NR316 final

A nurse is caring for a client with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the client has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? Select one: a. Constructional apraxia b. Palmar erythema c. Fetor hepaticus d. Asterixis

Asterixis

A nurse is creating a care plan for a client with acute pancreatitis. The care plan includes reduced activity. What rationale for this intervention should be cited in the care plan? Select one: a. Reduced activity protects the physical integrity of pancreatic cells. b. Bed rest lowers the metabolic rate and reduces enzyme production. c. Inactivity reduces caloric need and gastrointestinal motility. d. Bed rest reduces the client's metabolism and reduces the risk of metabolic acidosis.

Bed rest lowers the metabolic rate and reduces enzyme production

A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments? Select one: a. Fluid output b. Blood glucose levels c. Oral intake d. BUN and creatinine levels

Blood glucose levels

The nurse is caring for a client who is receiving a loop diuretic for the treatment of heart failure. What assessment should the nurse prioritize? Select one: a. Blood pressure b. Vitamin D intake c. Monitoring liver function studies d. Monitoring potassium levels

Blood pressure

A newly admitted client with type 1 diabetes asks the nurse what caused her diabetes. When the nurse is explaining to the client the etiology of type 1 diabetes, what process should the nurse describe? Select one: a. "Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down." b. "The tissues in your body are resistant to the action of insulin, making the glucose levels in your blood increase." c. "The amount of glucose that your body makes overwhelms your pancreas and decreases your production of insulin." d. "Damage to your pancreas causes an increase in the amount of glucose that it releases, and there is not enough insulin to control it."

Destruction of special cells in the pancreas causes a decrease in insulin production. Glucose levels rise because insulin normally breaks it down.

The nurse is reviewing the electronic health record of a client with an empyema. What health problem in the client's history is most likely to have caused the empyema? Select one: a. Asbestosis b. Smoking c. Pneumonia d. Lung cancer

Pneumonia

A client who has had an amputation is being cared for by a multidisciplinary rehabilitation team. What is the primary goal of this multidisciplinary team? Select one: a. Facilitate the client's adjustment to a new body image b. Promote the client's highest possible level of function c. Maximize the efficiency of care d. Ensure that the client's health care is holistic

Promote the client's highest possible level of function

A client with type 1 diabetes has told the nurse that his most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? Select one: a. The client's insulin levels are inadequate. b. The client would benefit from a dose of metformin. c. The client should withhold his next scheduled dose of insulin. d. The client should promptly eat some protein and carbohydrates

The client's insulin levels are inadequate

A pregnant woman has been diagnosed with gestational diabetes. The client is shocked by the diagnosis, stating that she is conscientious about her health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor? Select one: a. Changes in osmolality and fluid balance b. Overconsumption of carbohydrates during the first two trimesters c. Increased caloric intake during the first trimester d. The effects of hormonal changes during pregnancy

The effects of hormonal changes during pregnancy

The nurse is caring for a client with a severe nosebleed. The physician inserts a nasal sponge. What should the nurse teach the client about this intervention? Select one: a. The sponge can stay in place for 3 to 4 days if needed b. The sponge creates a risk for viral sinusitis c. NSAIDs are contraindicated while the sponge is in place d. The client should remain supine while the sponge is in place

The sponge can stay in place for 3-4 days if needed

A nurse is caring for a child who was admitted to the pediatric unit with infectious diarrhea. The nurse should be alert to what assessment finding as an indicator of dehydration? Select one: a. Labile BP b. Fever c. Diaphoresis d. Weak pulse

Weak pulse

The triage nurse in the ED is performing a rapid assessment of a man with reports of severe chest pain and shortness of breath. The client is diaphoretic, pale, and weak. When the client collapses, what should the nurse do first? Select one: a. Gently shake and shout, "Are you OK?" b. Give two full breaths c. Check for a carotid pulse d. Apply supplemental oxygen

Gently shake and shout, "Are you OK?"

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis? Select one: a. Positive end-expiratory pressure (PEEP) b. Bronchoscopy c. Incentive spirometry d. Intermittent positive-pressure breathing (IPPB)

Incentive spirometry

A 16-year-old presents at the emergency department reporting right lower quadrant pain and is subsequently diagnosed with appendicitis. When planning this client's nursing care, the nurse should prioritize what nursing diagnosis? Select one: a. Chronic Pain Related to Appendicitis b. Imbalanced Nutrition: Less Than Body Requirements Related to Decreased Oral Intake c. Risk for Infection Related to Possible Rupture of Appendix d. Constipation Related to Decreased Bowel Motility and Decreased Fluid Intake

Risk for infection related to possible rupture of the appendix

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? Select one: a. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions b. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) c. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) d. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L)

Fasting blood glucose greater than or equal to 126 mg/dL (7.0 mmol/L)

When a disease infects a host a portal of entry is needed for an organism to gain access. What has been identified as the usual portal of entry for tuberculosis? Select one: a. Urinary system b. Integumentary system c. Gastrointestinal system d. Respiratory system

Respiratory system

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region? Select one: a. Right shoulder b. Left upper chest c. Neck or jaw d. Inguinal region

Right shoulder

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? Select one: a. Absence of nausea and vomiting b. Two to three soft bowel movements daily c. Absence of blood or mucus in stool d. Significant increase in appetite and food intake

Two to three soft bowel movements daily

A 15-year-old child is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the child's pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes? Select one: a. Type 2 diabetes b. Prediabetes c. Non-insulin-dependent diabetes d. Type 1 diabetes

Type I diabetes

A client presents to the emergency department with paraphimosis. The health care provider is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, the nurse should prepare the client for what intervention? Select one: a. Needle aspiration of the corpus cavernosum b. Circumcision c. Administration of vardenafil d. Abstinence from sexual activity for 6 weeks

Circumcision

The nurse is planning client teaching for a client with ESKD who is scheduled for the creation of a fistula. The nurse should teach the client what information about the fistula? Select one: a. "The arm should be immobilized for 4 to 6 days." b. "One needle will be inserted into the fistula for each dialysis treatment." c. "The fistula can be used 5 to 7 days after the surgery for dialysis treatment." d. "A vein and an artery in your arm will be attached surgically."

