RSNG Unit 4 Test Review Spring 2018 ....................................................... Clotting, Hematology, Pneumonia, Cellulitis, Delegation, Cognition, Mobility, Infection, Immunity

Which patient has delirium? A. A patient is admitted to the ED with high fever, confusion and blood in the urine B. A patient presents in the ED with a fractured wrist following a fall at home. His family reports increased clumsiness for the past year.

A. A patient is admitted to the ED with high fever, confusion and blood in the urine

A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which way should the hospital admission process be modified for the client? A. Allow her sufficient extra time in which to gain an understanding of what is happening to her. B. Give her a tour of the unit to acquaint her with the new environment in which she will live. C. Medicate her to ensure her calm cooperation during the admission procedure. D. Leave her alone to promote recovery of her faculties and composure.

A. Allow her sufficient extra time in which to gain an understanding of what is happening to her. When admitting an elderly client, especially one who is confused and disoriented, it is best to give the client extra time in which to gain an understanding of what is happening to her. This will help her to get her bearings and adjust to a new environment. Leaving the client alone will not help her confusion and disorientation and will increase her fear and anxiety. Medication would not be appropriate until the cause of the client's confusion and disorientation is determined. Overmedicating elderly clients is sometimes a cause of their confusion. A tour of the unit will not be helpful for the client who is confused and disoriented.

A nurse records the assessment of statis dermatitis on an intake assessment for a patient with peripheral vascular disease (PVD). What is the best way to describe this finding? A. Brownish skin discoloration on the lower legs B. Ulceration on medial surface of the lower legs C. Edema in the lower legs D. Purple rash on medial surface of the lower legs

A. Brownish skin discoloration on the lower legs

A nurse is reviewing the epidemiology of pneumonia. The nurse should be aware of a seasonal pattern of incidence and prevalence in what type of pneumonia? A. Community-acquired pneumonia B. Hospital-acquired pneumonia C. Ventilator-associated pneumonia D. Health care-associated pneumonia

A. Community-acquired pneumonia Rationale: Most cases of CAP occur in the winter and early spring. The etiology of the other three major types of pneumonia does not include seasonal patterns of incidence and prevalence.

Which of the responsibilities related to the care of a client with a Foley catheter are appropriate for the nurse to delegate to the UAP? Select all that apply A. Empty drainage bag, and record output at specified times B. Apply catheter-securing device to the client's leg C. Ensure the urine drainage bag is below the level of the bladder at all times D. Flush the catheter as needed to ensure patency E. Provide Foley catheter and perineal care each shift F. Perform bladder irrigation as prescribed

A. Empty drainage bag, and record output at specified times B. Apply catheter-securing device to the client's leg C. Ensure the urine drainage bag is below the level of the bladder at all times E. Provide Foley catheter and perineal care each shift

The nurse is assessing a client who has Factor VIII deficiency (Hemophilia A). Which clinical manifestation does the nurse expect to assess in this client? A. Excessive bleeding from a cut B. Chronic lower back pain C. Nausea and vomiting D. Temperature of 101

A. Excessive bleeding from a cut

A nurse is caring for a patient who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. Heparin decreases the formation of microclots, which deplete clotting factors. Vitamin K promotes coagulation Mefoxin is an antibiotic Simvastatin is used to treat hyperlipidemia

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply) A. Platelets 100,000 B. Fibrinogen levels 57 C. Fibrin degradation products 4.3 D. D-dimer 0.03 mcg E. Sedimentation rate 38

A. Platelets 100,000 B. Fibrinogen levels 57 A & B. Fibrinogen and Platelet levels are decreased (normal 150,000-400,000), raises the risk of hemorrhage

What condition, with progression of Dementia/Alzheimer's, causes the client to have an inability to recognize oneself and other familiar faces? A. Prosopagnosia B. Pick's Disease C. Creutzfeldt-Jakob Disease (CJD) D. Huntington's Disease

A. Prosopagnosia B. Pick's Disease is a rare form of progressive dementia, typically occurring in late middle age and often familial, involving localized atrophy of the brain C. Creutzfeldt-Jakob Disease (CJD) is a degenerative brain disorder that leads to dementia and death D. Huntington's Disease is an inherited condition in which nerve cells in the brain break down over time.

A nurse is planning care for a client who has HGB 7.5 and Hct 21.5. Which of the following actions should the nurse include in the plan of care? (Select all that apply) A. Provide assistance with ambulation B. Monitor oxygen saturation C. Weigh the client weekly D. Obtain stool specimen for occult blood E. Schedule daily rest periods

A. Provide assistance with ambulation B. Monitor oxygen saturation D. Obtain stool specimen for occult blood E. Schedule daily rest periods A. Anemia can cause dizziness. B. Pt could need oxygen because Hgb carries oxygen in the blood D. An occult blood test could determine if patient is having gastrointestinal bleeding E. Anemic patients will be fatigued.

