Practice Questions for Renal, Reproductive, Integumentary, Geriatrics
2.The fastest growing group of older adults are those age 85+. (T/F)
true
4. Using the parkland formula, calculate the hourly rate of fluid replacement with lactated ringers solution during the first 8 hours for a client weighing 75 kg with total body surface area burn of 40%. Record your answer using a whole number:
750 mL/hr
4.A nurse is providing dietary teaching to a client who has chronic kidney disease (CKD).The nurse should instruct the client to limit which of the following nutrients? (Select all that apply.) A. Protein B. Calcium C. Calories D. Phosphorous E. Sodium
a, d, e -Protein is correct. A client who has CKD should restrict protein intake to prevent uremia that can develop as a result of the kidneys' inability to remove the waste products of protein.Calcium is incorrect. A client who has CKD is at risk for hypocalcemia due to an alteration in the conversion of vitamin D by the kidneys.Calories is incorrect. A client who has CKD requires adequate calories to meet metabolic needs.Phosphorous is correct. A client who has CKD is at risk for hyperphosphatemia due to a reduction in excretion of phosphorous by the kidneys.Sodium is correct. A client who has CKD is at risk for hypernatremia, edema, and hypertension due to sodium retention.
7. The nurse is discharging a client who just had cataract removal and intraocular lens implantation. The nurse is condiment the client understands discharge instructions when the client states the following. Select all that apply a. I understand the schedule for my eyedrops and will use the medications b. I feel good and am ready to drive home now c. I will call in the morning if I cannot see clearly d. I will wear the eye shield at night to protect my eye e. I will avoid lifting or pulling anything over 15 lbs f. I will call if I still have eye pain after taking acetaminophen
a, d, e, f
11.A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? A. The burned area is black in color and pain is absent. B. The burned area is pink in color with blisters present. C. The burned area is red in color with eschar present. D. The burned area is yellow in color with severe edema.
c -This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.
15.A nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make? A. "Yes, you are free to move around as you wish." B. "No, you are on strict bedrest and must not be up." C. "Please ring for assistance when you wish to get out of bed." D. "We will have to get a prescription from your provider."
c -This response is appropriate. With assistance, the client can ambulate safely. Tinnitus, one-sided hearing loss, and vertigo are all manifestations of Ménière's disease that can increase the client's risk of falls when ambulating.
17.A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A. Urinary retention B. Low back pain C. Incontinence D. Confusion
d -Confusion is a clinical finding of UTIs specifically associated with older adult clients.
15. To approach a deaf client, what should the nurse do first? a. Knock on the room's door loudly b. Close and open the vertical blinds rapidly c. Talk while walking into the room d. Get the client's attention
d
9. After cataract removal surgery, the client is instructed to report sharp pain in the operative eyes because this could indicate which postoperative complication? a. Detached retina b. Prolapse of the iris c. Extracapsular erosion d. Intraocular hemorrhage
d
1.Most falls in older adults occur in a health-care institution. (T/F)
false -at home
30.A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
1140 ml
35.A nurse is preparing to administer 0.9% sodium chloride 1,000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
125 ml/hr
31.A nurse is preparing to administer 0.9% sodium chloride (NSS) 3000 mL IV to infuse over 24 hr. The drop factor on the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
21 gtt/min
33.A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
24 ml/hr
32.A nurse is preparing to administer lactated Ringer's 400 mL IV bolus to infuse over 3 hr. The drop factor of the manual IV tubing is 20 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
44 gtt/min
34.A nurse is preparing to administer cefazolin IVPB over 20 min. Available is cefazolin 1 g in 100 mL of dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
75 gtt/min
10. The client is diagnosed with a detached retina in the right eye. What should the nurse do first? a. Apply compresses to the eye b. Instruct the client to lie prone c. Remove all bed pillows d. Promote measures that limit mobility
d
10. The nurse is planning a presentation about ovarian cancer to a group of women. Which topic should receive priority attention in the lesson plan? a. Ovarian cancer signs and symptoms are often vague until late in development b. Ovarian cancer should be considered in any woman older than 30 years of age c. A rigid board-like abdomen is the most common sign d. Methods for early detection have made a dramatic reduction in the mortality rate due to ovarian cancer
a
3. The nurse is performing a digital rectal examination. Which finding is a key sign for prostate cancer? a. A hard prostate, localized or diffuse b. Abdominal pain c. A boggy, tender prostate d. A nonindurated prostate
a
5. The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened, but not broken. The reddened area continues to blanch and refill with fingertip pressure. What is the most appropriate nursing action? a. Reposition the client off the reddened skin and reassess in a few hours b. Apply a moist to moist dressing, being careful to pack just the wound bed c. Consult with a wound-ostomy-continence nurse specialist d. Complete and document a Braden skin breakdown risk score for the client
a
6. Following a simple mastectomy, the nurse is totaling the amount of drainage in 24 hours from a suction drain in the incision. The nurse notes there is 200 mL of serosanguineous drainage for the first 24 hours. What action should the nurse take? a. Document the findings b. Notify the surgeon c. Remove the drain d. Place the client's arm in a dependent position
a
8. A female with uterine fibroids has dysmenorrhea and menorrhagia. After reviewing the laboratory reports, the nurse should report which results to the healthcare provider? a. Hematocrit 27.1% b. White Blood Cell 10,000 cells/mm3 c. Potassium 4.0 d. Normocytic red blood cells
a
8. The nurse is instructing the client about postoperative care following cataract removal. What position should the nurse teach the client to use? a. Remain in a semi-fowlers position b. Position the feet higher than the body c. Lie on the operative side d. Place the head in a dependent position
a
An 86-year old patient is admitted to the hospital from a nursing home. The nurse established a nursing diagnosis of fluid volume deficit related to decreased intake and fever. Which of the following symptoms would support this nursing diagnosis? A.The patient's pulse is 120, BP 90/60, temperature 101.2 degrees F, respirations 22 and deep. B.The patient has difficulty breathing in a low Fowler's position or with minimal activity. C.The patient's skin is pale and cool to touch with pitting edema in dependent areas. D.The patient complains of headache and appears lethargic.
a
Poorly controlled diabetes mellitus is a potential cause of reversible urinary incontinence primarily caused by which of the following mechanisms? A.Increased urinary volume B.Increased candidiasis and UTI risk C.Irritating effect of increased glucose in the urine D.Decreased ability to perceive need to void
a
21.A nurse is reviewing the provider's history and physical form for a client who has advanced multiple myeloma. Which of the following findings should the nurse expect? A. Ecchymoses B. Hypocalcemia C. Hypotension D. Polycythemia
a -A client who has multiple myeloma has an overgrowth of plasma cells in the bone marrow, which leads to a reduction in other types of blood cells. As the platelets are affected, the client is prone to bleeding and bruising.
