NCLEX PN REVIEW Adult Health

The nurse is caring for 4 clients. Which client should the nurse see first? 1. 2 days post abdominal aortic aneuysm repair with weak pedal pulses and mottled skin on the legs 2. 2days post coronary bypass graft surgery with a white blood cell count of 18,000/mm^3 3. Chronic heart failure with peripheral edema and shortness of breath on exertion 4. Pneumothorax with a chest tube negative suction and subcutaneous emphysema

1. 2 days post abdominal aortic aneurysm repair with weak pedal pulses and mottled skin on legs Rationale: A weak or absent pedal pulse and a cool or mottled extremity in a client who is post abdominal aortic aneurysm repair can indicate an arterial or graft occlusion, leading to possible life- or limb-threatening ischemia. * Fresh post op in first 12 hours beat ,edical or other surgical problems. no matter how bad other choices may seem

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? 1. 25 year old client who reports a fish like vaginal odor for the past month 2. 30 year old client with an intrauterine device who reports heavy bleeding with menses 3. 40 year old client with endometriosis who reports persistent pain during intercourse 4. 60 year old client who reports bloating and pelvic pressure for the past two months

4. 60 year old client who reports bloating and pelvic pressure for the past two months Rationale: Symptoms of ovarian cancer are often subtle, and the condition is often not discovered until an advanced stage due to a lack of routine screening guidelines. Clients may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.

The practical nurse is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis? 1. 25 year old client with abdominal pain who smokes cigarettes and takes oral contraceptives 2. 55 year old ambulatory client with exacerbation of chronic bronchitis and hematocrit of 56% 3. 72 year old client with a fever who is 2 days post coronary stent placement 4. 80 year old client who is 4 days postoperative from repair of a fractured hip

4. 80 year old client who is 4 days postoperative from repair of a fractured hip Rationale: Deep venous thrombosis (DVT) is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age. -The 80-year-old 4-day postoperative client is at greatest risk for developing DVT due to having the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age

The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? 1. I have been seeing small flashes of light 2. I have trouble threading my sewing needle. I have to hold it far away to see it 3. I notice that my peripheral vision is becoming worse 4. I see a blurry spot in the middle of the page when i read

4. I see a blurry spot in the middle of the page when i read Rationale: Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma. -"Dry" macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula

The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply. 1. African Americans 2. Diabetes mellitus type 2 3. Frequent stress at work 4. LDL OF 94 mg/dl 5. Smoking of 1 pack of cigarettes daily

1. African American ethnicity 2. Diabetes mellitus type 2 3. Frequent stress at work 5. Smoking of 1 pack of cigarettes daily Rationale: Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]).

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? 1. Aphasia 2. Apraxia 3. Dysarthria 4. Dysphagia

1. Aphasia Rationale: Aphasia refers to a neurological impairment of communication. Clients may have impaired speech and writing, impaired comprehension of words, or a combination of both.

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? Select all that apply. 1. Apply cool, moist washcloths to the affected areas 2. Keep the fingernails trimmed short to minimize skin scratching 3. Take a hot bath or shower to alleviate itching sensations 4. Use skin protectant or moisturizing cream over unbroken skin 5. Wear cotton gloves or long-sleeved clothing to avoid scratching

1. Apply cool, moist washcloths to the affected areas 2. Keep the fingernails trimmed short to minimize skin scratching 4. Use skin protectant or moisturizing cream over unbroken skin 5. Wear cotton gloves or long-sleeved clothing to avoid scratching Rationale: A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long-sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths also help. Cholestyramine increases the excretion of bile salts through feces, thereby decreasing itching

The nurse is caring for a client with primary adrenal insufficiency (Addison disease). The nurse recognizes which finding associated with the disease? 1. Bronze pigmentation of the skin 2. Increased body or facial hair 3. Purple or red striare on the abdomen 4. Supraclavicular fat pad

1. Bronze pigmentation of the skin Rationale: Addison disease, or primary adrenal insufficiency, is due to the under secretion of glucocorticoids and mineralocorticoids. Manifestations include bronze skin, hypovolemia, hypotension, hyponatremia, hyperkalemia, and vitiligo.