Which medication used for Dementia/Alzheimer's patients causes hepatotoxcity and should be given QID? A. Tacrine (Cognex) B. Donepril (Aricept) C. Rivastigmine (Exelon)

A. Tacrine (Cognex) Tacrine (Cognex) has a very short half life so it must be given QID. Adverse reactions: Must check liver function; contraindicated in liver and renal disease.

A client with Alzheimer's disease says, "I'm so afraid. Where am I? Where is my family?" How should the nurse respond? A. You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now B. You know where you are. You were admitted here 2 weeks ago. Don't worry, your family will be back soon. C. I just told you that you're in the hospital and your family will be here soon D. The name of the hospital is on the sign over the door. Let's go read it again.

A. You are in the hospital and you're safe here. Your family will return at 10 o'clock, which is 1 hour from now

A nurse providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply) A. You will need a monthly injection of Vitamin B12 for the rest of your life B. Using the nasal spray form of Vitamin B12 on a daily basis can be an option C. An oral supplement of Vitamin B12 taken on a daily basis can be an option D.. You should increase your intake of animal proteins, legumes, and dairy products to increase Vitamin B12 in your diet E. Add soy milk fortified with Vitamin B12 to your diet to decrease the risk of pernicious anemia

A. You will need a monthly injection of Vitamin B12 for the rest of your life B. Using the nasal spray form of Vitamin B12 on a daily basis can be an option A. needed because due to lack of intrinsic factor being produced by the parietal cells of the stomach B. Cyanocobalamin nasal spray is an option C. Oral B12 cannot be absorbed D. & E. Dietary B12 will not be absorbed

The nurse is assigned to care for five clients. Which of the following could be assigned by the nurse to the UAP? Select all that apply A. a client scheduled for cataract surgery with BP 134/78, P 70 bpm B. a newly admitted client with wheezing from an allergic reaction C. a client returning from the operating room post-colectomy for ulcerative colitis D. a client with a diagnosis of cholelithasis reporting pain of 8 out of 10 E. a client post-operative appendectomy with BP 110/80, P 84 bpm

A. a client scheduled for cataract surgery with BP 134/78, P 70 bpm E. a client post-operative appendectomy with BP 110/80, P 84 bpm

Two days after surgery to amputate his left lower leg, a client states that he has pain in the missing extremity. Which action by the nurse is most appropriate? A. administer medication, as ordered, for the reported discomfort B. contact the physician C. initiate a consult with a psychologist D. do nothing because it isn't possible to have pain in a missing limb

A. administer medication, as ordered, for the reported discomfort

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. "He know who we are, but that is about it. We do not know what to say to him." What should the nurse tell the family? (Select all that apply) A. answer his questions simply, honestly, slowly, and clearly B. correct him when he is hearing and seeing things that are not there C. occasionally remind him of the time, day, and place when he does not remember D. include him in your conversation, instead of talking about him while he is present E. raise you voice a bit so you are sure he hears you

A. answer his questions simply, honestly, slowly, and clearly C. occasionally remind him of the time, day, and place when he does not remember D. include him in your conversation, instead of talking about him while he is present

A nurse is teaching a class about osteoporosis. Which factors place a client at greater risk for developing this disease? (select all that apply) A. being postmenopausal B. long-term use of corticosteroids C. long-term use of ibuprofen D. excessive intake of calcium supplements E. early onset of menses F. sedentary lifestyle

A. being postmenopausal B. long-term use of corticosteroids F. sedentary lifestyle (because weight bearing exercises are necessary)

A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which activity should the nurse instruct the client to avoid? A. crossing the legs while sitting down B. sitting on a raised commode seat C. using an abductor splint while ling on the side D. rising straight from a chair to a standing position

A. crossing the legs while sitting down

A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes previously. Which area should be the nurse's next assessment? A. distal pulse B. pain with a pain rating scale C. vital sign changes D. potential for drug tolerance

A. distal pulse

Which characteristic would make the nurse suspect that a client with changes in cognition has delirium? A. disturbances in cognition and consciousness that fluctuate during the day B. failure to identify objects despite intact sensory functions C. significant impairment in social or occupational functioning over time D. memory impairment to the degree of being called amnesia

A. disturbances in cognition and consciousness that fluctuate during the day The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree of being called amnesia all indicate dementia.