13.A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds
a -A reddened area over bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.
9.A nurse is caring for a client who has a stage 3 pressure ulcer. The nurse should recognize that which of the following laboratory findings will affect wound healing? A. Serum albumin 3.2 g/dL B. Hemoglobin 16 g/dL C. WBC count 8,000/mm3 D. PTT 1.8
a -A serum albumin level is a good indicator of the nutritional status of a client. A value less than 3.5 g/dL is an indication of poor nutrition, can delay wound healing, and lead to infection
3.A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide? A. "This infection is treated with one dose of azithromycin." B. "If your sexual partner has no symptoms, no medication is needed." C. "You have to avoid sexual relations for 3 days." D. "You need to return in 6 months for retesting."
a -A single dose of azithromycin is an appropriate treatment for a chlamydial infection. An acceptable alternative is doxycycline twice a day for 7 days.
17.A nurse is caring for a client who has a stage I pressure ulcer. Which of the following dressings should the nurse plan to apply? A. Transparent dressing B. Wet-to-dry gauze dressing C. Hydrogel dressing D. Alginate dressing
a -A stage I pressure ulcer involves only the epidermal skin. A transparent dressing protects the ulcer from moisture and bacteria while allowing oxygen to reach the skin. This dressing also minimizes friction and shear on the ulcerated area.
16.A nurse is planning care for a client who has acute glomerulonephritis. Which of the following interventions should the nurse include in the plan? A. Administer antibiotics. B. Encourage increased fluid intake. C. Obtain weight weekly. D. Encourage frequent ambulation.
a -Acute glomerulonephritis related to a streptococcal infection is treated with antibiotic therapy, including penicillins and erythromycin.
11.A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction? A. "I will clean the hearing aids with alcohol wipes." B. "I will not use hairspray if I am wearing the hearing aids." C. "I will change the batteries once a week." D. "I will expect the hearing aids to whistle when I cup my hand over them."
a -Alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water.
12.A nurse is teaching a client who has a new diagnosis of genital herpes. Which of the following statements by the client indicates the need for further teaching? A. "Transmission of the disease will not occur when my lesions are gone." B. "Abstaining from sexual activity reduces the risk of transmission of the disease." C. "The use of condoms will reduce the risk of transmission." D. "Antiviral medications will not cure the infection."
a -Although the client might be asymptomatic during viral shedding, he is contagious and can transmit the genital herpes.
19.A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include? A. Basal cell carcinoma has a low incidence of metastasis. B. Basal cell carcinoma has a high mortality rate. C. Basal cell carcinoma is aggressive and rapid growing. D. Basal cell carcinoma develops from a nevi or mole.
a -Basal cell carcinoma is a localized lesion that seldom metastasizes.
13.A nurse is caring for a client who has right-sided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take? A. Place suction equipment at the client's bedside. B. Apply an eye patch to the client's right eye. C. Avoid the use of warm water to wash the client's face. D. Provide range-of-motion exercises to the client's neck and shoulders.
a -Cranial nerves IX (glossopharyngeal) and X (vagus) innervate the muscles of the soft palate, larynx, and pharynx. Impairment of these nerves places the client at risk for aspiration, making it necessary for the nurse to have access to suction for the client.
23.A nurse is assessing a client who presents to the provider's office for evaluation of multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? A. Irregular borders B. Purulent drainage C. Uniform pigmentation D. Intense pruritus
a -Findings associated with malignant changes in a nevus include asymmetry, irregular borders, non-uniform pigmentation, and increased diameter.
15.A nurse is caring for a client who has polycystic kidney disease (PKD). Which of the following findings should the nurse expect? A. Flank pain B. Hypotension C. Confusion D. Urinary retention
a -Flank pain is a finding associated with PKD
8.A nurse is speaking with a 35-year-old client who has fibrocystic disease of the breasts. At which of the following times should the nurse inform the client that manifestations are most evident? A. Before menstruation begins B. After menstruation ends C. During cold weather D. During hot weather
a -Manifestations of benign fibrocystic breast changes include painful breasts, smooth moveable lumps, and possible swelling of the breasts, which tends to worsen premenstrually. Reducing salt and caffeine intake sometimes helps.
6.A nurse is planning care for a client who has a detached retina and is preoperative for a surgical repair. The nurse should prepare to administer which of the following medications? A. Phenylephrine B. Latanoprost C. Pilocarpine D. Timolol
a -Mydriatic medications, such as phenylephrine, are used preoperatively to dilate pupils to facilitate intraocular surgery.
22.A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention? A. Daily weight B. Sodium level C. Tissue turgor D. Intake and output
a -Obtaining a client's daily weight and comparing it to previous weights is a reliable method for measuring a client's fluid volume over time.
1.A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear
a -Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear.
3.A school nurse identifies that a child has pediculosis capitis and educates the child's parents about the condition. Which of the following statements by the parents indicates an understanding of the teaching? A. "All recently used clothing, bedding, and towels must be washed in hot water." B. "My child must be free from nits before returning to school." C. "I will treat all the family members to be on the safe side." D. "Toys that can't be dry cleaned or washed must be thrown out."
a -Pediculosis capitis is commonly referred to as head lice. All recently used clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. Unwashable items can include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals. Furniture, carpets, and car seats can be sprayed with a variety of over-the-counter products.