The nurse is reinforcing discharge instructions for several clients. Which client should receive information about the need for prophylactic antibiotics prior to dental procedures? 1. Client who had mechanical aortic valve replacement 2. Client who had mitral valvuloplasty repair 3. Client who had myocardial infarction with subsequent heart failure 4. Client who had mitral valve prolapse with regurgitation

1. Client who had mechanical aortic valve replacement Rationale: Clients with any form of prosthetic material in their heart valves or who have an unrepaired cyanotic congenital heart defect or a prior history of infective endocarditis (IE) should take prophylactic antibiotics prior to dental procedures to prevent development of IE.

A nurse is reinforcing instructions regarding home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? 1. Exposure to sunlight will worsen my psoriasis 2. I should avoid drinking alcohol 3. I should avoid scratching lesions 4. Stress can worsen psoriasis

1. Exposure to sunlight can worsen psoriasis Rationale: Psoriasis is a chronic, autoimmune condition characterized by exacerbations of silver plaques on reddened skin. Although there is no cure, management includes topical and systemic medications, phototherapy, and avoidance of triggers.

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply. 1. Family history of skin cancer 2. high number of moles 3. history of severe adolescent acne 4. immunosuppressant medication used 5. Outdoor occupation

1. Family history of skin cancer 2. high number of moles 4. immunosuppressant medication used 5. Outdoor occupation Rationale: Risk factors for skin cancer include family or personal history of skin cancer atypical or high number of moles Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations and ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation).

The nurse dons personal protective equipment (PPE) before providing care for a client in airborne transmission-based precautions. Place the steps for donning PPE in the appropriate sequence. All options must be used. 1. Gloves 2. Goggles or face shield 3. Gown 4. Hand hygiene 5. Mask or respirator

1. Hand Hygiene 2. Gown 3. Mask or respirator 4. Googles or face shield 5. Gloves

A client who developed heart failure after a myocardial infarction is scheduled to be discharged this afternoon. Based on the discharge data, the nurse plans to reinforce which home care instructions? Select all that apply. 1. How to take own pulse 2. Monitoring daily weight 3. Need for monthly International Normalized Ratio testing 4. Need to increase foods high in potassium 5. Reduction of sodium in diet 6. Use of home oxygen

1. How to take own pulse 2. Monitoring daily weight 5. Reduction of sodium in diet Rationale: The client being discharged with heart failure should understand weight monitoring, diet, medication regimen, activity, and symptoms to report.

The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply. 1. I am going to join a walking program to lose excess weight 2. I may have dry mouth as a side effect from the oxybutynin 3. I really need caffeine to get myself going in the morning 4. I should perform Kegel excercises several times daily 5. I will void every 2 hours until i am having fewer accidents

1. I am going to join a walking program to lose excess weight 2. I may have dry mouth as a side effect from the oxybutynin 4. I shoud perform kegel excercises several times daily 5. I will void every 2 hours until im having fewer accidents Rationale: Management of urge incontinence includes loss of excess weight, anticholinergic medications (eg, oxybutynin), avoidance of bladder irritants, pelvic floor exercises, and bladder training. Dry mouth is a common adverse effect of anticholinergic medications

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. I am having problems extending my fingers since this morning 2. I cant take any of the pain medicine because it makes me feel sick 3. I have to scratch under the cast with a nail file because of the itching 4. I noticed a warm spot on my cast and a bad smell is coming from it

1. I am having problems extending my fingers since this morning Rationale: Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. Volkmann contracture occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply 1. I don't have to use protection if my sexual partner is also HIV positive 2. I have to make sure my family knows not to borrow my razors 3. I need to avoid eating raw or undercooked meats and eggs 4. I started to use lambskin condoms during sex, as i have latex allergy 5. I won't reuse or share any needles or syringes that i use to inject heroin