A client involved in a motor vehicle accident has a long leg cast applied to the right leg and is reporting heel pain. The nurse would assess for which of the following as part of a focused exam? (select all that apply) A. drainage at the heel site B. voiding since the accident C. level of consciousness D. recollection of the accident E. color and temperature of the toes

A. drainage at the heel site E. color and temperature of the toes the focused assessment is for the heel pain not the overall assessment from the accident

A client is diagnosed with gout. Which foods should the nurse instruct the client to eat? (select all that apply) A. green, leafy vegetables B. liver C. cod D. strawberries E. sardines F. eggs

A. green, leafy vegetables D. strawberries F. eggs Rationale: Organ meats such as liver, as well as certain sea foods, including scallops, sardines, and herring, should be omitted from the diet of the client who with gout because of the high purine content. The foods identified in the other options contain negligible amounts of purines and may be consumed freely by the client with gout.

Nursing staff are trying to provide for the safety of an elderly client with moderate dementia. The client is wandering at night and has trouble keeping her balance. She has fallen twice but has had no resulting injuries. The nurse should: A. move the client to a room near the nurse's station and install a bed alarm B. have the client sleep in a reclining chair across from the nurse's station C. help the client to bed and raise all four bed rails D. ask a family member to stay with the client at night

A. move the client to a room near the nurse's station and install a bed alarm

The nurse is providing discharge teaching for a client being discharged after a cast application for a fractured tibia. Teaching has been effective when the client states he will notify the physician for which of the following? A. pallor, coolness, and parasthesias of the toes B. pain at the fracture site and a small amount of bleeding through the cast C. inability to move the leg at the fracture site D. rubor (redness), slight edema of the foot, and presence of pedal pulse

A. pallor, coolness, and parasthesias of the toes

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? (select all that apply) A. provide a soft diet B. position the child on the left side C. irrigate the right ear with normal saline every 8 hours D. administer ibuprofen for fever every 4 hours as prescribed and as needed.

A. provide a soft diet D. administer ibuprofen for fever every 4 hours as prescribed and as needed.

A nurse is caring for a client with anorexia nervosa. Which interventions would be appropriate for this client? (select all that apply) A. provide small, frequent meals B. monitor weight gain C. allow the client to skip meals until the anti-depressant levels are therapeutic D. encourage the client to keep a journal E. encourage the client to eat three substantial meals per day

A. provide small, frequent meals B. monitor weight gain D. encourage the client to keep a journal

The charge nurse in the newborn nursery has an UAP with her for the shift. Under their care are 8 babies rooming in with their mothers, and 1 infant in the nursery for the night on tube feedings. There is a new client whose infant will be brought to the nursery in 15 minutes. Which tasks would the nurse assign to the UAP? Select all that apply A. record voids/stools B. vital signs on all stable infants C. tube feedings D. newborn admission E. bath and initial feeding for new admission F. document feedings of infants

A. record voids/stools B. vital signs on all stable infants F. document feedings of infants INITIAL baths and feedings for a new admission will be done by the RN.

The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which are expected normal findings? (select all that apply) A. reduced edema of the left knee B. skin warm to touch C. capillary refill response of less than 3 seconds D. moves toes E. pain absent F. pulse on left leg weaker than right leg

A. reduced edema of the left knee B. skin warm to touch C. capillary refill response of less than 3 seconds D. moves toes

Which nursing action would be therapeutic for the client being admitted to the unit with panic disorder? (Select all that apply) A. support the client's attempts to discuss feelings B. touch the client to provide contact with reality C. respect the client's personal space D. reassure the client of safety E. confront the client's dysfunctional coping behaviors

A. support the client's attempts to discuss feelings C. respect the client's personal space D. reassure the client of safety

A nurse is discharging a client diagnosed with a urinary tract infection. Which information should the nurse include in the discharge teaching? (Select all that apply) A. take all antibiotics as prescribed B. limit fluid intake C. strain all urine D. avoid coffee, tea, and alcohol E. wipe from back to front

A. take all antibiotics as prescribed D. avoid coffee, tea, and alcohol

The client in the early stage of Alzheimer's disease and his adult son attend an appointment at the community mental health center. While conversing with the nurse, the son states, "I am tired of hearing about how things were 30 years ago. Why does Dad always talk about the past?" The nurse should tell the son: A. your dad lost his short term memory, but he still has his long term memory B. you need to be more accepting of your dad's behavior C. I want you to understand your dad's level of anxiety D. reminding your dad that you have heard that story will help him stop

A. your dad lost his short term memory, but he still has his long term memory

Which of the following patients would be at greatest risk for developing impaired cognition? A. A 30 year old male who works in a chemical factory B. 70 year old female with kidney, heart and lung disease C. 22 year old who uses marijuana every weekend D. 42 year old marathoner who drinks protein shakes

B. 70 year old female with kidney, heart and lung disease

A 69 year old patient reports a burning, aching pain in the legs when walking to the mailbox. These symptoms are relieved with rest. What should the nurse suspect? A. Venous insufficiency B. Claudication C. Phlebitis D. Rest pain

B. Claudication Claudication is a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries. Phlebitis is Inflammation of a vein. Venous insufficiency is Improper functioning of the vein valves in the leg, causing swelling and skin changes.