4.A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? A. Protein B. Calcium C. Vitamin B1 D. Vitamin D
a -Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.
7.A nurse is teaching a group of nursing students about pyelonephritis. Which of the following statements should the nurse include in the teaching? A. "Pyelonephritis increases a pregnant woman's risk for preterm labor." B. "Pyelonephritis is most often caused by Staphylococcus saprophyticus." C. "Pyelonephritis is an infection of the lower urinary tract." D. "Pyelonephritis often causes no symptoms in affected clients."
a -Pyelonephritis is a serious complication of pregnancy that can lead to preterm labor.
12.A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect? A. Vertigo B. Dysphagia C. Diplopia D. Apraxia
a -The nurse should expect a client who has an acoustic neuroma, a benign tumor of cranial nerve VIII, to manifest mild to moderate vertigo as time progresses.
29.A nurse is assessing a client who has end-stage kidney disease and is receiving hemodialysis. Which of the following findings should the nurse identify as an indication the client is experiencing fluid overload? A. The client has a 5 lb weight gain since yesterday. B. Flattened neck veins C. Oxygen saturation 93% D. Return of skin to previous position when the client's shin is palpated
a -The nurse should identify that a gain of 2 lb per day is stable. A gain of more than 2 lb per day or 5 lb per week is an indication of fluid overload.
26.A nurse is teaching a client who has herpes simplex virus type 2 about disease transmission. Which of the following statements by the client indicates understanding of the teaching? A. "Itching or tingling occurs at the site where a blister forms." B. "It is okay to share towels as long as it belongs to a family member." C. "It is not contagious after the blisters rupture." D. "I will take medication daily to prevent more sores."
a -The nurse should instruct the client that itching or tingling will occur 1 to 2 days before the blister appears in herpes simplex virus type 2.
23.A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? A. The nurse separates the client's labia with her dominant hand. B. The nurse coats the indwelling urinary catheter with lubricant. C. The nurse provides perineal care prior to inserting the urinary catheter. D. The nurse applies the sterile drape prior to inserting the urinary catheter.
a -The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.
7.A nurse is caring for a client who is immobile. Which of the following actions is the priority for the nurse to include in the client's plan of care? A. Auscultate breath sounds at least every 2 hr. B. Perform range-of-motion (ROM) exercises at least two to three times daily. C. Make sure the client has an intake of 2,000 to 3,000 mL of fluid per day. D. Apply antiembolic stockings.
a -The priority action the nurse should contribute to the plan of care when using the airway, breathing, circulation approach to client care is auscultating breath sounds to determine the client's need for suctioning. With inactivity, secretions can pool in the airways, diminishing breath sounds and causing crackles and dyspnea.
26.A nurse is reviewing a client's lab results. Which of the following lab values should the nurse report to the provider? A. Sodium 126 mEq/L B. Potassium 3.6 mEq/L C. Magnesium 1.9 mEq/L D. Chloride 99 mEq/L
a -Therapeutic sodium level is 136 to 145 mEq/L. Low sodium values can be seen with dehydration, use of diuretics, adrenal insufficiency, and water toxicity. Sodium is essential for maintaining acid-base balance and conduction of nerve and muscles tissue. Hyponatremia is a net gain of water or loss of sodium that results in a sodium level less than 136 mEq/L. Manifestations of hyponatremia include headache, confusion, lethargy, muscle weakness, fatigue, decreased deep-tendon reflexes, and seizures.
22.A nurse is assessing a client who reports a nevus that has increased in size and an irregularly shaped lesion that varies in color. These findings are consistent with which of the following medical diagnoses? A. Malignant melanoma B. Basal cell carcinoma C. Squamous cell carcinoma D. Kaposi's sarcoma
a -These findings are consistent with malignant melanoma, which is associated with changes in preexisting nevi.
1.A nurse is assessing the respiratory pattern of an older adult client who is receiving end-of-life care. Which of the following assessment findings should the nurse identify as Cheyne-Stokes respirations? A. Breathing ranging from very deep to very shallow with periods of apnea B. Shallow to normal breaths alternating with periods of apnea C. Rapid respirations that are unusually deep and regular D. An inability to breathe without dyspnea unless sitting upright
a -This describes Cheyne-Stokes respirations, an indication that the client is approaching death.
19.A nurse is teaching a client about the adverse effects of cisplatin. Which of the following adverse effects should the nurse include in the teaching? A. Tinnitus B. Constipation C. Hyperkalemia D. Weight gain
a -Tinnitus and hearing loss are adverse effects of cisplatin.
6.A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Use a transfer device to lift the client up in bed. B. Apply cornstarch to keep sensitive skin areas dry. C. Massage the skin over the client's bony prominences. D. Elevate the head of the bed no more than 45°
a -Using a lifting device prevents dragging the client's skin across the bed linens, which can cause abrasions.
2.A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
a -When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
5.A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching? A. "I will need to wipe my perineal area from back to front after urination." B. "I will need to empty my bladder regularly and completely." C. "I will need to drink apple cider vinegar each day." D. "I need to drink 8 cups of liquid each day."
a -Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.
A nurse is teaching a group of older adults about normal changes in the eye related to aging. Which of these statements about eye changes and aging, if made the nurse, is true? A."Depth perception decreases." B."The pupil of the eye dilates more quickly in low light." C."There is increased color perception." D."There is increased peripheral vision with advancing age."
a -presbyopia
4. The nurse is teaching a client about prostate cancer. Which points should be included in the instruction? Select all that apply. a. Prostate cancer is usually multifocal and slow b. Most prostate cancers are adenocarcinoma c. The incidence of prostate cancer is higher in men of African descent, and the onset is earlier d. A prostate-specific antigen (PSA) lab test >4 ng/mg will need to be monitored e. Cancer cells are detectable in the urine
a, b, c
6.A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "Your provider might prescribe anticholinergic medications." B. "You should limit fluids in the evening." C. "You should restrict your intake of caffeine." D. "You might require intermittent urinary catheterization." E. "You might require an anterior vaginal repair."
a, b, c -"Your provider might prescribe anticholinergic medications" is correct. Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" is correct. Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" is correct. The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant. "You might require intermittent urinary catheterization" is incorrect. Intermittent urinary catheterization is used as a treatment for reflex incontinence. "You might require an anterior vaginal repair" is incorrect. An anterior vaginal repair, or colporrhaphy, is a surgical procedure for the treatment of stress incontinence.
