Theory Exam 4

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response? a. "It is always a good idea to rest quietly after surgery, which will help minimize further pain." b. "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." c. "The physician will probably order you to lie flat for 24 hours." d. "Why don't you decide about activity after you return from recovery?"

b. "Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

During a health screening event, which assessment finding in a 61-yr-old patient would alert the nurse to the possible presence of osteoporosis? a. Presence of bowed legs b. Measurable loss of height c. Poor appetite and aversion to dairy products d. Development of unstable, wide-gait ambulation

b. Measurable loss of height

A patient who has diabetes and uses insulin to control blood glucose has been NPO since midnight before having a knee replacement surgery. Which action should the nurse take? a. Withhold the usual scheduled dose because the patient is NPO. b. Obtain a blood glucose measurement before any insulin administration. c. Give the patient the usual scheduled insulin dose because stress will increase the blood glucose. d. Administer a lower dose of insulin because there will be no oral intake before surgery.

b. Obtain a blood glucose measurement before any insulin administration

A 58-yr-old woman is 1-day postoperative after an abdominal hysterectomy. Which intervention should the nurse perform to prevent VTE? a. Place the patient in a high Fowler's position. b. Provide pillows to place under the patient's knees. c. Encourage the patient to change positions frequently. d. Teach the patient deep breathing and coughing exercises.

c. Encourage the patient to change positions frequently.

The nurse determines dietary teaching for a 75-yr-old patient with osteoporosis has been successful when the patient selects which meal as highest in calcium? a. Chicken stir fry with 1 cup each onions and green peas, and 1 cup of steamed rice b. Ham and Swiss cheese sandwich on whole wheat bread, steamed broccoli, and an apple c. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk d. A 2-egg omelet with 2 oz of American cheese, 1 slice of whole wheat toast, and a half grapefruit

c. Sardine (3 oz) sandwich on whole wheat bread, 1 cup of fruit yogurt, and 1 cup of skim milk

A patient decides not to use hormone therapy after menopause. What instructions should the nurse provide to this patient to decrease the serious effects of menopause? a. Take 800 mg of calcium every day. b. Supplement the diet with vitamin E. c. Maintain a high-protein, low-fat diet. d. Engage in aerobic, weight-bearing exercise.

d. Engage in aerobic, weight-bearing exercise.

A patient arrives at the ambulatory surgery center for a scheduled laparoscopy procedure in outpatient surgery at 3pm. Which information is of most concern to the nurse? a. The patent had sausage, oatmeal, and coffee at noon. b. The patient had a sip of water 4 hours before arriving. c. The patient's insurance does not cover outpatient surgery. d. The patient had chicken broth and water at 7 AM.

a. The patient had sausage, oatmeal, and coffee at noon

A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? a. The patient was oriented and alert when admitted. b. The patient's speech is fragmented and incoherent. c. The patient is oriented to person but disoriented to place and time. d. The patient has a history of increasing confusion over several years.

a. The patient was oriented and alert when admitted.

Which persons are at high risk for chronic low back pain? (select all that apply) a. a 63-yr-old man who is a long-distance truck driver b. A 30-yr-old nurse who works on the orthopedic unit and smokes c. A 55-yr-old construction worker who is 6ft, 2 in and weighs 250 lbs d. A 44-yr-old female chef with prior compression fracture of the spine e. A 28-yr-old female yoga instructor who is 5 ft, 6 in and weights 130 lb

a. a 63-yr-old man who is a long-distance truck driver b. A 30-yr-old nurse who works on the orthopedic unit and smokes c. A 55-yr-old construction worker who is 6ft, 2 in and weighs 250 lbs d. A 44-yr-old female chef with prior compression fracture of the spine