A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching? A. This test will be performed while I am lying flat on my back B. I will need to stay in bed for about an hour after the test C. This test will determine which antibiotic I should take for treatment D. I will receive general anesthesia for the test

B. I will need to stay in bed for about an hour after the The nurse should inform the client of the need to stay on bed rest to reduce risk for bleeding. The client will be placed in a prone or side-lying position during the test to expose the iliac crest. A local anesthetic will be used at the site.

A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage? A. aPTT 38 seconds B. INR 1.1 C. PT 22 seconds D. D-dimer negative

B. INR 1.1 INR should be between 2 - 3 for adequate coagulation therapy.

During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, "She sleeps most of the day and is up most of the night. I cannot get a decent night's sleep anymore." Which suggestions should the nurse make to the daughter? Select all that apply. A. Have the daughter encourage the use of caffeinated beverages during the day to keep her mother awake. B. Promote relaxation before bedtime with a warm bath or relaxing music. C. Ask the client's health care provider (HCP) for a strong sleep medicine. D. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. E. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime.

B. Promote relaxation before bedtime with a warm bath or relaxing music. D. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. E. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping. A strong sleep medicine for an elderly client is contraindicated due to changes in metabolism, increased adverse effects, and the risk of falls. Using caffeinated beverages may stimulate metabolism but can also have long-lasting adverse effects and may prevent sleep at bedtime.

A nurse is completing an integumentary assessment of a client with anemia. Which of the following findings should the nurse expect? A. Absent turgor B. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

B. Spoon-shaped nails A. Absent turgor indicates dehydration C. Shiny, hairless legs are present in a client with peripheral vascular disease D. Yellow mucous membranes are found in a client with jaundice. The client with ANEMIA will have pale nail beds and mucous membranes

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly B. The client should have his hemoglobin checked twice a week C. Oxygen saturation levels should be monitored D. Folic acid production will increase

B. The client should have his hemoglobin checked twice a week Erythropoietin is a hormone secreted by the kidneys that increases the rate of production of red blood cells in response to falling levels of oxygen in the tissues. Hgb and Hct will be monitored twice a week until the targeted levels are reached. A. The nurse should teach that the effectiveness is evaluated by changes in the hematocrit not ESR. C. Blood pressure should be monitored for an increase to see if antihypertensive meds are needed D. Erythropoietin promotes increase in production of RBCs.

A nurse assesses a patient's capillary refill time as less than 3 seconds. What does this assessment indicate? A. Hytertension B. Tissue perfusion C. Excess fluid volume D. Increased blood viscosity

B. Tissue perfusion

Four hours after a cast has been applied for a fractured ulna, the nurse assesses that the client's fingers are pale and coo and capillary refill is delayed for 4 seconds. How should the nurse interpret these findings? A. nerve impairment is developing in the fingers B. arterial blood supply to the fingers is decreased C. venous stasis is occurring in the fingers D. the finding is normal for the recovery period

B. arterial blood supply to the fingers is decreased

A woman brings her 6 year old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A UTI is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? (Select all that apply) A. limit fluids for the next few days to decrease the frequency of urination B. assess the mother's understanding of UTI and its causes C. provide instructions only to the mother, not the child D. tell the mother to have the child wipe the back to the front after voiding and defecation. E. instruct the mother to administer the antibiotic as prescribed, even if the symptoms diminish

B. assess the mother's understanding of UTI and its causes E. instruct the mother to administer the antibiotic as prescribed, even if the symptoms diminish

The nurse assigns an UAP to care for a client who is 1 day postpartum. Which tasks would be appropriate to delegate to this person? Select all that apply A. checking the location of the fundus prior to ambulating the client B. assisting the client with ambulation shortly after birth C. reinforcing good hygiene while assisting the client with washing the perineum D. changing the perineal pad and reporting the drainage E. discussing postpartum depression with the client who is found crying F. assisting the mother to latch the infant onto the breast

B. assisting the client with ambulation shortly after birth C. reinforcing good hygiene while assisting the client with washing the perineum D. changing the perineal pad and reporting the drainage

The son of a client with Alzheimer's disease reports feeling guilty for wishing, at times, that his father would die. What is the nurse's best response? A. everyone in your situation must feel like that at times B. being responsible for your father's care must be difficult C. perhaps you should consider putting your father in a nursing home D. There is no reason to feel guilty. You've given your father excellent care.