7. A client develops lymphedema after a left mastectomy with lymph node dissection. The nurse should include which points in the discharge teaching plan? Select all that apply. a. Do not allow blood pressures or blood draws in the affected arm b. Avoid application of sunscreen on the left arm c. Use an electric razor for shaving d. Immobilize the left arm e. Elevate the left arm f. Perform hand pump exercises
a, c, e, f
12. Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do? a. Have the client lie on the left side b. Pull the auricle lobe up and back c. Pull the ear lobe down and back d. Chill the eardrops prior to administering
b
14. A 75-year-old client who has been taking furosemide regularly for 4 months tells the nurse about having trouble hearing. What should the nurse do? a. Tell the client that at age 75 years, it is inevitable that there will be hearing loss b. Report the hearing loss to the healthcare provider c. Schedule the client for audiometric testing and a hearing aid d. Tell the client that the hearing loss is only temporary; when the body adjusts to the furosemide, hearing will improve
b
3. In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? a. Oral analgesics such as ibuprofen or acetaminophen b. Intravenous opioids c. Intramuscular opioids d. Oral antianxiety agents such as lorazepam
b
5. A right orchiectomy is performed on a client with a testicular malignancy. The client expresses concerns regarding his sexuality. The nurse should base the response on the knowledge that the client: a. Is not a candidate for sperm banking b. Should retain normal sexual drive and function c. Will be impotent d. Will have a change in secondary sexual characteristics
b
A nurse is conducting an initial assessments for a newly-admitted 85-year old female patient. The nurse documents that the patient demonstrates "significant kyphosis." The nursing student should know that this means that the: A.Patient demonstrates mild hemiplegia when walking. B.Patient's spine has slowly collapsed due to microfractures. C.Patient will need a wheelchair for mobility. D.Patient will be incontinent of urine.
b
Medications used to treat urge incontinence and overactive bladder (e.g., Ditropan, Detrol, Vesicare) usually have anticholinergic and antimuscarinic effects that can lead to problems in older adults including: A.Tachycardia and hypertension B.Sedation and dry mouth C.Loose stools and loss of appetite D.Agitation and excessive saliva production
b
18.During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? A. Squamous cell carcinoma B. Basal cell carcinoma C. Malignant melanoma D. Actinic keratosis
b -A basal cell tumor usually begins as a small, waxy nodule with rolled, translucent, pearly borders. Telangiectatic vessels can also be present. As a basal cell tumor grows, it can undergo central ulceration.
12.A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take? A. Apply dry, sterile gauze dressings to affected areas. B. Prepare to administer acyclovir. C. Instruct family members with a history of chickenpox that they are still at risk for contracting the virus. D. Apply topical corticosteroids to the affected areas.
b -Acyclovir is effective in the treatment of herpes zoster especially if administered within 24 hr of the eruption.
25.A nurse is teaching a client who has a new prescription for ciprofloxacin to treat an uncomplicated UTI. Which of the following instructions should the nurse include? A. "Take this medication with an antacid." B. "Monitor for tendon pain." C. "Drink 1,000 milliliters of fluid daily." D. "Expect urine to turn dark orange."
b -Ciprofloxacin can cause tendinitis and tendon rupture. The client should monitor and report tendon pain or inflammation.
19.A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? A. COPD B. Diabetes mellitus C. Anemia D. ?Osteoporosis
b -Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.
14.A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer? A. Danazol B. Finasteride C. Fluoxymesterone D. Methyltestosterone
b -Finasteride, a 5-alpha-reductase inhibitor, is used in the treatment of BPH to prevent the conversion of testosterone and to decrease prostate size.
12.A nurse is assessing an older adult client who has experienced some loss of bone density. The nurse observes a "hunchback" curvature of the client's spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis D. Ankylosis
b -Kyphosis, a forward, "hunchback" curvature of the spine, is an abnormal angulation of the posterior curve of the thoracic spine resulting from multiple compression fractures, usually a result of osteoporosis. It is most common in older adults and tends to increase with aging.
15.A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin. Which of the following adverse effects should the nurse include in the teaching? A. Temporary loss of libido. B. Dizziness. C. Bradycardia D. Burning with urination
b -Lightheadedness or dizziness is likely with the first several doses. Clients should be taught to rise slowly and carefully from lying or sitting positions until the sensation disappears.
2.A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis? A. Hyperactive bowel sounds B. Nausea and vomiting C. Bradycardia D. Increased urinary output
b -Peritonitis is an inflammation of the peritoneum and is a potential complication of peritoneal dialysis. The nurse should monitor the client for manifestations such as abdominal tenderness or pain, anorexia, nausea, vomiting, restlessness, and confusion.
4.A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome. The nurse should plan to monitor which of the following laboratory values? A. BUN B. Glucose C. Liver function D. Thyroid-stimulating hormone
b -Polycystic ovarian syndrome is a disease in which many estrogen producing cysts develop on the ovaries. Manifestations include irregular menstruation, hyperinsulinemia, and glucose tolerance dysfunction. The nurse should anticipate that the client will require a glucose test to monitor for type 2 diabetes mellitus.
4.A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk? A. Electrical cords are placed along the walls. B. Scatter rugs are present in the kitchen. C. Handrails are present in the bathroom. D. Uses a microwave for cooking.
b -Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision.