"A vein and an artery in your arm will be attached surgically"

The nurse is speaking with a 20-year-old client who has class II obesity. The client states, "No matter what I do, I can't lose weight. How soon do you think I could get bariatric surgery?" What is the nurse's best response? Select one: a. "In most cases, clients have to be older than around 25 in order to be candidates for bariatric surgery." b. "Bariatric surgery does help many clients lose weight, but it's normally reserved for clients with more severe obesity than yours." c. "Bariatric surgery is often very effective, but it usually happens after a lengthy process of consultations and referrals." d. "Depending on the results of your assessments, you can likely have surgery very soon."

"Bariatric surgery is often very effective, but it usually happens after a lengthy process of consultations and referrals."

The nurse has completed the admission assessment of a client and has determined that the client's body mass index (BMI) is 33.5 kg/m2. What health promotion advice should the nurse provide to the client? Select one: a. "It would be very helpful if you could integrate more physical activity into your routine." b. "You're considered to be overweight, so it would be healthy for you to be diligent about maintaining a healthy diet." c. "You might want to consider some of the surgical options that have been developed for treating obesity." d. "With your permission, I'd like to refer to a support group for individuals who live with severe obesity."

"It would be very helpful if you could integrate more physical activity into your routine."

An occupational health nurse is screening a group of workers for diabetes. What statement should the nurse interpret as being suggestive of diabetes? Select one: a. "When I went to the washroom the last few days, my urine smelled odd." b. "Lately, I drink and drink and can't seem to quench my thirst." c. "I've always been a fan of sweet foods, but lately I'm turned off by them." d. "No matter how much sleep I get, it seems to take me hours to wake up."

"Lately, I drink and drink and can't seem to quench my thirst."

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What should the nurse describe? Select one: a. 10% to 20% of calories from carbohydrates, 20% to 30% from fat, and the remaining 50% to 60% from protein b. 20% to 30% of calories from carbohydrates, 50% to 60% from fat, and the remaining 10% to 20% from protein c. 10% of calories from carbohydrates, 50% from fat, and the remaining 40% from protein d. 50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which of the following clients as having the highest risk for chronic pancreatitis? Select one: a. A 51-year-old woman who smokes one and a half packs of cigarettes per day b. An 18-year-old man who is a weekend binge drinker c. A 39-year-old man with chronic alcoholism d. A 45-year-old obese woman with a high-fat diet

A 39yo man with chronic alcoholism

The nurse coming on shift on the medical unit is taking a report on four clients. What client does the nurse know is at the greatest risk of developing ESKD? Select one: a. A client who is morbidly obese with a history of vascular disorders b. A client with a history of polycystic kidney disease c. A client with severe chronic obstructive pulmonary disease d. A client with diabetes mellitus and poorly controlled hypertension

A client with diabetes mellitus and poorly controlled hypertension

A client with a history of injection drug use has been diagnosed with hepatitis C. When collaborating with the care team to plan this client's treatment, the nurse should anticipate what intervention? Select one: a. Administration of immune globulins b. A regimen of antiviral medications c. Administration of fresh-frozen plasma (FFP) d. Rest and watchful waiting

A regimen of antiviral medications

The surgical nurse is admitting a client from postanesthetic recovery following the client's below-the-knee amputation. The nurse recognizes the client's high risk for postoperative hemorrhage and should keep what equipment at the bedside? Select one: a. A syringe preloaded with vitamin K b. A tourniquet c. A unit of packed red blood cells, placed on ice d. A dose of protamine sulfate

A tourniquet

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan? Select one: a. Administration of diuretics as prescribed b. Vitamin B12 injections as prescribed c. Mobilization with assistance at least 4 times daily d. Administration of beta-adrenergic blockers as prescribed

Administration of diuretics as prescribed

A nurse is assessing a client who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis? Select one: a. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin b. Jaundiced skin, weakness, and capillary refill of 3 seconds c. Hot skin with a capillary refill of 1 to 2 seconds d. Pain, diaphoresis, and erythema

Absence of feeling, capillary refill of 4-5sec, and cool skin

What health promotion teaching should the nurse prioritize to prevent drug-induced hepatitis? Select one: a. Ensure that expired medications are disposed of safely. b. Finish all prescribed courses of antibiotics, regardless of symptom resolution. c. Ensure that pharmacists regularly review drug regimens for potential interactions. d. Adhere to dosing recommendations of over-the-counter analgesics.