B. being responsible for your father's care must be difficult

Following a client's total hip replacement, what should the nurse do? (Select all that apply) A. with the aid of a coworker, turn the client from the supine to the prone position every 2 hours B. encourage the client to use the overhead trapeze to assist with position changes C. for meals, elevate the HOB to 90 degrees D. use a fracture bedpan when needed by the client E. when the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises

B. encourage the client to use the overhead trapeze to assist with position changes D. use a fracture bedpan when needed by the client E. when the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

Cognitive impairment or intellectual loss is a part of normal aging. A. True B. False

B. false

The client sustained an open fracture of the femur from an automobile accident. The nurse should assess the client for which type of shock? A. cardiogenic B. hypovolemic C. neurogenic D. anaphylactic

B. hypovolemic (could have had a large loss of blood)

A client has short term memory loss. To help the client cope with memory loss, the nurse should: A. instruct family members to ignore the behavior B. place a single-date calendar where the client can view it C. tell the client in the morning what activities will be expected to be performed that day D. ask the client to try harder to remember things

B. place a single-date calendar where the client can view it

A client had a posterolateral total hip replacement 2 days ago. What information should the nurses include in the client's plan of care? (select all that apply) A. when using a walker, encourage the client to point the toes pointing inward B. position a pillow between the legs to maintain abduction C. allow the client to be in the supine position or lateral position on the unoperated side D. do not allow the client to bend down or to tie or slip on shoes E. place ice on the incision after physical therapy

B. position a pillow between the legs to maintain abduction C. allow the client to be in the supine position or lateral position on the unoperated side D. do not allow the client to bend down or to tie or slip on shoes

Which activities should the nurse encourage the UAP to that apply A. teach clients the proper use of incentive spirometer B. reposition clients for pain relief C. empty and measure indwelling urinary catheter collection bags D. tell the nurse if clients report they are having pain E. assess IV insertion site for redness

B. reposition clients for pain relief C. empty and measure indwelling urinary catheter collection bags D. tell the nurse if clients report they are having pain

A client is admitted with hemophilia A. Which sports should the nurse recommend as safe for the client to participate? (Select all that apply) A. basketball B. swimming C. baseball D. golf E. soccer

B. swimming D. golf

A nurse is putting groceries in the car when an elderly client falls off of a curb. The nurse assesses the client and has a bystander call for an ambulance. Which assessment findings provide data of a suspected right hip fracture? (select all that apply) A. the right leg is longer than the left leg B. the right leg is shorter than the left leg C. the right leg is abducted (outwards) D. the right leg is adducted (towards) E. the right leg is externally rotated F. the right leg is internally rotated

B. the right leg is shorter than the left leg D. the right leg is adducted E. the right leg is externally rotated

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

C. Cyanotic nail beds indicate microvascular clotting - could cause loss of fingers and toes. idiopathic thrombocytopenic purpura (ITP)Low levels of the blood cells that prevent bleeding (platelets). A and B can indicate impaired clotting. D. Severe headache can indicate cerebral bleeding

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Exerostomia

C. Epistaxis - this is an unexpected bleeding of the gums and nose. Tachycardia and hypotension is expected. Xerostomia is dryness of the mouth-not expected of DIC

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red B. Take with a glass of milk is gastrointestinal distress occurs C. Foods high in vitamin C will promote absorption D. Take for 14 days

C. Foods high in vitamin C will promote absorption

Which client statement identifies a knowledge deficit about cast care? A. I will elevate the cast above my heart initially B. I will exercise my joints above and below the cast C. I can pull out cast padding to scratch inside the cast D. I will apply ice for 10 minutes to control edema for the first 24 hours

C. I can pull out cast padding to scratch inside the cast

Which statement made by a patient indicates to the nurse that a teaching plan for the use of warfarin was not effective? A. I don't take aspirin anymore B. I read that grapefruit interferes with warfarin C. I'm drinking too much tea. My urine looks like tea D. I wear my medical alert bracelet all the time

C. I'm drinking too much tea. My urine looks like tea

A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where? A. In the spleen B. In the kidneys C. In the bone marrow D. In the liver

C. In the bone marrow Hemopoiesis is the production of blood cells and platelets, which occurs in the bone marrow.

A nurse performs Homans maneuver by flexing the knee and sharply dorsiflexing the foot. What response indicates a positive Homan's sign? A. Cramping of the toes B. resisting dorsiflexion C. Pain in the calf area D. Blancing of the sole

