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A nurse is caring for 4 clients. Which of the following clients is at greatest risk for pulmonary embolism? a) A client who is 48 hrs postoperative following a total hip arthroplasty b) A client who is 8 hrs postoperative following an open surgical appendectomy c) A client who is 2 hrs postoperative following an open reduction external fixation of the right radius d) A client who is 4 hrs postoperative following a laparoscopic cholecystectomy

a) A client who is 48 hrs postoperative following a total hip arthroplasty

A nurse is managing the care of a client who is postoperative and has acute adrenal insufficiency. Which of the following actions should the nurse take? a) Administer IV hydrocortisone sodium b) Give oral spironolactone c) Infuse 1 unit of platelets d) Restrict daily fluid intake

a) Administer IV hydrocortisone sodium

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? a) Drink at least 3 L of fluid daily b) Weigh yourself weekly while wearing similar clothing at the same time of the day c) Notify the provider of a weight loss of 0.45 kg (1 lb) or more per week d) Report nocturia because it requires a dosage adjustment

d) Report nocturia because it requires a dosage adjustment

While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? a) Implement seizure precautions b) Administer phosphate c) Initiate diuretic therapy d) Prepare the client for hemodialysis

a) Implement seizure precautions

A nurse is caring for a 2-year-old child who has not received any immunizations. During assessment, the child is noted to have a maculopapular rash and fever. The child's parent tells the nurse that the child has been exposed to rubeola. Which of the following assessment findings should the nurse expect? a) Koplik's spots b) Vesicles and crusts c) Strawberry tongue d) Paroxysmal cough

a) Koplik's spots

A nurse is providing discharge teaching for a client who has heart failure. The nurse should instruct the client to report which of the following findings immediately to the provider? a) Weight gain of 0.9 kg (2 lb) in 24 hr b) Increase of 10 mmHg in systolic BP c) Dyspnea with exertion d) Dizziness when rising quickly

a) Weight gain of 0.9 kg (2 lb) in 24 hr

A nurse is caring for a client who has acute acetaminophen toxicity. The nurse should anticipate administering which of the following medications? a) Vitamin K b) Acetylcysteine c) Benztropine d) Physostigmine

b) Acetylcysteine

A client receives terbutaline for the management of preterm labor. Which of the following findings should the nurse report immediately? a) HR 110 b) Dyspnea and crackles c) Tremors and headache d) BP 100/60

b) Dyspnea and crackles

A nurse is providing teaching for a client who has cirrhosis and a new prescription for lactulose. The nurse should include which of the following instructions in the teaching? a) Notify the provider if bloating occurs b) Expect to have 2-3 soft stools per day c) Restrict carbohydrates in the diet d) Limit oral fluid intake to 1,000 mL/day of clear fluids

b) Expect to have 2-3 soft stools per day

A nurse is reviewing the lab report of a client who has FVE. Which of the following lab values should the nurse expect? a) Hemoglobin 20 g/dL b) Hematocrit 34% c) BUN 25 mg/dL d) Urine SG 1.050

b) Hematocrit 34%

A nurse is assessing a client who is receiving epoetin alpha to treat anemia. Which of the following findings should the nurse monitor? a) Paresthesia b) Increased BP c) Fever d) Respiratory depression

b) Increased BP

A nurse provides end of life care to a client of Chinese heritage. Which of the following rituals may be practiced by the family following death? a) A priest will place an amulet on the pillow b) The oldest child will bathe the body c) A window will be opened by the partner d) The bed will be placed facing east

b) The oldest child will bathe the body

A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record? a) Completion of the incident report b) Time the medication was given c) Reason for the medication error d) Notification of the pharmacist

b) Time the medication was given

A nurse is teaching a female client about a healthy diet to control HTN. Which of the following client statements indicates an understanding of the teaching? a) "I will drink 2 glasses of whole milk daily." b) "I will decrease the potassium in my diet." c) "I will eat 4 servings of unsalted nuts per week." d) "I will limit alcohol consumption to 2 drinks/day."

c) "I will eat 4 servings of unsalted nuts per week."

A nurse is providing dietary teaching to a client who has celiac disease. Which of the following information should the nurse include in the teaching? a) "You will need to take a glucocorticoid when you have an exacerbation." b) "You should avoid taking enteric-coated medications." c) "You will need to eat a gluten-free diet." d) "You will need to follow a low-lactose diet."

c) "You will need to eat a gluten-free diet."

A nurse is caring for a client who has acute blood loss following trauma. The client refuses a blood transfusion that might potentially save his life. Which of the following actions should the nurse take first? a) Document the client's refusal in the medical record b) Honor the client's decision to refuse the blood transfusion c) Explore the client's reasons for refusing treatment d) There was no D

c) Explore the client's reasons for refusing treatment

A nurse is caring for a client who has a retinal detachment. Which of the following client reports about the affected eye should the nurse expect? a) Photophobia b) Complete blindness c) Flashes of bright light or floating dark spots d) Pain

c) Flashes of bright light or floating dark spots

A nurse is admitting a client who has a leg ulcer and a history of diabetes mellitus. The nurse should use which of the following focused assessments to help differentiate between an arterial ulcer and a venous stasis ulcer? a) Explore the client's family history of peripheral vascular disease b) Note the presence or absence of pain at the ulcer site c) Inquire about the presence or absence of claudication d) Ask if the client has had a recent infusion

c) Inquire about the presence or absence of claudication

The nurse is planning care for a client who is receiving mannitol via continuous IV infusion. The nurse should monitor the client for which of the following adverse effects? a) Weight loss b) increased intraocular pressure c) Auditory hallucinations d) Bibasilar crackles

d) Bibasilar crackles

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? a) Loss of body hair b) Report of anorexia c) Mucositis of the oral cavity d) Erythema at the IV insertion site

d) Erythema at the IV insertion site


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