Adhere to dosing recommendations of over-the-counter analgesics

A client has returned to the floor after undergoing a transurethral resection of the prostate (TURP). The client has a continuous bladder irrigation system in place. The client reports bladder spasms.. What is the most appropriate nursing action to relieve the discomfort of the client? Select one: a. Administer a smooth muscle relaxant as prescribed. b. Notify the urologist promptly. c. Apply a cold compress to the pubic area. d. Irrigate the catheter with 30 to 50 mL of normal saline as prescribed

Administer a smooth muscle relaxant as prescribed

A client with esophageal varices is being cared for in the ICU. The varices have begun to bleed. The client has Ringer lactate at 150 cc/hr infusing. The nurse should also anticipate what intervention? Select one: a. Administering diuretics b. Oxygen by nasal cannula c. Administering volume expanders d. Positioning the client supine

Administering volume expanders

A client who is scheduled for an open prostatectomy is concerned about the potential effects of the surgery on his sexual function. What aspect of prostate surgery should inform the nurse's response? Select one: a. Modern surgical techniques have eliminated the risk of erectile dysfunction following prostatectomy. b. Erectile dysfunction is common after prostatectomy as a result of hormonal changes. c. Erectile dysfunction after prostatectomy is expected, but normally resolves within several months. d. All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction

All prostatectomies carry a risk of nerve damage and consequent erectile dysfunction

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of what sound would signal the possibility of impending heart failure? Select one: a. A heart murmur b. Faint breath sounds c. Pleural friction rub d. An S3 heart sound

An S3 heart sound

A clinic nurse is caring for a client with a history of osteoporosis. What diagnostic test will best allow the care team to assess the client's risk of fracture? Select one: a. Arthrography b. Bone scan c. Arthroscopy d. Bone densitometry

Bone densitometry

A nurse is assessing a client who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize? Select one: a. Assess for signs of infection. b. Assess for ability to communicate. c. Assess for a patent airway. d. Assess ability to clear oral secretions.

Assess for a patent airway

The nurse is reviewing the medication administration record of a client diagnosed with systolic heart failure. What medication should the nurse anticipate administering to this client? Select one: a. A nonsteroidal anti-inflammatory drug (NSAID) b. An antiplatelet aggregator c. A calcium channel blocker d. A beta-adrenergic blocker

Beta-adrenergic blocker

A nurse is working with a client who has chronic constipation. What should be included in client teaching to promote normal bowel function? Select one: a. Use glycerin suppositories on a regular basis. b. Limit physical activity in order to promote bowel peristalsis. c. Resist the urge to defecate until the urge becomes intense. d. Consume high-residue, high-fiber foods.

Consume high-residue, high-fiber foods

A nursing home resident has been diagnosed with Clostridium difficile. What type of precautions should the nurse implement to prevent the spread of this infectious disease to other residents? Select one: a. Airborne b. Positive pressure isolation c. Droplet d. Contact

Contact

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response? Select one: a. Position the client supine and insert an NG tube. b. Page the primary provider and report that the client may be obstructed. c. Contact the primary provider promptly and report these signs of perforation. d. Administer a Fleet enema as prescribed and remain with the client

Contact the primary provider promptly and report these signs of perforation

A client has presented with signs and symptoms that are characteristic of acute kidney injury, but preliminary assessment reveals no obvious risk factors for this health problem. The nurse should recognize the need to interview the client about what topic? Select one: a. Typical diet b. Psychosocial stressors c. Current medication use d. Allergy status

Current medication use

A client in a hypertensive emergency is admitted to the ICU. The nurse anticipates that the client will be treated with IV vasodilators, and that the primary goal of treatment is what? a. Lower the BP to reduce onset of neurologic symptoms, such as headache and vision changes b. Reduce the BP to ≤120/75 mm Hg as quickly as possible c. Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment d. Decrease the BP to a normal level based on the client's age

Decrease the mean arterial pressure between 20% and 25% in the first hour of treatment

A client with cystic fibrosis takes pancreatic enzyme replacements on a regular basis. The client's intake of trypsin facilitates what aspect of GI function? Select one: a. Digestion of fats b. Vitamin D synthesis c. Digestion of proteins d. Maintenance of peristalsis

Digestion of proteins

A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? Select one: a. Performing meticulous hand hygiene at the appropriate moments in care b. Wearing an N95 mask when providing care for clients on airborne precautions c. Disposing of sharps appropriately and not recapping needles d. Adhering to the recommended schedule of immunizations

Disposing of sharps appropriately and not recapping needles

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)? Select one: a. Maintaining the client in a supine position b. Administering aspirin with warfarin c. Early ambulation d. Increased dietary intake of protein

Early ambulation

A client has been admitted to the hospital for the treatment of chronic pancreatitis. The client has been stabilized and the nurse is now planning health promotion and educational interventions. Which of the following should the nurse prioritize? Select one: a. Educating the client about postdischarge lifestyle modifications b. Educating the client about the management of blood glucose after discharge c. Educating the client about expectations and care following surgery d. Educating the client about the potential benefits of pancreatic transplantation

Educating the client about post discharge lifestyle modification

A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Select one: a. Excess Fluid Volume b. Sedentary Lifestyle c. Imbalanced Nutrition: More than body requirements d. Adult Failure to Thrive

Excess fluid volume

A client admitted with nephrotic syndrome is being cared for on the medical unit. When writing this client's care plan, based on the major clinical manifestation of nephrotic syndrome, what nursing diagnosis should the nurse include? Select one: a. Constipation related to immobility b. Excess fluid volume related to generalized edema c. Hyperthermia related to the inflammatory process d. Risk for injury related to altered thought processes

Excess fluid volume related to generalized edema

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with his residual limb supported on pillow. What is the nurse's most appropriate action? Select one: a. Encourage the client to perform active ROM exercises with the residual limb b. Explain the risks of flexion contracture to the client c. Inform the surgeon of this finding d. Transfer the client to a sitting position

Explain the risks of flexion contracture to the client

A client is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in clients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication? Select one: a. Sudden increase in random blood glucose readings b. Fever, increased heart rate, and decreased blood pressure c. Increased abdominal girth accompanied by decreased level of consciousness d. Abdominal pain unresponsive to analgesics

Fever, increased heart rate, and decreased blood pressure

Your patient has been diagnosed with Peyronie's disease, you understand that this is Select one: a. A sexually transmitted disease that causes pain and discharge from the penis. b. An inflamed prostate gland causing difficulty with urination. c. Fibrous scar tissue inside of the penis that causes curved, painful erections. d. The inability to retract foreskin from the head of the penis.