C. Pain in the calf area (could have a DVT)

Which medication can be given to an dementia/Alzheimer's patient that does not cause hepatotoxcity to a client with known liver disease? A. Tacrine (Cognex) B. Donepril (Aricept) C. Rivastigmine (Exelon)

C. Rivastigmine (Exelon) Rivastigmine (Exelon) is not known to cause hepatotoxicity so it is very useful for patients with known liver disease. Action: Allow more acetylcholine in neuron receptors; increase cognitive function Use: Mild to moderate Alzheimer's disease

A client with dementia who prefers to stay in his room has been brought to the day room. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the day room. Which is most likely the occurrence that is disturbing to this client? A. there is only one other client in the day room; the rest are in a group session in another room B. there are three staff members and one healthcare provider in the nurse's station working on charting C. a relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner D. a housekeeping staff member is washing off the counter tops in the kitchen, which is on the far side of the day room

C. a relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner D. a housekeeping

When the client who has had a hip replacement is lying on the side, the nurse should place pillows or an abductor splint between the legs to prevent: A. flexion of the knees B. abduction of the thighs C. adduction of the hip joint D. hyperextension of the knees

C. adduction of the hip joint (towards the outside of the body)

The nurse and an UAP are caring for clients in a birthing center. Which tasks should the nurse delegate to the UAP? Select all that apply A. intake and output catheterization for culture and sensitivity B. removing a foley catheter from a pre-eclamptic client C. ambulating a post-cesarean client to the bathroom calculating hourly IV totals for a preterm labor client D. calculating hourly IV totals for a preterm labor client E. assisting an active labor client with breathing and relaxation F. calling a report of normal finding to the HCP

C. ambulating a post-cesarean client to the bathroom calculating hourly IV totals for a preterm labor client E. assisting an active labor client with breathing and relaxation

To help prevent osteoporosis, what should a nurse advise a young woman to do? A. avoid trauma to the affected bone B. encourage the use of a firm mattress C. consume at least 1000 mg of calcium daily D. keep the serum uric level within the normal range

C. consume at least 1000 mg of calcium dail

When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which intervention should the nurse employ as the first step? A. using gentle touch to convey empathy B. rephrasing questions the client does not understand C. eliminating distracting stimuli such as turning off the television D. asking the client to go for a walk while talking

C. eliminating distracting stimuli such as turning off the television

After surgery and insertion of a total hip prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating: A. a developing infection B. bleeding in the operative site C. joint dislocation D. glue seepage into soft tissue

C. joint dislocation

A client with dementia must be temporarily hospitalized. The family wants to take proactive measures to assure the client does not experience further confusion. Which measure if suggested by the family would the nurse discourage? A. posting a calendar in the room B. bringing familiar objects from home for the room C. keeping lights dimmed during daylight hours D. providing for uninterrupted sleep

C. keeping lights dimmed during daylight hours Clients with dementia are at risk for sudden decreases in their mental status when placed in unfamiliar settings. Keeping clients in a darkened room during the day simulates night and can disrupt the client's sleep wake cycle which exacerbates confusion. Providing for uninterrupted sleep helps maintain cognition. Bringing familiar objects from home makes the environment more comfortable and less strange. Clocks and calendars help keep the clients oriented to time.

When planning care for a client with ulcerative colitis who is experiencing an exacerbation of symptoms, which client care activities can the nurse appropriately delegate to an unlicensed assistive personnel (UAP)? Select all that apply A. assessing the client's bowel sounds B. evaluating the client's response to anti-diarrheal medications C. maintaining intake and output records D. providing skin care following bowel movements E. obtaining the client's weight

C. maintaining intake and output records D. providing skin care following bowel movements E. obtaining the client's weight

A client has been diagnosed with degenerative joint disease (osteoarthritis) of the left hip. Which factor in the client's history would most likely increase the joint symptoms of osteoarthritis? A. a long history of smoking B. excessive alcohol use C. obesity D. emotional stress

C. obesity

When caring for the client diagnosed with delirium, which condition is the most important for the nurse to investigate? A. cancer of any kind B. impaired hearing C. prescription drug intoxication D. heart failure

C. prescription drug intoxication

Which activity would be appropriate to delegate to the UAP for a client diagnosed with a myocardial infarction who is stable? A. provide teaching on a 2 g sodium diet B. evaluate the lung sounds C. record the intake and output D. help the client identify risk factors for CAD

C. record the intake and output

The husband of a client who was diagnosed 6 years ago with Alzheimer's disease approaches the nurse and says, "I am so excited that my wife is starting to use donepezil (Aricept) for her illness." The nurse should tell the husband: A. effectiveness in the terminal phase of the illness is scientifically proven. B. the adverse effects of the drug are numerous. C. the medication is effective mostly in the early stages of the illness. D. the client will attain a functional level equal to that of 6 years ago.