1. I don't have to use protection if my sexual partner is also HIV positive 4. I started to use lambskin condoms during sex, as i have latex allergy Rationale: -Unprotected sex increases the risk of transmitting HIV and other sexually transmitted infections (STIs). Protected sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may hasten progression to AIDS -Clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure (ie, oral, vaginal, anal) to semen or vaginal secretions. Natural barriers (eg, lambskin) do not prevent transmission of STIs due to the presence of small pores

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next? 1. Leave the catheter in place and insert a new catheter higher up in the perrineal area 2. Leave the catheter in place for 30 min and then recheck 3. Notify the prescribing health care provider that there is an obstruction 4. Remove the catheter and reinsert it at a position higher than the initial insertion

1. Leave the catheter in place and insert a new catheter higher up in the perrineal area Rationale: If no urine is returned from Foley catheter insertion in a female client after a short time, the nurse has probably not inserted it into the correct opening. The nurse should leave the original catheter in place and reinsert a new sterile catheter above the original position

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless and has been given IV morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas results best indicate that the client is in acute respiratory failure and needs immediate intervention? 1. PaO2 49 mm Hg (6.5 kPa), PaCO2 6-mm Hg (8.0 kPa) 2. PaO2 64 mm Hg (8.5 kPa), PaCO2 45 mm Hg (6.0 kPa) 3. PaO2 70 mm Hg (9.3 kPa), PaCO2 30 mm Hg (4.0 kPa) 4. PaOz 86 mm Hg (11.5 kPa) PaCO2 25mm Hg (3.33 KPa)

1. PaO2 49 mm Hg (6.5 kPa) PaCO2 60 mm Hg (8.0 kPa) Rationale Acute respiratory failure (ARF) is defined as inadequate gas exchange that results from too much carbon dioxide or inadequate oxygen. ARF may be intrapulmonary (eg, pneumonia, pulmonary embolism) or extrapulmonary (eg, head injury, opioid overdose) in origin. ARF is a potential complication of oversedation or following major surgical procedures, especially those involving the thorax and abdomen that may result in injury to the lung ABG values that indicate the presence of ARF are decreased PaO2 ≤60 mm Hg (8.0 kPa)

The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply 1. Blood 2. Feces 3. Semen 4. Urine 5. Vaginal Secretions

1.Blood 3. Semen 5. Vaginal Secretions Rationale: The transmission of hepatitis B occurs through parenteral or sexual contact with body fluids such as blood, semen, or vaginal secretions (mnemonic: B for body fluids)

A hospitalized client is receiving chemotherapy. Based on today's blood laboratory results, what action should the nurse take? Click on the exhibit button for additional information. 1. Check for hematuria 2. check for peaked T waves 3. obtain prescription for epoetin alfa 4. place a mask on the client

4. Place a mask on the client Rationale: -The client needs reverse or protective isolation from microorganisms, on people or objects, to which the client lacks resistance. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA (high-efficiency particulate air) filtration -Until the room can be readied, this client should be protected with a mask and separated from infectious clients. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. *The normal range for a white blood cell (WBC) count is 4,000-11,000/mm3

An elderly client with a history of stable chronic obstructive pulmonary disease, alcohol abuse, and cirrhosis has a serum theophylline level of 25.8 mcg/mL (143 µmol/L). Which clinical manifestation associated with theophylline toxicity should worry the nurse most? 1. Alterations in color vision 2. Gum hypertrophy 3. Hyperthermia 4. Seizure activity

4. Seizure activity Rationale: Theophylline has narrow therapeutic index and plasma concentrations >20 mcg/mL (111 µmol/L) are associated with theophylline drug toxicity Seizures (central nervous system stimulation) and cardiac arrhythmias are the most serious and lethal consequences.