Fibrous scar tissue inside of the penis that causes curved, painful erections

The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. On day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client? Select one: a. Keep the remaining tablets for an infection at a later time. b. Dispose of the remaining medication in a biohazard receptacle. c. Finish all the antibiotics to eliminate the organism completely. d. Discontinue the medications if the fever is gone.

Finish all the antibiotics to eliminate the organism completely

An older adult client with type 2 diabetes is brought to the emergency department by his daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? Select one: a. Reversing acidosis by administering insulin b. Administration of antihypertensive medications c. Administering sodium bicarbonate intravenously d. Fluid and electrolyte replacement

Fluid and electrolyte replacement

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? Select one: a. Following proper hand-washing techniques b. Wearing a condom during sexual contact c. Avoiding chemicals that are toxic to the liver d. Limiting alcohol intake

Following proper hand-washing techniques

The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? Select one: a. Hypotension unresolved by fluid administration b. Precipitous decrease in serum creatinine levels c. Glucosuria d. Hematuria

Hematuria

A 45-year-old man with diabetic nephropathy has ESKD and is starting dialysis. What should the nurse teach the client about hemodialysis? Select one: a. "Hemodialysis is a treatment option that is usually required three times a week." b. "This will require you to have surgery and a catheter will need to be inserted into your abdomen." c. "Hemodialysis is a treatment that is used for a few months until your kidney heals and starts to produce urine again." d. "Hemodialysis is a program that will require you to commit to daily treatment."

Hemodialysis is a treatment option that is usually required three times a week.

A tumor marker that may be elevated in testicular cancer is. Select one: a. Cancer Antigen 19-9 b. Human Chorionic Gonadotrophin c. Estrogen and Progesterone Receptors Incorrect d. Alpha-feto-protein

Human chorionic gonadotrophin

An adolescent is identified as having a collection of fluid in the tunica vaginalis of the testis. The nurse knows that this adolescent will receive what medical diagnosis? Select one: a. Cryptorchidism b. Prostatism c. Hydrocele d. Orchitis

Hydrocele

A client has been brought to the emergency department by paramedics after being found unconscious. The client's Medic Alert bracelet indicates that the client has type 1 diabetes and the client's blood glucose is 22 mg/dL (1.2 mmol/L). The nurse should anticipate what intervention? Select one: a. Subcutaneous administration of 10 units of Humalog b. IV bolus of 5% dextrose in 0.45% NaCl c. IV administration of 50% dextrose in water d. Subcutaneous administration of 12 to 15 units of regular insulin

IV administration of 50% dextrose in water

A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? Select one: a. IV administration of albumin b. STAT administration of vitamin K by the intramuscular route c. Infusion of intravenous heparin d. IV administration of octreotide

IV administration of octeotide

A client with ESKD receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? Select one: a. Remove the catheter promptly and have the catheter tip cultured. b. Inform the health care provider and assess the client for signs of infection. c. Administer a bolus of IV normal saline as prescribed. d. Flush the peritoneal catheter with normal saline.

Inform the health care provider and assess the client for signs of infection

The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client states that he has hereditary angioedema. The nurse should identify what implication of this health condition? Select one: a. It can cause life-threatening airway obstruction. b. It will result in increased loss of work days. c. It is a risk factor for ischemic heart disease d. It may cause episodes of weakness due to reduced cardiac output

It can cause life-threatening airway obstruction

As a nurse working in a urology office, you know this about testicular cancer? Select one: a. It is the most common cancer in men between the ages of 15-40 b. It requires extensive surgical resection and long-term chemotherapy. c. It has a 95% mortality rate d. It is the most common cancer in med between the ages of 25-50

It is the most common cancer in men between the ages of 15-40

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk? Select one: a. Keep a complete suction setup at the bedside. b. Refer the client for occupational therapy. c. Feed the client several small meals daily. d. Facilitate total parenteral nutrition (TPN).

Keep a complete suction setup at bedside

A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing what health problem? Select one: a. Anemia b. Glaucoma c. Right ventricular hypertrophy d. Kidney injury

Kidney injury

An older adult client has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the client's spine. The nurse should document the presence of: Select one: a. scoliosis. b. kyphosis. c. lordosis. d. epiphyses

Kyphosis

The nurse is assessing a client new to the clinic. Records brought to the clinic show that the client's hypertension has not improved. What contributing factor should the nurse first explore in an effort to identify the cause of the client's inadequate BP control? Select one: a. Possible heavy alcohol use or use of recreational drugs b. Possibility of medication interactions c. Lack of adherence to prescribed drug therapy d. Progressive target organ damage

Lack of adherence to prescribed drug therapy

A client with ongoing back pain, nausea, and abdominal bloating has been diagnosed with cholecystitis secondary to gallstones. The nurse should anticipate that the client will undergo what intervention? Select one: a. Laparoscopic cholecystectomy b. Intracorporeal lithotripsy c. Methyl tertiary butyl ether (MTBE) infusion d. Extracorporeal shock wave therapy (ESWL)

Laparoscopic cholecystectomy

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure? Select one: a. A laparoscopic approach can be performed under conscious sedation. b. Laparoscopic cholecystectomy can be performed in a clinic setting, while an open procedure requires an OR. c. Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure. d. A laparoscopic approach allows for the removal of the entire gallbladder.