8.A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma? A. Painless, raised purple nodules on the hard palate B. A firm nodule with a hard crust C. A small macule with a yellow-brown scale D. Yellow-white patches of growth on the tongue
b -Squamous cell carcinoma appears as a firm nodule, which can either have a crust or a depressed area in the center. The margins are indurated, and the lesion is fixed to the deeper tissue of the area.
9.A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect? A. Anuria B. Influenza-like symptoms C. White- or flesh-colored papillary growths in the genital area D. Green penile discharge
b -Symptoms of genital herpes develop 3 to 7 days after skin-to-skin contact with an infected person. The nurse should expect the client to have influenza-like symptoms, along with genital herpes lesions which appear as small blisters on the genitals. Other symptoms can include painful urination, vaginal discharge, and enlarged lymph nodes in the groin.
9.A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? A. "I'll urinate a little then stop." B. "I'll use the cleansing wipe from front to back." C. "I'll clean the inside of the container with a wipe." D. "I'll use each cleansing wipe twice."
b -The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.
21.A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no-salt-added diet. B. Check the child's daily weight. C. Educate the parents about potential complications. D. Maintain a saline-lock.
b -The first action the nurse should take using the nursing process is to assess the child. Therefore, checking the child's weight daily is the priority.
2.A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? A. Document the bruises in the client's chart. B. Report the findings to a supervisor. C. Provide the client with a crisis hotline number. D. Discuss respite care with the client's family.
b -The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.
18.A nurse is assessing a client in the oliguric phase of acute kidney injury. Which of the following findings should the nurse expect? A. Decreased creatinine level B. Hyperkalemia C. Hypomagnesaemia D. Increased glomerular filtration rate (GFR)
b -The nurse should expect the client to have an increase in the serum concentration of potassium during the oliguric phase. Potassium can rise to a life-threatening level during this phase and should be monitored closely.
27.A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? A. Omeprazole B. Vancomycin C. Ondansetron D. Diphenhydramine
b -The nurse should identify that vancomycin, an antibiotic, to be associated with nephrotoxic adverse effects.
11.The nurse is planning an educational program on sildenafil to a group of older male clients. Which of the following information should the nurse include in the educational program? A. Swallow the medication with grapefruit juice to improve the action. B. Ingestion of the medication with nitrates causes hypotension. C. Take the medication 2 hr prior to sexual activity. D. Consume a high-fat meal to increase the medication absorption.
b -The nurse should include in the teaching to take nitrates with sildenafil may cause severe hypotension due to the vasodilation effect of each medication and is not recommended.
2.A nurse is reviewing discharge instructions with a client following a right cataract extraction. Which of the following instructions should the nurse include? A. Sleep on the abdomen to facilitate wound healing. B. Avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week. C. Bend at the waist to pick objects up from the floor. D. Notify the surgeon if white drainage develops on the eyelids.
b -The nurse should instruct the client to avoid activities that increase intraocular pressure. Therefore, the nurse should instruct the client to avoid lifting anything heavier than 4.5 kg (10 lb) for 1 week following surgery.
8.A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? A. "Take aspirin for discomfort." B. "Restrict lifting objects greater than 10 pounds." C. "Expect reduced vision for 48 hours after procedure." D. "Apply warm compresses for discomfort."
b -The nurse should instruct the client to restrict lifting objects greater than 10 lb to reduce the risk for increased intraocular pressure.
5.A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? A. Call the family and ask them to stay with the client. B. Move the client to a room closer to the nurses' station. C. Apply wrist and leg restraints to the client. D. Administer medication to sedate the client.
b -This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.
14.A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25 mL/hr B. Difficulty swallowing C. Heart rate 122/min D. Pain of 6 on a scale of 0 to 10
b -Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is difficulty swallowing as this is can be an indication that the client's airway is obstructed.
1.A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. BP B. Heart rate C. Urine output D. Weight
b -When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
13. The risk for injury during an attack of Meniere's Disease is high. The nurse should instruct the client to take which immediate action when experiencing vertigo? a. Place your head between your knees b. Concentrate on rhythmic deep breathing c. Close your eyes tightly d. Assume a reclining or flat position
d
25.A nurse is caring for a client who has shingles with multiple skin lesions. Which of the following actions by the nurse require intervention by the nurse's supervisor? A. The nurse wears an N95 respirator mask. B. The nurse admits another client who has shingles to the client's double room. C. The nurse wears gloves when providing direct care to the client. D. The nurse wears a gown when bathing the client.
b -When a private room is not available, clients who are infected with the same organism may be placed together in a double room. However, cohorting is reserved for clients who both require droplet precautions. This client should be in a private room.
6.A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is not recommended due to which of the following findings in the client's medical history? A. History of dermatitis B. History of breast cancer C. Multiple hospitalizations for COPD D. Concurrent treatment for GERD
b -Women with a history of breast cancer should be counseled against using HT.
6. A client has a wound on the ankle that is not healing. The nurse should assess the client for which risk factors for delayed wound healing? Select all that apply. a. Atrial fibrillation b. Advancing age c. Type 2 diabetes mellitus d. Hypertension e. Smoking
b, c, e
3.A nurse is teaching a client who has chronic kidney disease about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.) A. Green Beans B. Tomatoes C. Bananas D. Asparagus E. Raisins
b, c, e -Green beans are incorrect. Green beans are not high in potassium and can be eaten by a client who is on a potassium-restricted diet.Tomatoes is correct. Tomatoes are high in potassium and should be avoided by a client who is on a potassium- restricted diet.Bananas is correct. Bananas are high in potassium and should be avoided by a client who is on a potassium-restricted diet.Asparagus is incorrect. Asparagus is safe to eat by a client who is on a potassium-restricted diet.Raisins is correct. Raisins are high in potassium and should be avoided by a client who is on a potassium-restricted diet.