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? 1. Beans, yogurt, and a fruit cup 2. Beef, broccoli, and a glass of wine 3. Eggs, a bagel, and black coffee 4. Steak. tomato basil soup, and cornbread

4. Steak, tomato basil soup, and cornbread rationale: Irritable bowel syndrome is a chronic condition characterized by altered intestinal motility, causing abdominal discomfort with diarrhea and/or constipation. Clients can manage symptoms by avoiding gas-producing foods (eg, broccoli), caffeine, alcohol, and gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and by increasing fiber.

The nurse is assisting with the care of an adolescent diagnosed with type 1 diabetes. The client has hot, dry skin and a glucose level of 350 mg/dL (19.4 mmol/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been ordered. Cardiac monitoring reveals a sinus rhythm with peaked T waves, and the client has minimal urine output. What does the nurse anticipate as the next priority action? 1. Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain client's urine for urinalysis 4. Request a potassium infusion prescription

2. Administer normal saline infusion Rationale: This client has diabetic ketoacidosis, and all clients with this condition experience dehydration due to osmotic diuresis. Prompt and adequate fluid therapy restores tissue perfusion and suppresses the elevated levels of stress hormones. The initial hydrating solution is a normal saline (0.9%) infusion * next insulin and be administered and potassium can be given once levels are normal and low

Back Front The nurse is assisting with procedural moderate sedation (conscious sedation) at a client's bedside. The unlicensed assistive personnel (UAP) comes to the door and indicates that the client in the next room needs the nurse right now. How should the nurse respond? 1. Ask the UAP to go back and ask the client what the current needs are 2. Ask the UAP to stay and take over while the nursing goes to check on the client in the next room 3. Tell the UAP to inform the client in the next room that the nurse will be there shortly 4. Tell the UAP to tell the charge nurse about the needs of the client in the next room

4. Tell the UAP to tell the charge nurse about the needs of the client in the next room Rationale: The nurse should never leave the client during the procedure. The best response is to have an available nurse (the charge nurse) go assess and deal with the needs of the client next door.

A client has chronic obstructive pulmonary disease exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse finds bilateral diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? 1. Nasal cannula 2. Non-rebreathing mask 3. Oxymizer 4. Venturi mask

4. Venturi mask Rationale: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable chronic obstructive pulmonary disease [COPD]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, COPD exacerbation

The nurse reinforces discharge instructions to a client who was hospitalized for deep venous thrombosis that has now resolved. Which instructions should the nurse include to prevent reoccurrence? Select all that apply. 1) Do not travel by car or airplane for at least 3-4 weeks 2. Drink plenty of fluids daily and limit caffeine and alcohol intake 3. Elevate legs on a footstool when sitting and dorsifllex the feet often 4. Resume the walking or swimming exercise program as soon as possible after getting home 5. sit in a cross-legged yoga position for 5-10 mins as this benefits circulation

2. Drink plenty of fluids daily and limit caffeine and alcohol intake 3. Elevate legs on a footstool when sitting and dorsiflex the feet often 4. Resume the walking or swimming exercise program as soon as possible after getting home Rationale: Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism Elevate legs when sitting, and dorsiflex the feet often to reduce venous hypertension and edema and to promote venous return Begin or resume a walking/swimming exercise program as soon as possible to promote venous return through contraction of the calf and thigh muscles Stop smoking Avoid wearing restrictive clothing

Which appearance of a stoma immediately after colostomy requires that the practical nurse contact the supervising registered nurse immediately? 1. Brick red with slight moisture 2. Dusky with moderate edema 3. Pink with slight oozing of blood 4. Rosy with no stool produced

2. Dusky with moderate edema Rationale: A healthy stoma has the characteristics of mucosal tissue and should appear vascular and moist. Indications of decreased blood supply (pale, dusky, or cyanotic color changes) should be reported to the registered nurse and health care provider immediately.