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure

A client is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag? Select one: a. Light pink b. Amber c. Red wine colored d. Tea colored

Light-pink

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test? Select one: a. In a prone position with two pillows elevating the buttocks b. In a knee--chest position (lithotomy position) c. Lying on the left side with legs drawn toward the chest d. Lying prone with legs drawn toward the chest

Lying on the left side with legs drawn towards the chest.

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care? Select one: a. Encourage activity as tolerated. b. Limit the use of opioid analgesics. c. Monitor the client for signs of dysphagia. d. Measure the client's abdominal girth daily.

Measure the client's abdominal girth daily

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs? Select one: a. Simple mask b. Nasal cannula c. Non-rebreathing mask d. Partial-rebreathing mask

Nasal Cannula

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin? Select one: a. Ask the client to describe the process in detail. b. Observe the client drawing up and administering the insulin. c. Review the client's first hemoglobin A1C result after discharge. d. Provide a health education session reviewing the main points of insulin delivery.

Observe the client drawing up and administering insulin

The school nurse is planning a health fair for a group elementary school students and dental health is one topic that the nurse plans to address. When teaching the children about the risk of tooth decay, the nurse should caution them against consuming large quantities of Select one: a. roasted nuts. b. cheddar cheese. c. red meat that is high in fat. d. organic fruit juice.

Organic fruit juice

A nurse is assessing a client who presented to the ED with priapism. The student nurse is aware that this condition is classified as a urologic emergency because of the potential for what? Select one: a. Urinary tract infection b. Permanent vascular damage c. Chronic pain d. Future erectile dysfunction

Permanent vascular damage

A 14-year-old uncircumcised male patient presents to the primary care office complaining of significant discomfort as a result of the inability to retract his penile foreskin. You understand he may be suffering from Select one: a. An inflammed prostate gland b. A sexually transmitted infection c. Pyeronie's Disease d. Phimosis

Phimosis

What nursing intervention should the nurse prioritize to facilitate healing in a client who has suffered a hip fracture? Select one: a. Maintain prone positioning at all times b. Administer analgesics as required c. Place a pillow between the client's legs when turning d. Encourage internal and external rotation of the affected leg

Place a pillow between the clients legs when turning

The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? Select one: a. Aspiration b. Cardiac ischemia c. Pneumothorax d. Acute bronchitis

Pneumothorax

A client was fitted with an arm cast after fracturing her humerus. Twelve hours after the application of the cast, the client tells the nurse that her arm hurts. Analgesics do not relieve the pain. What would be the most appropriate nursing action? Select one: a. Encourage the client to wiggle and move the fingers b. Prepare the client for opening or bivalving of the cast c. Obtain a prescription for a different analgesic d. Petal the edges of the client's cast

Prepare the client for opening or bivalving of the cast

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response? Select one: a. Report this finding to the primary provider due to the possibility of hepatic encephalopathy. b. Ensure that the client's sodium intake does not exceed recommended levels. c. Inform the primary provider that the client should be assessed for alcoholic hepatitis. d. Implement interventions aimed at ensuring a calm and therapeutic care environment.

Report this finding to the primary provider due to the possibility of hepatic encephalopathy

A client presents at a clinic complaining of back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain? Select one: a. Sciatica b. Tendonitis c. Bursitis d. Radiculopathy

Sciatica

A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care? Select one: a. Avoiding airplanes, buses, and other crowded public places. b. Adhering to the treatment regimen in order to cure the disease c. Setting realistic short- and long-term goals d. Taking prophylactic antibiotics as prescribed

Setting realistic short- and long-term goals

A client has undergone a laparoscopic cholecystectomy and is being prepared for discharge home. When providing health education, the nurse should prioritize what topic? Select one: a. Appropriate use of prescribed pancreatic enzymes b. The need for blood glucose monitoring for the next week c. Management of fluid balance in the home setting d. Signs and symptoms of intra-abdominal complications

Signs and symptoms of intra-abdominal complications

A nurse is caring for a client hospitalized with an exacerbation of chronic gastritis. What health promotion topic should the nurse emphasize? Select one: a. Safe technique for self-suctioning b. Strategies for avoiding irritating foods and beverages c. Strategies for maintaining an alkaline gastric environment d. Techniques for positioning correctly to promote gastric healing

Strategies for avoiding irritating foods and beverages

A 15 year old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Select one: a. Menarche b. Streptococcal infection c. Hypersensitivity to an immunization d. Psychosocial stress

Streptococcal infection

The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? Select one: a. The client feels best immediately after the dialysis treatment. b. The client should not feel pain during initiation of dialysis. c. Using a stethoscope for auscultating the fistula is contraindicated. d. Taking a BP reading on the affected arm can damage the fistula.

Taking a BP reading on the affected arm can damage the fistula

The nurse is providing health education to a client with a gastrointestinal disorder. What should the nurse describe as a major function of the GI tract? Select one: a. The absorption into the bloodstream of nutrient molecules produced by digestion b. The maintenance of fluid and acid--base balance c. The breakdown of food particles into cell form for digestion d. The control of absorption and elimination of electrolytes

The absorption into the bloodstream of nutrient molecules are produced by digestion

The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize? Select one: a. The client's swallowing ability b. The client's airway patency c. Signs and symptoms of infection d. The client's carotid pulses

The clients airway patency

Diagnostic testing of a client with a history of dyspepsia and abdominal pain has resulted in a diagnosis of gastric cancer. The nurse's anticipatory guidance should include what information? Select one: a. The possibility of surgery, chemotherapy and radiotherapy b. The possibility of needing a short-term or long-term colostomy c. The good prognosis for clients who are treated for gastric cancer d. The benefits of weight loss and exercise as tolerated during recovery

The possibility of surgery, chemotherapy and radiotherapy

The nurse is providing client teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season? Select one: a. Wash her hands frequently b. Take preventative antibiotics, as prescribed c. Dress herself and her infant warmly d. Gargle with warm salt water regularly