1. The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first and second degree burns on 10% of the body surface area). What should the nurse do first? a. Clean the wounds with warm water b. Apply antibiotic cream c. Refer the client to a burn center d. Cover the burns with a sterile dressing
c
11. A client uses timolol maleate eyedrops. The expected outcome of this drug is to control glaucoma by: a. Constricting the pupils b. Dilating the canals of Schlemm c. Reducing aqueous humor formation d. Improving the ability of the ciliary muscle to contract
c
2. The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding? a. Pulse rate of 112 bpm b. Blood pressure of 94/64 mm Hg c. Urine output of 30 mL/h d. Serum sodium level of 136 mEq/L
c
2. The nurse is reviewing the medication history of a client with benign prostatic hypertrophy. Which medication will likely aggravate BPH? a. Metformin b. Buspirone c. Inhaled ipratropium d. Ophthalmic timolol
c
A patient with Alzheimer's disease is hospitalized for surgery. The nurse notes that the settings on the IV infusion pump are incorrect. The patient's order is for 125ml/hr of 0.9% NaCl, but the patient received 250ml of IV fluid in one hour. The nurse should assess the patient for: A.Postural hypotension and hyperthermia. B.Warm, dry skin and an irregular pulse. C.Distended neck veins and moist crackles. D.Decreased urinary output and thirst.
c
While making a home visit to a bedridden 89 year old man, you note that he is cachectic, dehydrated, but cognitively intact. He states he is not receiving his medications regularly, and that his granddaughter is supposed to take care of him, but mentions, "She seems more interested in my Social Security check." The patient is unhappy, but asks that you not "tell anybody" because he wants to remain in his home. The most appropriate action would be to: A.Talk with the patient's granddaughter and evaluate her ability to care for the patient. B.Visit the patient more frequently to ensure that his condition does not deteriorate. C.Report the situation to the appropriate state agency. D.Honor the patient's wishes a competent patient has the right to determine care.
c
17.A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand? A. Buttoning her blouse B. Eating her breakfast C. Combing her hair D. Brushing her teeth
c -Abduction of the arm is the most difficult, and usually the last, type of movement to be regained by a client following a mastectomy.
14.A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing
c -Accumulation of exudate caused by otitis media with effusion increases pressure behind the tympanic membrane. The pressure releases when the tympanic membrane ruptures, which results in sudden pain relief.
20.A client is receiving treatment for stage IV ovarian cancer and asks the nurse to discuss her prognosis. The client plans to have aggressive surgical, radiation, and chemotherapy treatments. Which of the following prognoses should the nurse discuss with the client? A. Good B. Guarded C. Poor D. Very good
c -At this advanced stage, the prognosis for ovarian cancer is poor. Ovarian cancer is the leading cause of death from female reproductive cancers. Survival rates are low because it is not often discovered until its late stages.
13.A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? A. Bladder spasms B. Severe pain. C. An inability to void D. Frequent episodes of painful urination
c -Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.
24.A nurse is caring for a client who has malignant melanoma. Which of the following findings should the nurse expect when assessing the lesion? A. Pain B. Pruritus C. Purplish in color D. Purulent drainage
c -Dark pigmentation of the lesion is an expected finding of malignant melanoma. Colors are varied and can include red, white and blue tones.
1.A nurse is caring for a client who has chronic renal disease and is receiving therapy with epoetin alfa. Which of the following laboratory results should the nurse review for an indication of a therapeutic effect of the medication? A. The leukocyte count B. The platelet count C. The hematocrit (Hct) D. The erythrocyte sedimentation rate (ESR)
c -Epoetin alfa is an antianemic medication that is indicated in the treatment of clients who have anemia due to reduced production of endogenous erythropoietin, which may occur in clients who have end-stage renal disease or myelosuppression from chemotherapy. The therapeutic effect of epoetin alfa is enhanced red blood cell production, which is reflected in an increased RBC, Hgb, and Hct.
16.A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings? A. Urge incontinence B. Critically elevated prostate-specific antigen (PSA) level C. Difficulty starting the flow of urine D. Painful urination
c -Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.
12.A nurse is teaching a client who has acute kidney injury about the oliguric phase. Which of the following information should the nurse include in the teaching? A. Renal function is reestablished. B. BUN and creatinine levels decrease. C. Urine output is less than 400 mL per 24 hr. D. The glomerular filtration rate (GFR) recovers.
c -Inadequate urinary output is associated with the oliguric phase of acute kidney injury. The minimum amount of urine needed to rid the body of metabolic waste products is 400 mL. Therefore, a client who is producing less than 400 mL of output in 24 hr is manifesting acute kidney injury.
6.A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the following morning. The client asks the nurse why he has to go to "that place." Which of the following responses should the nurse make? A. "Your doctor feels that this is the best place for you right now." B. "Why don't you ask your doctor about that when she comes in to see you?" C. "Did your doctor or anyone else talk to you about going to the nursing home?" D. "Your family can't take care of you at home, so you will need to go there."
c -It is important to identify what the client thinks he has heard about his discharge. Clarification of information can proceed after this.
7.A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect? A. Seizures B. Bradycardia C. Constipation D. Hypothermia
c -Mydriatic eye drops can cause systemic anticholinergic effects, such as constipation and dry mouth.
24.A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)? A. Perform wound irrigation for a client. B. Evaluate pain relief for a client following the administration of a pain medication. C. Measure and record intake and output for a client. D. Teach a client about low-sodium foods.
c -The AP can measure and record intake and output (I&O) for a client. It is the nurse's responsibility to review the recorded results and respond as necessary.
10.A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make? A. "Sometimes the same pill comes in a different color." B. "Let me explain the purpose of the medication." C. "I will check your medication order again." D. "This is the medication that your doctor wants you to take."
c -The appropriate nursing response is to check the provider's original medication order to avoid a medication error.
28.A nurse is teaching a client who has pre-dialysis end-stage kidney disease about diet. Which of the following instructions should the nurse include? A. "Increase intake of dietary phosphorous." B. "Eliminate foods high in protein from your diet." C. "Reduce intake of foods high in potassium." D. "Increase intake of sodium-containing food."
c -The client should reduce foods high in potassium because potassium clearance is impaired in the client who has end-stage kidney disease.