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply. 1. Decrease fluid intake to 1 glass with each meal at bedtime 2. Encourage the client to bear down while attempting to void 3. Inspect the perineal area for evidence of skin breakdown 4. Measure postvoid residual volumes as prescribed 5. Tell the client to wait 30 seconds after voiding and then attempt to void again

2. Encourage the client to bear down while attempting to void 3. Inspect the perineal area for evidence of skin breakdown 4. Measure postvoid residual volumes as prescribed 5. Tell the client to wait 30 seconds after voiding and then attempt to void again Rationale: When caring for clients with overflow incontinence, the nurse should implement a fixed voiding schedule, teach the client techniques that assist with bladder emptying (eg, Valsalva maneuver, Credé maneuver, double voiding), monitor for perineal skin breakdown, and measure postvoid residual volumes as prescribed.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility? 1. Genital Herpes and HIV 2. Gonorrhea and chlamydia 3. Human papillomavirus and syphilis 4. yeast and trichomoniasis

2. Gonorrhea and chlamydia Rationale: Gonorrhea and chlamydia are the most common causes of pelvic inflammatory disease, which can lead to infertility. Therefore, annual gonorrhea and chlamydia screening is recommended for all sexually active females age <25 and older females with risk factors.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? 1. Brain natriuretic peptide 70 pg/ml 2. Hematocit 21% 3. Leukocytes 3,500/mm^3 4. Platelets 105,000/mm^3

2. Hematocrit 21% Rationale: Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

The nurse cares for a client with type 2 diabetes mellitus and hemoglobin A1C results of 8% at an outpatient health clinic. Which statement by the nurse will best address these results? 1. It is important for us to review the signs and symptoms of a hypoglycemic reaction 2. Let's review your diet, excercise, and medication regimen over the past 2-3 months 3. Please describe what you have eaten in the last 24-48 hours 4. You should fast for at least 8 hours prior to your morning blood work

2. Let's review your diet, excercise, and medication regimen over the past 2-3 months Rationale: Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood over a period of 2-3 months. A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes. *It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C.

The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply. 1. Oral bite prevention device 2. Oxygen delivery system 3. Padding on the bed side rails 4. Soft arm and leg restraints 5. Suction equipment

2. Oxygen delivery system 3. Padding on the bed side rails 5. Suction equipment Rationale: Turning the client on the side, providing oxygen and suctioning as needed, and padding the side rails or removing objects that are near the client can decrease the risk for injury during a seizure. Restraints should not be used. Nothing should be placed in mouth during seizure.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? Select all that apply. 1. Encourage adequate sodium intake 2. Place in semi-fowler position 3. Place client in Trendelenburg position 4. Provide alternating air pressure mattress 5. Use music to provide a distraction

2. Place client in semi-Fowler position 4.Provide alternating air pressure mattress 5. use music to provide a distraction Rationale: The client with discomfort and shortness of breath due to ascites should be positioned in the semi-Fowler or Fowler position to promote comfort and lung expansion. Music and other methods of distraction may also promote comfort. Meticulous skin interventions (eg, specialty mattress, turning schedule) are important to prevent tissue breakdown.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The practical nurse is assisting the registered nurse in preparing the client for a paracentesis. Which nursing actions should be implemented prior to the procedure? Select all that apply. 1. Obtain informed consent for the procedure 2. Place the client in the high Fowler's position 3. Place the client on npo status 4. request that the client empty the bladder 5. take baseline vital signs and weight

2. Place the client in high Fowler's position 4. request that the client empty the bladder 5. Take baseline vital signs and weight Rationale: Paracentesis removes fluid from the abdominal cavity to improve symptoms or provide a specimen for testing. The client should be instructed to void prior to the procedure and be placed in high Fowler's position. Abdominal girth, weight, and vital signs should be recorded before and monitored after paracentesis. *NPO status not required and informed consent can only be obtained by HCP