Wash her hands frequently

A client in hypertensive urgency is admitted to the hospital. The nurse should be aware of what goal of treatment for a client in hypertensive urgency? a. Obtaining a BP of less than 120/80 mm Hg within 36 hours b. Normalizing BP within 24 to 48 hours c. Normalizing BP within 2 hours d. Obtaining a BP of less than 110/70 mm Hg within 36 hours

b. Normalizing BP within 24 to 48 hours

An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicate to the nurse to monitor the client for what? Select one: a. Dyspnea and hypoxemia b. Bradypnea and pursed-lip breathing c. Kyphosis and clubbing of the fingers d. Sepsis and pneumothorax

dyspnea and hypoxemia

The nurse is assessing a client who has a 35 pack-year history of cigarette smoking. In light of this known risk factor for lung cancer, what statement by the client should prompt the nurse to refer the client for further assessment? Select one: a. "Lately, I have this cough that just never seems to go away." b. "I seem to get nearly every cold and flu that goes around my workplace." c. "I find that I don't have nearly the stamina that I used to." d. "I never used to have any allergies, but now I think I'm developing allergies to dust and pet hair."

"Lastly, I have this cough that just never seems to go away."

The nurse is planning the care of a client who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, what blood pressure would be the goal of treatment? Select one: a. 120/80 mm Hg or lower b. 140/90 mm Hg or lower c. Average of two BP readings of 150/80 mm Hg d. 156/96 mm Hg or lower

140/90mmHg or lower

A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client most likely faces the highest immediate risk of oral cancer? Select one: a. A 32-year-old man who is obese and uses smokeless tobacco b. A 65-year-old man with alcoholism who smokes c. A 57-year-old man with GERD and dental caries d. A 45-year-old woman who has type 1 diabetes and who wears dentures

A 65yo man with alcoholism who smokes

The nurse provides care for several clients who have obesity. Which client's obesity is most likely to resolve with medication? Select one: a. A client whose obesity is characterized as android rather than gynoid b. A client whose obesity has been attributed to hypothyroidism c. A client with long-standing obesity who has recently been diagnosed with type 2 diabetes d. An obese client whose parents and siblings are not obese

A client whose obesity has been attributed to hypothyroidism

A client presents to the ED reporting increasing shortness of breath. The nurse assessing the client notes a history of left-sided heart failure. The client is agitated and occasionally coughing up pink-tinged, foamy sputum. The nurse should recognize the signs and symptoms of what health problem? Select one: a. Cardiogenic shock b. Acute pulmonary edema c. Right-sided heart failure d. Pneumonia

Acute pulmonary edema

An older adult who resides in an assisted living facility has sought care from the nurse because of recurrent episodes of constipation. Which of the following actions should the nurse first perform? Select one: a. Encourage the client to take stool softener daily. b. Assess the client's surgical history. c. Assess the client's food and fluid intake. d. Encourage the client to take fiber supplements.

Assess the client's food and fluid intake

A client's plan of care specifies postural drainage. What action should the nurse perform when providing this noninvasive therapy? Select one: a. Assist the client into a position that will allow gravity to move secretions. b. Administer the treatment with the client in a high Fowler's or semi-Fowler's position. c. Perform the procedure immediately following the client's meals. d. Apply percussion firmly to bare skin to facilitate drainage.

Assist the client into a position that will allow gravity to move secretions.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication? Select one: a. Pulmonary embolism b. Acute respiratory distress syndrome (ARDS) c. Aspiration d. Atelectasis

Atelectasis

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma? Select one: a. Bradypnea b. Shallow respirations c. Increased anterior--posterior (AP) diameter d. Bilateral wheezes

Bilateral wheezes

Diagnostic imaging reveals that the quantity of fluid in a client's pericardial sac is dangerously increased. The nurse should collaborate with the other members of the care team to prevent the development of what complication? Select one: a. Pericardiocentesis b. Pericarditis c. Cardiac tamponade d. Pulmonary edema

Cardiac tamponade

While assessing a client, the client tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. The nurse should recognize the presence of: Select one: a. effusion. b. contractures. Incorrect c. fasciculations. d. clonus.

Clonus

The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this client? Select one: a. Correct and safe use of oxygen therapy equipment b. Technique for performing postural drainage c. Safe technique for self-suctioning of secretions d. How to provide safe and effective tracheostomy care

Correct and safe use of oxygen therapy equipment

A client with gastric cancer has been scheduled for a total gastrectomy. During the pre-operative assessment, the client confides in the nurse that she feels like she will be "mutilated by the surgery." The nurse should plan interventions that address what nursing diagnosis? Select one: a. Disturbed Body Image related to surgery b. Chronic Low Self-Esteem Related to surgery c. Anxiety related to surgery d. Deficient Knowledge related to risks and expectations of surgery

Deficient knowledge related to risks and expectations of surgery

The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax? Select one: a. Muffled heart sounds b. Sudden loss of consciousness c. Paradoxical chest wall movement with respirations d. Diminished or absent breath sounds on the affected side

Diminished or absent breath sounds on the affected side

An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients? Select one: a. Ensuring that clients keep their immunizations up to date b. Educating clients about recognizing and avoiding asthma triggers c. Teaching clients to utilize alternative therapies in asthma management d. Encouraging clients to carry a corticosteroid rescue inhaler at all times

Educating clients about recognizing and avoiding asthma triggers

A nurse is caring for a client who is 12 hours postoperative following foot surgery. The nurse assesses the presence of edema in the foot. What nursing measure should the nurse implement to control the edema? Select one: a. Elevate the foot on several pillows b. Apply warm compresses intermittently to the surgical area c. Increase circulation through frequent ambulation d. Administer a loop diuretic as prescribed

