client who reports erectile dysfunction and requests a prescription for sildenafil. Which of the following medications currently prescribed for the client is a contraindication to taking sildenafil? Isosorbide Phenytoin Metronidazole Prednisone
Isosorbide Clients who are on nitrates including isosorbide and nitroglycerin preparations cannot take sildenafil, because of the serious medication interaction. There is the possibility of sudden death due to hypotension.
A nurse is assessing a client who has a puncture wound on his foot. Which of the following findings is a manifestation of acute osteomyelitis? Numbness of toes on the affected foot Hypothermia Localized erythema Bradycardia
Localized erythema Swelling and localized erythema are manifestations of acute osteomyelitis.
A nurse is caring for a client who is 1 day postoperative following hip open reduction with internal fixation. The client is scheduled to begin physical therapy in 30 min. Which of the following actions should the nurse take? Position the client's legs in an adducted position. Offer to administer analgesia. Tell the client to bend forward at the waist when getting out of bed. Bathe and dress the client.
Offer to administer analgesia. The nurse should offer to premedicate the client prior to painful procedures, such as physical therapy, to help keep pain under control.
A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? -Output of burgundy colored urine -Pulse rate of 88/min -Oral temperature of 38.2° C (100.76° F) -An urge to void despite having an indwelling urinary catheter
Output of burgundy colored urine Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter.
A nurse is caring for an adolescent client who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take? -Perform a neurovascular assessment. -Explain the discharge instructions to the client and parents. -Provide reassurance to the client and parents. -Apply an ice pack to the casted leg.
Perform a neurovascular assessment. The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."
A nurse is caring for a client who has osteoporosis and takes a daily calcium supplement. Which of the following adverse effects of calcium should the nurse suspect when the client reports having flank pain? Hepatitis Hip fracture Renal stones Pancreatitis
Renal stones Calcium supplements can cause renal stones. Clients should increase their water intake while taking calcium supplements to hydrate the kidneys and should report any blood in the urine or flank pain.
A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period? -Medicate the client for pain. -Instruct the client on use of crutches. -Perform neurovascular checks of the extremities. -Direct the client to perform exercises of the ankle and toes.
Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.
A nurse is assessing the elastic bandage on the stump of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? -Pitting edema around the stump dressing -Looseness of the stump dressing -The dressing forms a cone shape over the stump -Figure-eight wrapping around the stump
Pitting edema around the stump dressing If the elastic bandage is properly applied, it should prevent edema. The nurse should remove the bandage and rewrap the stump.
A nurse is evaluating a client's laboratory results. The nurse should recognize that an increase in the client's prostate specific antigen (PSA) laboratory value is indicative of which of the following diagnoses? Breast cancer Colon cancer Liver cancer Prostatic cancer
Prostatic cancer An increased PSA level is indicative of a prostate cancer diagnosis, as well as other prostate problems.
A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? Provide high-flow oxygen. Check the client for a positive Chvostek's sign. Administer an IV vasopressor medication. Monitor the client for headache.
Provide high-flow oxygen. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation.
A nurse overhears two assistive personnel (AP) from the medical-surgical unit discussing a hospitalized client while in the cafeteria. Which of the following is the priority nursing action? \ Quietly tell the APs that this is not appropriate. Ask the nurse manager to provide an inservice program about confidentiality to the staff on the unit. Complete an incident report. Document the occurrence in a personal log.
Quietly tell the APs that this is not appropriate. The nurse has a professional duty to protect the client's confidential information. When using the urgent vs. nonurgent approach to client care, the nurse determines the priority is to stop the APs before there is an additional breach of confidentiality.
A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include? Restrict the client's oral fluid intake. Remind the client he might feel a constant urge to void. Monitor the client's urine output every 6 hr. Weigh the client every evening.
Remind the client he might feel a constant urge to void. The client who is receiving continuous bladder irrigation will experience a continuous urge to void because of pressure on the internal sphincter from the catheter balloon.
A nurse is providing discharge teaching to a client who has a fracture of the right tibia and a fiberglass cast. Which of the following instructions should the nurse include in the teaching? Use a blow dryer on a moderate heat setting to dry the cast after showering. Use a cotton swab to relieve itching under the cast. Report any worsening or unrelieved pain. Avoid moving the affected leg.