C. the medication is effective mostly in the early stages of the illness. : When compared with other similar medications, donepezil has fewer adverse effects. Donepezil is effective primarily in the early stages of the disease. The drug helps to slow the progression of the disease if started in the early stages. After the client has been diagnosed for 6 years, improvement to the level seen 6 years ago is highly unlikely. Data are not available to support the drug's effectiveness for clients in the terminal phase of the disease.

A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the UAP to do during postmortem care? Select all that apply A. notify the family B. remove all tubes and IV lines C. transport the body to the morgue D. notify the chaplain E. cover the body with a sheet

C. transport the body to the morgue E. cover the body with a sheet

The nurse is teaching a client with osteoporosis about taking alendronate sodium. The nurse emphasizes that the client is to take the medication: A. at bedtime B. with food C. with a full glass of water and remain upright for 30 minutes D. with a full glass of juice and then rest for 30 minutes

C. with a full glass of water and remain upright for 30 minutes

A nurse notes ulcerations on the surfaces of a patient's toes. What should this assessment most likely indicate? A. Skin breakdown from pressure B. Nutritional deficit C. Venous stasis D. Arterial stasis

D. Arterial stasis (impaired skin integrity) Arterial insufficiency is any condition that slows or stops the flow of blood through your arteries

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse? A. The nursing staff should rely on the family to assist with care because family members know the client best. B. Alzheimer's disease affects memory so the client doesn't need an explanation before procedures are performed. C. As long as the client receives the ordered medication, special care measures aren't necessary. D. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgement.

D. Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgement.

A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching? A. Warfarin therapy for atrial fibrillation B. Pacental abruption C. Systemic lupus erythematosus D. Herparin therapy for deep vein thrombosis

D. Herparin therapy for deep vein thrombosis Heparin-induced thrombocytopenia (HIT) is the development of thrombocytopenia (a low platelet count), due to the administration of various forms of heparin, an anticoagulant. ... HIT is caused by the formation of abnormal antibodies that activate platelets

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A. iron 90 B. RBC 6.5 C. WBC 4,800 D. Hgb 10

D. Hgb 10 (12-16 female, 14-18 male) An iron level of 90 is normal (60-160) female RBCs are above range (anemia would be below normal (4.2 - 6 mil) WBCs are below normal (5 to 10,000)

A nurse is caring for a client who has been diagnosed with delirium. Which statement about delirium is true? A. It's characterized by an acute onset and lasts about 1 month B. It's characterized by a slowly evolving onset and lasts about 1 week C. It's characterized by a slowly evolving onset and lasts about 1 month D. It's characterized by an acute onset and lasts hours to a number of days

D. It's characterized by an acute onset and lasts hours to a number of days

What should a nurse ask a patient related to past history of deep-vein thrombosis and other vascular problems? A. An aneurysm B. Rheumatoid Arthritis C. A peptic ulcer D. Recurring chest pain

D. Recurring chest pain (could be a clot, PE or dyspnea)

The nurse is planning an educational program about the prevention of osteoporosis for a group of women. Which preventive measures would be appropriate for the nurse to include in the teaching plan? A. increasing daily intake of protein B. ingesting 2,000 mg of calcium supplements daily C. sunbathing for 1 hour a day during the summer months D. encouraging weight bearing exercise on a regular basis

D. encouraging weight bearing exercise on a regular basis

After a total hip replacement, the client tells the nurse that the pain in the operative hip has increased. Assessing the hip and leg, the nurse notes that the leg is internally rotated and shorter than the other leg and that the client has difficulty moving the leg. Based on this information, the nurse determines that the client: A. has experienced increased pain due to a muscle spasm B. requires repositioning to achieve better alignment of the leg C. would benefit from additional muscle-strengthening exercises D. has experienced a dislocation of the hip prostesis

D. has experienced a dislocation of the hip prostesis

An elderly woman experiences short-term memory problems and occasional disorientation a few weeks after her husband's death. She also is not sleeping, has urinary frequency and burning, and sees rats in the kitchen. The home care nurse calls the woman's health care provider to discuss the client's situation and background, assess, and give recommendations. The nurse concludes that the woman: A. is experiencing the onset of Alzheimer's disease B. is having trouble adjusting to living alone without her husband C. is having delayed grieving related to her Alzheimer's disease D. is experiencing delirium and a UTI

