Quiz 2

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first? Pain severity Wound drainage Tissue integrity Airway patency

Airway patency

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was dysphagia. hoarseness. dyspnea. weight loss.

hoarseness.

A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider? WBC 2300/mm3 RBC 5 million/mm3 Hemoglobin 12 g/dL Platelets 155,000/mm3

WBC 2300/mm3

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.) Polyuria Blurred vision Polydipsia Tachycardia Moist, clammy skin

Blurred vision Tachycardia Moist, clammy skin

A nurse is reviewing laboratory values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function? Serum creatinine Blood urea nitrogen (BUN) Serum sodium Urine-specific gravity

Serum creatinine

A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first? Stop the infusion of blood. Inform the provider. Obtain a urine specimen. Notify the laboratory.

Stop the infusion of blood.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds? The fourth heart sound (S4) A friction rub The third heart sound (S3) A split second heart sound S2

The fourth heart sound (S4)

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? Tell the client to expect dark stools following chemotherapy. Have the client floss 4 times daily. Have the client swish with commercial mouthwash before therapy. Administer an antiemetic prior to the procedure.

Administer an antiemetic prior to the procedure.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.

Check the tubing for kinks.

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? Check the tubing connections for leaks. Check the suction control outlet on the wall. Clamp the chest tube. Continue to monitor the client's respiratory status.

Continue to monitor the client's respiratory status.

A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching? "I should consume most of the fluid during the evening." "I will make a list of my favorite beverages." "I will put beverages in large containers to give the appearance of drinking a lot." "I will not add ice cream to the amount of fluid intake."

"I will make a list of my favorite beverages."

A nurse is teaching about risk factors for developing a stroke with a group of older adult clients. Which of the following nonmodifiable risk factors should the nurse include? History of smoking Obesity History of hypertension Genetics

Genetics

A nurse in a clinic is assessing a client who has AIDS and a significantly decreased CD4-T-cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions? Halitosis Gingivitis Xerostomia Candidiasis

Candidiasis

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? Replace the catheter every 3 days. Check the catheter tubing for kinks or twisting. Irrigate the catheter once each shift. Clean the perineal area with an antiseptic solution daily.

Check the catheter tubing for kinks or twisting.

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include? Do not apply heat to the area of irradiation. Do not wash the area of irradiation. Use an antibiotic ointment to treat skin breakdown. Lubricate the skin lubricated with hypoallergenic lotion.

Do not wash the area of irradiation.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? Maintaining a semi-Fowler's position as often as possible Administering oxygen via nasal cannula at 2 L/min Helping the client select a low-salt diet Encouraging the client to drink 2 to 3 L of water daily

Encouraging the client to drink 2 to 3 L of water daily

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions? Elevating her feet Massaging her legs Flexing her ankles Ambulating soon after surgery

Massaging her legs

A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding. Which of the following actions should the nurse take? Ambulate the client four times per day. Encourage the client to consume clear liquids. Provide frequent oral and nares care. Keep the client in a supine position.

Provide frequent oral and nares care.

A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level? Administer diuretics. Restrict the client's intake of fluids. Reduce the client's intake of protein. Administer vitamin K.

Reduce the client's intake of protein.

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes? To prevent fluid from accumulating in the wound To limit the amount of bleeding from the surgical site To provide a means for medication administration To eliminate the need for wound irrigations

To prevent fluid from accumulating in the wound

A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first? Turn the client's head to the side. Check the client's motor strength. Loosen the clothing around the client's waist. Document the time the seizure began.

Turn the client's head to the side.

A nurse is caring for a client who is scheduled to have a magnetic resonance imaging (MRI) scan. The client asks the nurse what to expect during the procedure. Which of the following statements should the nurse make? "An MRI scan is not distorted by movement, so you do not have to lie still." "An MRI scan is a short procedure and should take no longer than 30 minutes." "The MRI contrast dye contains iodine and can cause your skin to itch." "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

"An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."

A nurse is teaching the partner of a client who had an acute myocardial infarction (MI) about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies? "These tests help determine the degree of damage to the heart tissues." "Cardiac enzymes will identify the location of the MI." "These tests will enable the provider to determine the heart structure and mobility of the heart valves." "Cardiac enzymes assist in diagnosing the presence of pulmonary congestion."

"These tests help determine the degree of damage to the heart tissues."

A nurse is instructing a client who is newly diagnosed with pulmonary tuberculosis (TB) about the use of antitubercular medications. Which of the following information should the nurse include in the teaching? Medications will need to be taken for the rest of the client's life, even if the client feels better. Medications will need to be taken until the Mantoux test is negative. A typical course of treatment involves 6 to 9 months of consistent medication use. The client's family will also need to take medications to prevent infection.

A typical course of treatment involves 6 to 9 months of consistent medication use.

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? Airway obstruction Infection Fluid imbalance Paralytic ileus

Airway obstruction

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first? Review the client's electrolyte values. Check the client's perianal skin integrity. Investigate the client's emotional concerns. Obtain a dietary history from the client.

Review the client's electrolyte values.

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values? Thyroid stimulating hormone (TSH) Free T4 Serum T4 Serum T3

Thyroid stimulating hormone (TSH)