9. Which action should be included in the nursing care for a client with cervical cancer who has an internal radium implant in place? a. Offer the bed pan every 2 hours b. Provide perineal care twice daily c. Check the position of the applicator hourly d. Offer a low-residue diet
d
The diagnosis of _____ should be considered in an older adult with new-onset urinary incontinence coupled with acute changes in mental status. A.Dementia B.Spinal cord compression C.Bladder stone D.Delirium
d
7.A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority? A. Recommend that the partner place the client in a long-term care facility. B. Suggest that the partner see a counselor to help him cope with his exhaustion. C. Ask the partner to talk about his difficulties in caring for the client. D. Tell the partner to call a family meeting to get help.
c -The first action the nurse should take using the nursing process priority framework is to assess the partner's difficulties in caring for his wife.
11.A nurse suspects that a family caregiver is neglecting an older adult client. Which of the following statements by the caregiver should the nurse identify as the priority to address? A. "We only have enough money for two meals a day." B. "We sit outside every afternoon." C. "We buy the prescriptions we can afford." D. "We cannot afford new batteries for his hearing aid."
c -The greatest risk to this client is injury from not receiving the medications the provider has prescribed; therefore, the priority intervention is to determine which medications the client is receiving and which prescriptions the caregiver is not filling. A referral to social services can assist the client and family with purchasing prescriptions. In addition, the nurse should educate the client and family about the importance of correct medication administration.
9.A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take? A. Speak loudly and into the client's good ear. B. Use sign language when communicating with the client. C. Speak directly to the client in a normal, clear voice. D. Sit by the client's side and speak very slowly.
c -The nurse is correct to speak directly and normally for the client to hear what is spoken.
11.A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft? A. Measure the client's blood pressure to ensure it is higher in the left arm than the right. B. Check the brachial and radial pulses of the left arm simultaneously. C. Auscultate the site for a bruit. D. Auscultate the antecubital fossa using a Doppler stethoscope
c -The nurse should auscultate the AV graft site for the presence of a bruit or palpate the site for a thrill every 4 hr to assess for blood flow.
7.A nurse in a clinic is caring for a female client who was exposed to gonorrhea. Which of the following actions should the nurse take? A. Instruct the client about preventing reinfection by using a diaphragm. B. Tell the client to expect some joint pain. C. Obtain information about the client's recent sexual experiences. D. Collect a urine specimen from the client.
c -The nurse should obtain information from the client about the types of sexual exposure the client may have had in order to thoroughly assess the client.
20.A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Reflex incontinence
c -These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.
3.A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the client's fluid intake in the evening. B. Obtain a bedside commode for the client's use. C. Leave a nightlight on in the client's room. D. Put the side rails up and tell the client to call the nurse before voiding.
c -This is an appropriate action for keeping the client safe. Night vision may be impaired in older adult clients. If the client awakens in the night, a nightlight may help the client to recognize the surroundings, decreasing the likelihood of disorientation. It will also help to decrease the possibility of a fall on the way to the bathroom because the path will be illuminated and the client will be less likely to trip over objects in the room.
15.A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion B. Auscultating breath sounds C. Confirming the gag reflex D. Measuring blood pressure
c -When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway.
1. The nurse is providing preoperative instructions to a client who is having a transurethral resection of the prostate. What should the nurse tell the client? a. You will have a central venous access inserted just prior to the procedure b. Plan on being in the hospital anywhere from 5-7 days following the procedure c. You will be taught care of the incision and suture line prior to your discharge home d. Expect blood in your urine in the first couple of days following the procedure
d
8.A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have? A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.49, HCO3 30, PaCO2 40 C. pH 7.26, HCO3 24, PaCO2 46 D. pH 7.26, HCO3 14, PaCO2 30
d -AKI causes metabolic acidosis because the kidneys cannot adequately process and excrete the acidic substances the usual bodily functions produce every day. With metabolic acidosis, the pH is low, the bicarbonate is low, and the PaCO2 is low or in the expected range, as in these results.
5.A nurse working on an orthopedic unit is caring for four clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown? A. An adolescent who has a cervical fracture and is in a halo brace B. A young adult who has a femur fracture and is in skeletal balanced suspension traction C. A middle adult who has a fractured radius and an arm cast D. An older adult who has a hip fracture and is in Buck's traction
d -According to evidenced-based practice, this client has multiple risk factors for skin breakdown: the aging process (decreased muscle mass, thin and fragile skin) and the limitation of movement due to traction. Therefore, this client is at the greatest risk for skin breakdown.
20.A nurse is assessing a client at a dermatology clinic. Which of following findings places the client at risk for developing malignant melanoma? A. Female gender B. Age 19 to 30 years C. Dark hair D. History of chronic skin irritation
d -Clients who have a history of chronic inflammatory skin irritations are at increased risk for skin cancer. Other risk factors include exposure to chronic sunlight, chemical pollution, and immunosuppression.
8.A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A. Urinary retention B. Low back pain C. Incontinence D. Confusion
d -Confusion is a clinical finding of UTIs specifically associated with older adult clients.
10.A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)? A. 9 percent B. 18 percent C. 36 percent D. 54 percent
d -Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA totaling 54%.
2.A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client? A. Unilateral swelling on the posterior of the vulva B. Extreme abdominal pain with intercourse C. Green, malodorous vaginal discharge D. Postmenopausal bleeding
d -Endometrial cancer involves cancerous growth of the endometrium (lining of the uterus). The most common manifestation of endometrial cancer is abnormal uterine bleeding, including postmenopausal bleeding and bleeding between normal periods in premenopausal women.
1.A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis? A. A history of pelvic inflammatory disease (PID). B. Abdominal bloating starting several days before menses. C. An atypical Papanicolaou smear at her last clinic visit. D. Dysmenorrhea that is unresponsive to NSAIDs.
d -Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period but can cause pain at other times in the cycle. THe discomfort is often unrelieved by the use of NSAIDs.