D. is experiencing delirium and a UTI

The nurse is evaluating the outcome of therapy for a client with osteoarthritis. Which outcome indicates the goals of therapy have been met? A. joint degeneration arrested B. able to self-administer gold compound safely C. feels better than on hospital admission D. joint range of motion improved

D. joint range of motion improved

Which condition should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? A. anemia B. osteoporosis C. weight loss D. local joint pain

D. local joint pain

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which suggestion is most relevant? A. allow the client to go to bed four to five times during the day B. test the cognitive functioning of the client several times a day C. provide reality orientation even if the memory loss is severe D. maintain consistency in environment, routine, and caregivers

D. maintain consistency in environment, routine, and caregivers

A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan? A. removing the weights once every shift B. maintaining the bed in the knee-Gatch position C. keeping the client in semi-fowler's position D. maintaining correct body alignment

D. maintaining correct body alignment

When assessing a client who reports a back injury, it is critical for the nurse to question the client about: A. family history of back problems B. previous hospitalizations C. personal history of illness D. mechanism of injury (how did it happen)

D. mechanism of injury (how did it happen)

A nurse is giving instruction to a client who's going home with a cast on his leg. Which teaching point is most critical? A. using crutches properly B. exercising joints above and below the cast, as ordered C. avoiding walking on a leg cast without the physician's permission D. reporting signs of impaired circulation

D. reporting signs of impaired circulation

A nurse is caring for a client who complains of lower back pain. Which instruction should the nurse give to the client to prevent back injury? A. bend over the object you're lifting B. narrow the stance when lifting C. push or pull an object using your arms D. stand close to the object you're lifting

D. stand close to the object you're lifting

After the application of an arm cast, the client has pain on passive stretching of the fingers, finger swelling and tightness, and loss of function. Based on these date, the nurse anticipates that the client may be developing: A. delayed bone union B. compartment syndrome C. fat embolism D. osteomyelitis

B. compartment syndrome Compartment syndrome is a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissues.

The nurse is collecting data on the client with a UTI. Which statements should the nurse expect the client to make? (Select all that apply) A. I urinate large amounts B. I need to urinate frequently C. It burns when I urinate D. my urine smells sweet E. I need to urinate urgently

B. I need to urinate frequently C. It burns when I urinate E. I need to urinate urgently

Following a total joint replacement, which complication has the greatest likelihood of occurring? A. DVT B. polyuria C. displacement of the new joint D. wound evisceration

A. DVT

The client has just had a total knee replacement for severe osteoarthritis. When assessing the client, which finding should lead the nurse to suspect possible nerve damage? A. numbness B. bleeding C. dislocation D. pinkness

A. numbness

A client is with osteoporosis. Which statements would the nurse include when teaching the client about the disease? (Select all that apply) A. osteoporosis is common in females after menopause B. osteoporosis is a degenerative disease characterized by a decrease in bone density C. the disease is inherited, caused by an inability to tolerate milk products D. osteoporosis can cause pain and injury E. passive ROM exercises can promote bone growth F. weight-bearing exercise would be avoided

A. osteoporosis is common in females after menopause B. osteoporosis is a degenerative disease characterized by a decrease in bone density D. osteoporosis can cause pain and injury

The client is to undergo a series of diagnostic tests to determine if the client's cognitive impairment is treatable. Which state can lead to non-reversible cognitive impairment? A. cerebral abscess B. Alzheimer's disease C. delirium D. electrolyte imbalance

B. Alzheimer's disease

A client in a double hip spica cast is constipated. The surgeon cuts a window into the front of the cast. Which outcome is intended? A. the window will allow the nurse to palpate the superior mesenteric artery B. the window will allow the surgeon to manipulate the fracture site C. the window will allow the nurses to reposition the client D. the window will provide some relief from the pressure due to abdominal distention as a result of constipation

D. the window will provide some relief from the pressure due to abdominal distention as a result of constipation

A client is scheduled for a laminectomy to repair a herniated intervertebral disk. When developing the postoperative care plan, the nurse should include which action? A. keeping a pillow under the client's knees at all times B. placing the client in semi-fowler's position C. maintaining bed rest for 72 hours after laminectomy D. turning the client from side to side, using the logroll technique

D. turning the client from side to side, using the logroll technique (takes several people)

A nurse is caring for a 14 year old client who was admitted with cellulitis and has been ordered warm compresses. The nurse delegates the treatment to the UAP. The compress causes a first-degree burn to the area. Which of the following actions should the nurse initiate? A. complete an incident report regarding the event B. Initiate a disciplinary action toward the UAP C. document the injury indicating that the UAP is liable D. place cold compresses on the injured area E. notify the healthcare provider of the injury

E. notify the healthcare provider of the An incident report be done after the incident is reported to the provider