The practical nurse is assisting the registered nurse in conducting client intake histories at a family practice clinic. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply. 1. 60 year old client was just diagnosed with benign prostatic hyperplasia 2. Client reports a doughy-feeling, mobile, golf ball size lesion under the skin over the right thigh 3. Client reports a nagging cough with hoarseness for the past 3 months 4. Female client weighed 150lb and lost 15lb in 3months without dieting 5. Male client reports a skin change on the breast that looks like an orange peel

3. Client reports a nagging cough with hoarseness for the past 3 months 4. female client weighed 150lb and lost 15lbs in 3 months without dieting 5. Male client reports a skin change on the breast that looks like an orange peel Rationale: Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses; nonhealing ulcers; and changing moles may also indicate malignancy and require further workup.

The nurse is reinforcing instructions to a client scheduled for cardiac pharmacologic nuclear stress testing. Which client statements indicate appropriate understanding? 1. I can smoke 1 cigarette the day of the test so that I won't have withdrawal 2. I should eat a hearty breakfast the morning of the test to avoid nausea 3. I should stop drinking coffee 24 hours before the procedure 4. I should take my usual dose of insulin the day of the test

3. I should stop drinking coffee 24 hours before the procedure Rationale: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; they should avoid caffeinated products for 24 hours before the test and avoid taking certain cardiac medications (eg, nitrates, beta blockers) unless otherwise instructed by the health care provider

The pediatric clinic nurse reinforces culturally competent care at an in-service. Which finding would be inappropriate to include as a common dermatologic effect of alternative medicine therapies? 1. Blisters with garlic scent near the wrists 2. Circular bruised blemishes on the back 3. Markings appearing to be human bites on the arm 4. Welt-like linear lesions on the back

3. Markings appearing to be human bites on the arm Rationale: To provide culturally competent care, nurses should be aware of alternative medicine practices that can present with dermatologic findings. Any marks consistent with child abuse should be reported to the appropriate authorities.

The nurse responds to a call for help from another staff member. Upon entering the client's room, the nurse observes an unlicensed assistive personnel (UAP) performing chest compressions on an unconscious adult client while another nurse is calling for the emergency response team. What action by the arriving nurse is the priority? 1. Ask the UAP to stop compressions and check for a pulse 2. Establish additional IV access with large-bore IVs 3. Obtain the defibrillator and apply the pads to the client's chest 4. Prepare to administer 100% O2 with a bag valve mask

3. Obtain the defibrillator and apply the pads to the clients chest Rationale: For the client in cardiac arrest, cardiopulmonary resuscitation must be started immediately. Early defibrillation is key in resolving life-threatening ventricular fibrillation or ventricular tachycardia and should not be delayed. The arriving nurse should obtain the defibrillator and apply the pads to the client's chest

The student nurse is applying a condom catheter for an ambulatory client who is uncircumcised and incontinent of urine. The precepting nurse should intervene when the student performs which action? 1. Attaches the drainage tubing to a lower leg collection bag 2. Leaves a 1-2in space at the tip of the condom 3. Retracts the foreskin before applying the condom sheath 4. Uses elastic adhesive in a spiral fashion to secure device

3. Retracts the foreskin before applying the condom sheath Rationale: Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans

The nurse is caring for a client diagnosed with ulcerative colitis and prescribed sulfasalazine. Which instructions should be reinforced at discharge? Select all that apply. 1. Avoid small, frequent meals 2. consume a cup of coffee with each meal if desired 3. continue medication even after resolution of symptoms 4. Eat a low-residue, high-protein, high-calorie diet 5. Increase fluid intake to at least 2000 mL/day

3. consume medication even after resolution of symptoms 4. Eat a low-residue, high protein, high-calorie diet 5. Increase fluid intake to at least 2000 ml/day Rationale: Ulcerative colitis is characterized by chronic inflammation and ulcerations in the large intestines, resulting in bloody diarrhea and decreased nutrient absorption. Sulfasalazine is a 5-aminosalicylate used to decrease inflammation in the intestines. To prevent relapse, the medication should be continued even when symptoms subside