Elevated the foot on several pillows

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it? Select one: a. Erosion of the lining of the stomach or intestine b. Viral invasion of the stomach wall c. Inflammation of the lining of the stomach d. Bleeding from the mucosa in the stomach

Erosion of the lining of the stomach or intestine

The nurse is caring for a client who is undergoing diagnostic testing for suspected malabsorption. When taking this client's health history and performing the physical assessment, the nurse should recognize what finding as most consistent with this diagnosis? Select one: a. Recurrent constipation coupled with weight loss b. Foul-smelling diarrhea that contains fat c. Bloody bowel movements accompanied by fecal incontinence d. Fever accompanied by a rigid, tender abdome

Foul-smelling diarrhea that contains fat

A cardiologist tells a heart failure patient with slight fluid overload that "the increased volume of blood stretches the ventricular wall, causing cardiac muscle to contract more forcefully". The cardiologist is referring to________. a. Cardiomyopathy b. Pulmonary edema c. Pericardial effusion d. Frank-Starling law

Frank- Sterlings law

A medical nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice? Select one: a. Frequent handwashing reduces transmission of pathogens from one client to another. b. Waterless products should be avoided in situations where running water is unavailable. c. Bar soap is preferable to liquid soap. d. Wearing gloves is known to be an adequate substitute for handwashing.

Frequent handwashing reduces transmission of pathogens from one client to another.

A client is postoperative day 2 after bariatric surgery. The nurse's most recent gastrointestinal assessment indicates the return of bowel sounds. How should the nurse best promote the client's nutritional status? Select one: a. Provide soft, calorie-dense foods for the next 24 hours and reassess b. Resume providing three nutritious meals a day and emphasize the need for the client to report GI symptoms c. Provide the client with a small snack and then increase the quantity of food by 10% per meal until normal intake is resumed d. Give the client six small meals a day and encourage fluid intake, as tolerated

Give the client six small meals a day and encourage fluid intake, as tolerated

A client is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The client has an open fracture on his tibia. The wound is highly contaminated and there is extensive soft tissue damage. How would this client's fracture likely be graded? Select one: a. Grade IV b. Grade I c. Grade III d. Grade II

Grade III

A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension: Select one: a. does not normally cause target organ damage. b. has a specific cause. c. does not normally respond to antihypertensive drug therapy. d. has a more gradual onset than primary hypertension.

Has a specific cause

The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery? Select one: a. Hemorrhage b. Difficulty ambulating c. Bradycardia d. Infrequent swallowing

Hemorrhage

A clinic client has described recent dark-colored stools and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT? Select one: a. Recurrent nausea and vomiting b. Hemorrhoids c. Peptic ulcers d. Gastroesophageal reflux disease (GERD)

Hemorrhoids

An asthma educator is teaching a client newly diagnosed with asthma and her family about the use of a peak flow meter. The educator should teach the client that a peak flow meter measures what value? Select one: a. Highest airflow during a forced expiration b. Highest airflow during a forced inspiration c. Airflow during a normal inspiration d. Airflow during a normal expiration

Highest airflow during a forced expiration

The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer? Select one: a. Dyspnea b. Frequent nosebleeds c. Dysphagia d. Hoarseness

Hoarseness

A nurse is taking a health history on a new client who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the client's altered sensations? Select one: a. Does the client have a family history of paresthesia or other forms of altered sensation? b. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity? c. Does the color in the affected extremity match the color in the unaffected extremity? d. How does the strength in the affected extremity compare to the strength in the unaffected extremity?

How does the feeling in the affected extremity compare with the feeling in the unaffected extremity.

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client? Select one: a. "The body requires an acidic environment in order to synthesize pancreatic digestive enzymes; the stomach provides this environment." b. "As digestion occurs in the stomach, the stomach combines free hydrogen ions from the food to form acid." c. "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." d. "The acidic environment in the stomach exists to buffer the highly alkaline environment in the esophagus."

Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food

A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? Select one: a. Preventing the need for suctioning b. Increasing the client's lung compliance c. Maintaining the sterility of the client's airway d. Maintaining a patent airway

Maintaining a patent airway

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem? Select one: a. Septic arthritis b. Osteomyelitis c. Osteomalacia d. Osteoporosis

Osteomyelitis

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis? Select one: a. Hematogenous osteomyelitis b. Osteomyelitis with vascular insufficiency c. Osteomyelitis with muscular deterioration d. Contiguous focus osteomyelitis

Osteomyelitis with vascular insufficiency

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. How should the nurse best assess whether the client is hypoxemic? By monitoring the client's: Select one: a. extremities for signs of cyanosis. b. oxygen saturation level. c. level of consciousness (LOC). d. hemoglobin, hematocrit, and red blood cell levels. Feedback

Oxygen saturation level

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2°F) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next? Select one: a. Test the integrity of cranial nerve XII by asking the client to protrude the tongue. b. Assess the temporomandibular joint for evidence of a malocclusion. c. Palpate the client's parotid glands to detect swelling and tenderness. d. Inspect the client's gums for bleeding and hyperpigmentation.