14.A nurse is discussing laboratory values associated with the renal system with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the values? A. Potassium levels are increased in clients who have polyuria. B. Specific gravity is decreased in clients who have hypovolemia. C. BUN is decreased in clients who have dehydration. D. Creatinine levels are increased in clients who have acute kidney injury.
d -Increased creatinine levels are associated with renal failure.
14.A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include? A. "Have an eye examination once per year." B. "Examine your feet carefully every day." C. "Wear compression stockings daily." D. "Maintain stable blood glucose levels."
d -Keeping blood glucose under control is the client's best protection against long-term complications of diabetes, since increased blood sugar contributes to neuropathic disease, and microvascular complications such as retinopathy and nephropathy, as well as to macrovascular complications.
13.A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury? A. Dextrose 5% in water B. Dextrose 5% in 0.9% sodium chloride C. 0.9% sodium chloride D. Lactated Ringer's
d -Lactated Ringer's is used in the first 24 hr following a burn injury because it is a crystalloid solution whose composition and osmolality most closely resembles plasma.
10.A nurse is presenting educational materials for a group of middle-aged clients about menopausal hormone therapy following total hysterectomy. Which of the following information should the nurse include in the information? A. Take at different times of the day. B. Take an extra dose if missed a day. C. Prevents from having a cerebral hemorrhage. D. Prevents osteoporotic fractures
d -Menopausal hormone therapy may decrease and protect the client from osteoporotic fracture due to the preservation of bone mineral density.
An 82 year old client is in the clinic for a routine assessment. Based on age-related changes in the cardiac system, which instructions would the nurse likely give to the client? A. Explain that the client should drink 8 glass of water a day B. Encourage the client to avoid irritants C. Tell the client to cover her mouth and nose when sneezing D. Tell the client to stand up or change positions slowly
d -Orthostatic hypotension in the elderly is common due to age-related changes in the cardiac system (e.g., weak contractility and decreased filling of the heart). This can lead to decreased blood volume. LOW volume = LOW pressure
13.A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values? A. RBC count B. Protein C. Calcium D. Potassium
d -Potassium levels are reduced by the process of diffusion during dialysis
3.A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report A. loss of central vision. B. having a loss of peripheral vision. C. seeing bright flashes of light and floaters. D. having a decreased ability to perceive colors.
d -Symptoms of cataracts include painless blurred vision and a decrease in the ability to perceive colors.
10.A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions? A. Mastoiditis B. Ménière's disease C. Acoustic neuroma D. Perforated tympanic membrane
d -The client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.
15.A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury? A. Initiate fluid resuscitation. B. Medicate for pain. C. Insert an indwelling urinary catheter. D. Maintain the airway
d -The client is at risk for respiratory obstruction. Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the client has a patent airway.
5.A nurse is teaching a group of teenage clients about the use of condoms for the prevention of sexually transmitted infections (STIs). Which of the following statements should the nurse include in the teaching? A. "Use a natural membrane condom rather than a polyurethane condom." B. "You may use a condom more than once." C. "Use an oil-based lubricant when you use a condom." D. "Female condoms can help prevent transmission of sexually transmitted viruses."
d -The client who uses a female condom can prevent sexually transmitted viruses when the polyurethane or nitrile sheath is placed in the vagina.
18.A nurse is preparing a client who is to receive chemotherapy for treatment of ovarian cancer. Which of the following actions should the nurse plan to take? A. Tell the client to expect dark stools following chemotherapy. B. Have the client floss 4 times daily. C. Have the client swish with commercial mouthwash before therapy. D. Administer an antiemetic prior to the procedure.
d -The nurse can help prevent nausea and vomiting by administering an antiemetic prior to chemotherapy, and to tell the client to continue taking medication until nausea and vomiting resolve.
16.A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? A. One cup of brown rice B. One cup of orange juice C. One cup of pureed avocado D. One cup of lentils
d -The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.
10.A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? A. "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." B. "High frequency sound waves will be used to identify renal system structures." C. "You will be able to resume your regular diet as soon as the test is complete." D. "After the procedure you will be encouraged to drink plenty of fluids."
d -The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.
9.An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide? A. "This is a minor procedure; there is no need for this request." B. "You need to let your provider know your wishes after the procedure." C. "You need to discuss your request with the hospital chaplain." D. "Your provider needs to talk with you concerning your request."
d -The nurse should inform the client that the provider is responsible for consulting with the client and writing a DNR order.
5.A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching? A. Take ibuprofen for eye discomfort. B. Creamy white drainage is an indication of infection. C. Notify the provider immediately if the operative eye itches. D. The client should wear dark glasses while outdoors.
d -The nurse should instruct the client and his spouse that he should wear dark glasses when outside or in bright light until pupil reaction returns.
4.A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions? A. Carbonated beverage B. Milk C. Orange juice D. Grapefruit juice
d -There is a high rate of food-drug interactions between grapefruit juice and many medications frequently taken by older adults, especially lipid-lowering agents. It is thought that one or more of the chemicals (most likely flavonoids) in grapefruit juice alter the activity of specific enzymes (such as CYP3A4 and CYP1A2) in the intestinal tract. These enzymes decrease the rate at which medications enter the systemic circulation. This could allow a larger amount of these drugs to reach the bloodstream, resulting in increased drug levels and possibly toxicity.
The nurse is making rounds on the unit and visits Mr. Smith in Room 138. Mr. Smith is finishing up his shower and walking to the bedroom while holding on to the wall. He is alert and oriented x 3. He is schedule to receive 2 units of packed red blood cells this morning and his central line is intact in the left forearm. He states he is afraid to fall again. He reports 2 falls in August, and he was admitted yesterday after he fell at home. It was discovered that his Hgb was low. He has a history of cardiac arrythmia, Diabetes Type II, COPD, and anemia. He has a single prong cane at home. He walks in small steps and requires assistance rising from the chair. -Please complete Morse Fall Scale.
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