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? 1. 0.45% sodium chloride IV 2. Calcium gluconate 3. Furosemide 4. Sodium polystyrene sulfonate

Furosemide Rationale: Heart failure is characterized by reduced cardiac output, which can reduce renal blood flow. Reduced renal blood flow activates the renin-angiotensin system, resulting in fluid volume excess and dilutional hyponatremia. Loop diuretics (eg, furosemide) promote free water excretion, allowing for hemoconcentration and increased sodium levels.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? 1. I got short of breath this morning when i worked out. 2. I have cut down on smoking 1/2 packs per day 3. I haven't been feeling well, so I have been sleeping a lot 4. I took an acetaminophen in the waiting room for this bad headache

I took an acetaminophen in the waiting room for this bad headache. Rationale: An arteriovenous malformation is a congenital deformity of tangled blood vessels often occurring in the brain. These vessels may weaken and rupture, causing an intracranial hemorrhage. Any neurologic changes and severe headache need to be addressed immediately as these may indicate hemorrhage.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. I need to raise the head of my bed on blocks by at least 6 inches 2. I will remain sitting up for several hours after I eat any food 3. If my reflux and abdominal pain don't improve, I might need surgery 4. Losing weight may reduce my reflux, so I plan to take a weight-lifting class

Losing weight may reduce my reflux, so I plan to take a weight-lifting class Rationale: Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.

The nurse employed in a woman's health care clinic would be most concerned about which client statement? 1. I recently noticed a small, round, painless, mobile lump in my left breast while showering 2. Last night while breastfeeding, my nipples were cracked and my breast were painful 3. My right breast is red and warm with little tiny indented areas on the surface of the skin 4. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch

My right breast is red and warm with little tiny indented areas on the surface of the skin Rationale: The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface.

The nurse assesses a client who had a thyroidectomy 8 hours ago. The nurse finds the client anxious, with tingling around the mouth and muscle twitching in the right arm. Which action is most important for the nurse to implement first? 1. Change the surgical dressing to assess for bleeding 2. Document the findings in the electronic medical record 3. Draw arterial blood gases 4. Obtain a serum calcium level

Obtain a serum calcium level Rationale: Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy. The nurse should monitor for signs and symptoms of tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign), confirm with serum calcium results, and administer calcium gluconate as prescribed. Untreated clients can develop life-threatening laryngeal spasm.

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1.Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shields 4. Remove the splinter using tweezers

Patch both eyes with eye shields Rationale: When a foreign body becomes accidentally embedded in the eye, both eyes should be shielded to prevent eye movement and additional injury. The nurse should immediately refer the client to an ophthalmologist for further evaluation and treatment.

The nurse evaluates the results of laboratory tests completed on a client admitted for a non-healing wound. Which of the following values would be a priority for the nurse? 1. Blood urea nitrogen 15 mg/dl 2. Serum albumin 3.7 g/L 3. Serum Potassium 4. Serum Sodium 153 mEq/L

Serum Sodium 153 mEq/L Rationale: The normal value for serum sodium is 135-145 mEq/L. Remember that "water goes where salt is." This action decreases wound healing at a cellular level, reducing the nutrients cells need for repair.

The nurse cares for a group of clients on a medical surgical floor. The client with which condition is at highest risk for developing syndrome of inappropriate antidiuretic hormone (SIADH)? 1. Carpal tunned syndrome 2. Diabetes mellitus 3. Sciatica 4. Small cell lung cancer

Small cell lung cancer Rationale: ADH is sometimes produced and secreted by cancer cells, especially lung cancer cells causing SIADH, a condition in which too much ADH causes water retention, increased total water, and dilutional hyponatremia.