Report any worsening or unrelieved pain. Pain can be a sign of complications such as compartment syndrome or skin breakdown. The client should report it to the provider.
A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? ?Scoliosis Kyphosis Lordosis Torticollis
Scoliosis Scoliosis is an abnormal lateral curvature of the spine that typically observed in children over the age of 10 years. Mild scoliosis usually has few consequences, but more severe curvature can restrict lung function.
When planning delegation of tasks to assistive personnel (AP), a nurse considers the five rights of delegation. Which of the following should the nurse consider when using one of the five rights of delegation? The AP's ability to prioritize The AP has the knowledge and skill to perform the task The AP's rapport with clients The AP's ability to complete the task without assistance
The AP has the knowledge and skill to perform the task The right person is one of the five rights of delegation. The nurse should seek information from the AP about his individual skill level before delegating the task.
A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs? The client complains of pain. The client develops a life-threatening situation. The client needs to have an x-ray of the femur performed. The client has to be repositioned in the bed.
The client develops a life-threatening situation. Traction weights, which are to hang freely at all times, are never to be removed without a specific provider prescription unless there is a life-threatening situation.
A nurse is caring for a client who is experiencing impaired mobility. Medical History: Client is admitted to the rehabilitation unit following a hip fracture 7 days ago. Client has limited mobility and requires full assistance to turn and transfer out of bed. Diagnostic Results: Hct 48% (37% to 47%) Hgb 17 g/dL (12 g/dL to 16 g/dL) Urine specific gravity 1.040 (1.005 to 1.030) Nurses Notes: Day 1: Skin dry, skin turgor decreased Left calf circumference 31 cm (12.2 in) Right calf circumference 32 cm (13.8 in) Day 2: 2 cm (0.8 in) warm, reddened area noted on right calf Left calf circumference 31 cm (12.2 in) Right calf circumference 35 cm (13.8 in)
The client is at risk for developing *deep vein thrombosis* and *pulmonary embolism*. Deep vein thrombosis is correct. The nurse should identify that the client is experiencing impaired immobility and dehydration, increases the client's risk for developing deep vein thrombosis. Pulmonary embolism is correct. The nurse should identify that the client is experiencing Impaired immobility and dehydration, increases the client's risk for developing pulmonary embolism. The client also has a unilateral increase in calf circumference, which indicates a possible thrombus formation that could result in pulmonary embolism.
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide? -This service began with the client's admission to the hospital. -This service focuses on teaching the primary caregiver to meet the client's needs. -The emphasis is on the client's complete recovery from the illness or injury. -Services are centered in long-term care facilities.
This service began with the client's admission to the hospital. Rehabilitation is a process that assists an ill person or a person with a disability or impairment to achieve the highest possible level of functioning. The process of rehabilitation begins with the client's admission to a health care facility for treatment.
A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use? -One nurse lifting as the client pushes with his feet -Two nurses lifting the client under the shoulders -One nurse lifting the client's legs as the client uses a trapeze bar -Two nurses using a friction-reducing device
Two nurses using a friction-reducing device This method reduces the risk of injury to the nurses and to the client. The nurses can use a draw sheet as a friction-reducing device.
A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? Perform catheterization when you recognize the urge to void. Hold the penis at a 30° to 45° angle when inserting the catheter. Inflate the balloon when the urine flow stops. Use soap and water to wash the catheter after each use.
Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.
A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make? -High-impact aerobics -Walking briskly -Riding a bicycle -Stretching exercises
Walking briskly Weight-bearing exercises are essential for maintaining bone mass. Walking is an appropriate activity for an older client to promote weight bearing and to maintain bone mass.
A nurse at an extended-care facility is instructing a class of assistive personnel (AP) about client use of assistive devices during ambulation. Which of the following instructions should the nurse give the APs about the clients' use of a cane? "When the client moves, he should move the cane forward first." "The client should hold the cane on the weak side of his body." "The grip should be level with the client's waist." "The client should first move the strong leg, then the weak one."
When the client moves, he should move the cane forward first." When the client moves, he should first move the cane forward about 30.5 cm (12 in). Then, he should move the weak leg even with the cane. Finally, he should bring the strong leg forward and ahead of the cane and his weak leg.