An older adult woman who is usually meticulous about her appearance and dress arrives today for her 23rd day of radiation therapy. She appears disheveled and emotionally labile, and her responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm, her respirations are 32 breaths/min, and her skin is cold and clammy. Based on these findings, the nurse should further assess the client for which condition? a. delirium b. schizophrenia c. depression d. panic disorder

a. delirium

An older adult 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 client most likely has which problem? a. delirium and a urinary tract infection b. the onset of Alzheimer's disease c. trouble adjusting to living alone without her husband d. delayed grieving related to her Alzheimer's disease

a. delirium and a urinary tract infection

A client is scheduled to have surgery to relieve an intestinal obstruction. Prior to surgery, the nurse should verify that the client has followed which preoperative instructions? a. discontinued use of blood thinners b. eaten a low-residue diet c. performed abdominal tightening exercises d. signed a last will and testament

a. discontinued use of blood thinners

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? a. transurethral resection of the prostate (TURP) b. suprapubic prostatectomy c. retropubic prostatectomy d. transurethral laser incision of the prostate

a. transurethral resection of the prostate (TURP)

An older adult client is admitted to the unit after being examined in the emergency department (ED) and diagnosed with delirium. After the admission interviews with the client and her grandson, the nurse explains that there will be more laboratory tests and X-rays done that day. The grandson says, "She's already been stuck several times and had a brain scan or something. Just give her some medicine and let her rest." What should the nurse tell the grandson? Select all that apply. a. "I'll ask the health care provider to postpone more tests until tomorrow." b. "Delirium commonly results from underlying medical causes that we need to identify and correct." c. "The health care provider will look at the results of those tests in the ED and decide what other tests are needed." d. "I agree she needs to rest, but there's no one specific medicine for your grandmother's condition." e. "Delirium is a common complication of hospitalization."

b. "Delirium commonly results from underlying medical causes that we need to identify and correct." c. "The health care provider will look at the results of those tests in the ED and decide what other tests are needed." d. "I agree she needs to rest, but there's no one specific medicine for your grandmother's condition." e. "Delirium is a common complication of hospitalization."

A nurse notes increasing edema in the calf of a client who has multiple fractures of the leg. The nurse should recognize that increasing edema is a manifestation of which of the following complications? a. Fat embolism syndrome b. Acute compartment syndrome c. Pulmonary embolism d. Malignant hypothermia

b. Acute compartment syndrome

A patient that has never had any prior surgeries tells the nurse doing the preoperative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take? a. Notify the dietitian about the food allergies. b. Alert the surgery center about a possible latex allergy. c. Reassure the patient that all allergies are noted on the medical record. d. Ask whether the patient uses antihistamines to reduce allergic reactions.

b. Alert the surgery center about a possible latex allergy.

Surgeon prescribes cefazolin 1g via IV at 0730 when the pt's surgery is scheduled at 0800. What is the rationale? a. Legally the medication has to be given at the prescribed time. b. Antibx help prevent infection if given 30-60 mins prior to the incision c. Postop dose of cefazolin should be started exactly 8 hours after the 1st d. The peak and titer levels are needed for antibiotic therapy.

b. Antibx help prevent infection if given 30-60 mins prior to the incision

A nurse is providing teaching to a client who has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine cancer. Which of the following instructions should the nurse include in the teaching? a. A Papanicolaou (Pap) test should be performed every 6 months. b. Artificial lubrication can be used to treat vaginal itching and dryness. c. Increased vaginal drainage typically occurs 5 days following surgery. d. Resume sexual intercourse in 2 to 3 weeks.

b. Artificial lubrication can be used to treat vaginal itching and dryness.