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching? 1. A 5/8 inch, 25-gauge needle is appropriate for intramuscular injection in newborns 2. I will clean the injection site with an antiseptic swab before administration 3. I will draw the medication into a 1-mL syringe 4. The medication should be administered into the deltoid muscle

The medication should be administered into the deltoid muscle Rationale: The preferred site for intramuscular (IM) injection in newborns is the vastus lateralis muscle in the anterolateral portion of the middle thigh. A 1-mL syringe should be used, and medication dosages should be calculated to two decimal places. A ⅝-inch, 22- to 25-gauge needle is appropriate for IM injection in a newborn

The nurse is reinforcing discharge instructions for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? 1. I will ask the HCP to explain the consequences of your procedure 2. This is a common complication that will require you to have a hearing test every year 3. This is a common complication, your HCP will order a consult for the speech pathologist 4. This is the reason you are using a special swallowing technique when you eat and drink

This is the reason you are using a special swallowing technique when you eat and drink Rationale: -Inhale deeply -Hold breath tightly to close the vocal cords -Place food in mouth and swallow while continuing to hold breath -Cough to dispel remaining food from vocal cords -Swallow a second time before breathing -Clients who undergo a partial laryngectomy are at increased risk for aspiration. As a result, they are taught a swallowing technique (supraglottic swallow) to decrease this risk.

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? Select all that apply. 1. Abdominal pain 2. Blood in the stools 3. Change in bowel habits 4. Low hemoglobin level 5. Unexplained weight loss

abdominal pain, blood in sttols, change in bowel, low hemoglobin level, and unexplained weight loss Rationale: Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? Select all that apply. 1. Avoid irritants such as acidic, spicy foods 2. Discourage the use of topical analgesics 3. Encourage liquid nutritional supplements 4. Perform oral hygiene once a day 5. Use artificial saliva to control dryness

Back Front 1. Avoid irritants such as acidic, spicy foods 3. Encourage liquid nutritional supplements 5. Use artificial saliva to control dryness Rationale: The nurse teaches the client to: -Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol -Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow -Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function. Sipping water throughout the day is equally effective and less expensive.

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? Select all that apply. 1. Call for help 2. Hold down clients arms 3. Insert a tounge depresser to move the tounge 4. Prepare for suctioning 5. Turn the client on the side

Back Front 1.Call for help 4. Prepare for suctioning 5. Turn the client to the side Rationale: During an active seizure, the nurse should call for additional help, turn the client on the side if possible, and have suction equipment ready to clear any excessive secretions that may block the airway. The nurse should not restrain the client or force anything into the client's mouth. * The client should not be restrained as this could cause an injury (Option 2). Oral airways should be kept at the bedside for postictal airway management and recovery, but during an active seizure it is dangerous to attempt to insert anything in the client's mouth, especially if the teeth are clenched (Option 3).

The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply. 1. Dysuria 2. Jaundice 3. Lower back pain 4. Night sweats 5. Purulent or blood-tinged sputum 6. Weight loss

Back Front Night sweats. purulent or blood-tinged sputum, and weight loss Rationale: Mycobacterium tuberculosis (TB) is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). Additional symptoms depend on the location of the infection. Pulmonary TB typically includes: -Cough -Purulent or blood-tinged sputum (hemoptysis) -Shortness of breath -Dyspnea -Characteristic signs and symptoms associated with tuberculosis (TB) infection, regardless of location, include low-grade fever, night sweats, anorexia, weight loss, and fatigue. Pulmonary TB will also include respiratory symptoms (eg, cough, hemoptysis, dyspnea).

A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should the nurse reinforce to reduce the risk of future episodes? Select all that apply. 1. Drink plenty of fluids 2. Exercise regularly 3. Follow a low-fiber diet 4. Include whole grains, fruits, and vegetables in the diet 5. Increase intake of red meat

Drink plenty of fluids, exercise regularly, include whole grains, fruits and vegetables in diet Rationale: Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine. Diverticulitis occurs when diverticula become infected and inflamed. Clients with diverticulosis should take measures to prevent constipation (eg, high-fiber diet, increased fluid intake, regular exercise), which may help prevent recurring episodes of acute diverticulitis