Palpate the clients parotid glands to detect swelling and tenderness

A nurse is caring for a 6-year-old client with cystic fibrosis. In order to enhance the child's nutritional status, what intervention should most be included in the plan of care? Select one: a. Provision of five to six small meals per day rather than three larger meals b. Total parenteral nutrition (TPN) c. Pancreatic enzyme supplementation with meals d. Magnesium, thiamine, and iron supplementation

Pancreatic enzyme supplementation with meals

A client with diabetes is attending a class on the prevention of associated diseases. What action should the client perform to reduce the risk of osteomyelitis? Select one: a. Exercise 3 to 4 times weekly for at least 30 minutes b. Perform meticulous foot care c. Take corticosteroids as prescribed d. Increase calcium and vitamin intake

Perform meticulous foot care

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? Select one: a. Gastritis b. Gastroesophageal reflux c. Acute pancreatitis d. Peritonitis

Peritonitis

The nurse's comprehensive assessment of a client includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages? Select one: a. Diffuse inflammation of the buccal mucosa b. Presence of a painless sore with raised edges c. Dull pain radiating to the ears and teeth d. Areas of tenderness that make chewing difficult

Presence of a painless sore with raised edges

A nurse is caring for a client who has undergone neck resection with a radial forearm free flap. The nurse's most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurse's most appropriate action? Select one: a. Promptly report these indications of venous congestion. b. Document the findings as being consistent with a viable graft. c. Reposition the client to promote peripheral circulation. d. Closely monitor the client and reassess in 30 minutes.

Promptly report these indications of venous congestion

A cardiovascular client with a previous history of pulmonary embolism (PE) is experiencing a sudden onset of dyspnea, rapid breathing, and chest pain. The nurse recognizes the characteristic signs and symptoms of a PE. What is the nurse's best action? a. Arrange for an ECG b. Manage the client's anxiety c. Increase the height of the client's bed d. Rapidly assess the client's cardiopulmonary status

Rapidly assess the client's cardiopulmonary status

A client has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the client to describe what sign or symptom? Select one: a. Regurgitation of undigested food b. Burning pain on swallowing c. Chronic parotid abscesses d. Symptoms mimicking a myocardial infarction

Regurgitation of undigested food

A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD? Select one: a. Hemothorax b. Pneumothorax c. Respiratory failure d. Lung cancer

Respiratory failure

A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of what? Select one: a. Hypertensive emergency b. Retinal blood vessel damage c. Glaucoma d. Cranial nerve damage

Retinal blood vessel damage

A client on the medical unit is found to have pulmonary tuberculosis (TB). What is the most appropriate precaution for the staff to take to prevent transmission of this disease? Select one: a. Standard and airborne precautions b. Standard and contact precautions c. Standard precautions only d. Droplet precautions

Standard and airborne precautions

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis? Select one: a. The focus of care is resting the voice to prevent chronic hoarseness. b. The client should be preliminarily screened for surgery. c. Teaching focuses on safe and effective use of antibiotics. d. Symptom management is the main focus of medical and nursing care

Symptom management is the main focus of medical and nursing care

The nurse is educating an 80-year-old client diagnosed with heart failure about his medication regimen. What should the nurse teach this client about the use of oral diuretics? Select one: a. Avoid drinking fluids for 2 hours after taking the diuretic b. Take the diuretic only on days when experiencing shortness of breath c. Avoid taking the medication within 2 hours consuming dairy products d. Take the diuretic in the morning to avoid interfering with sleep

Take the diuretic in the morning to avoid interfering with sleep

The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment? Select one: a. The client's respiratory status requires a system that provides an FiO2 of 65%. b. The client desires a portable oxygen delivery system that can deliver 2 L/min. c. The client requires a high-flow system for use with a tracheostomy collar. d. The client desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min.

The client desires a portable oxygen delivery system that can deliver 2L/min

The nurse is assessing a client who has a chronic pain disorder and who also has class II obesity. What principle should guide the care team's choice of pain treatments for this client? Select one: a. The client may require higher doses of opioids than clients without obesity b. Adverse effects of opioids may be more difficult to assess than in clients without obesity c. The client is more likely to experience relief with NSAIDs than with opioids d. The client's renal function must be monitored more closely during pain treatment than clients without obesity

The client may require higher doses of opioids than clients without obesity

The nurse is assessing an older adult client with numerous health problems. What assessment datum indicates an increase in the client's risk for heart failure? Select one: a. The client's age is greater than 75. b. The client is an African-American man. c. The client's potassium level is 4.7 mEq/L. d. The client takes furosemide 20 mg/day.

The client's age is greater than 75

A client with a recent history of intermittent bleeding is undergoing capsule endoscopy to determine the source of the bleeding. When explaining this diagnostic test to the client, what advantage should the nurse describe? Select one: a. The test allows for painless biopsy collection. b. The test is noninvasive. c. The test allows visualization of the entire peritoneal cavity. d. The test does not require fasting.

The test is noninvasive

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? Select one: a. To monitor bleeding around the lungs b. To assist with mechanical ventilation c. To remove air from the pleural space d. To drain copious sputum secretions

To remove air from the pleural space

A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe? Select one: a. Face tent b. Tracheostomy collar c. Venturi mask d. Non-rebreather air mask

Venturi mask

A nurse's assessment reveals that a client with COPD may be experiencing bronchospasm. What assessment finding would suggest that the client is experiencing bronchospasm? Select one: a. Reduced respiratory rate or lethargy b. Wheezes or diminished breath sounds on auscultation c. Fine or coarse crackles on auscultation d. Slow, deliberate respirations and diaphoresis

Wheezes or diminished breath sounds on auscultation

A client recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the client? Select one: a. Assure the client that everything will be all right and that remaining calm is the best strategy. b. Ask a family member to interpret what the client is trying to communicate. c. Ask the physician to wean the client off the mechanical ventilator to allow the client to speak freely. d. Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board.

d. Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board.

A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication? Select one: a. Venous thromboembolism (VTE) b. Bleeding at the injury site c. Inadequate immobilization d. Inadequate vitamin D intake

inadequate immobilization