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority? a. Increase the oxygen flow to 3 L/min. b. Assess the client's respiratory status. c. Call emergency services for the client. d. Have the client cough and expectorate secretions.

b. Assess the client's repiratory status

The RN is removing staples from an abd incision when the pt sneezes & the incision opens. What should the RN do 1st? a. Press the emergency alarm to call the resuscitation team. b. Cover the abd organs with sterile dressings moistened with sterile 0.9% NS c. Have all visitors and family leave the room. d. Call the surgeon to come to the client's room immediately.

b. Cover the abd organs with sterile dressings moistened with sterile 0.9% NS

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications? a. Hypovolemic shock b. Fat embolism syndrome c. Compartment syndrome d. Venous thromboembolism

b. Fat embolism syndrome

A nurse is caring for a client who has fractures of the symphysis pubis and pelvis. The nurse should monitor the client for which of the following findings of a common complication of pelvic fractures? a. Diarrhea b. Hematuria c. Increased thirst d. Impaired taste

b. Hematuria

A nurse is collaborating care for a client who has COPD. Which of the following tasks should the nurse recommend be referred to an occupational therapist for assistance? a. Instructing how to measure oxygen saturation b. Instructing how to use kitchen tools to prepare a meal c. Instruction how to plan a diet based on individual caloric needs d. Instructing how to perform pursed-lip breathing

b. Instructing how to use kitchen tools to prepare a meal

Which of the following is NOT a diagnostic test that would need to be done in an elderly individual presenting with delirium? a. Medication reconciliation b. Kidney Biopsy c. Urine culture d. Serum blood levels- TSH, T3, T4

b. Kidney Biopsy

The client's identification armband was cut and removed to start an IV line as a part of the preoperative preparation. The transport team has arrived to transport the client to the operating room. The nurse notices that the client's identification band is not on either wrist. What should the nurse do? a. Send the removed armband with the medical record and the client to the operating room. b. Place a new identification armband on the client's wrist before transport. c. Tape the cut armband back onto the client's wrist. d. Send the client without an armband because the client is alert and can respond to questions about his or her identity.

b. Place a new identification armband on the client's wrist before transport.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? a. Provide complete personal hygiene care for the patient. b. Remind the patient frequently about being in the hospital. c. Reposition the patient frequently to avoid skin breakdown. d. Place suction at the bedside to decrease the risk for aspiration.

b. Remind the patient frequently about being in the hospital.

Alendronate (Fosamax) is prescribed for a patient with osteoporosis. The nurse teaches the patient that: a. the drug must be taken with food to prevent GI side effects. b. bisphosphonates prevent calcium from being taken from the bones. c. lying down after taking the drug prevents light-headedness and dizziness. d. taking the drug with milk enhances the absorption of calcium from the bowel

b. bisphosphonates prevent calcium from being taken from the bones. Alendronate is a bisphosphonate that prevents calcium from being taken from the bones by inhibiting osteoclast-mediated bone resorption. Bisphosphonates should be taken with a full glass of water, 30 minutes before food or other medications, and the patient should remain upright for at least 30 minutes after administration. These precautions aid in drug absorption and decrease gastrointestinal side effects (especially esophageal irritation).

When caring for the client diagnosed with delirium, the nurse should investigate which condition as the most important? a. cancer of any kind b. prescription drug intoxication c. impaired hearing d. heart failure

b. prescription drug intoxication

Which nursing action does not aid in meeting the goal of clear breath sounds? a. offering pain relief before having the client cough b. providing a minimum of 1,000 mL of fluid per day c. using an incentive spirometer d. assisting with early ambulation

b. providing a minimum of 1,000 mL of fluid per day

Which statement(s) accurately describe(s) mild cognitive impairment? (Select all that apply) a. Cannot be detected by screening tests b. the person may appear normal to the casual observer c. family memebers may see changes in the patient's abilities d. problems that the person is experiencing interfere with daily activities e. the person is usually aware that there is a problem with his or her memory

b. the person may appear normal to the casual observer c. family memebers may see changes in the patient's abilities e. the person is usually aware that there is a problem with his or her memory

The pre-op RN is speaking to a pt who added garlic daily to her diet to help with her BP. What should the RN ask next? a. "What type of surgery are you having?" b. "What is your normal blood pressure?" c. "How much garlic are you eating?" d. "What type of anesthesia are you having?"

c. "How much garlic are you eating?"

Which patient statement indicates understanding of the nurse's teaching about a new short-arm synthetic cast? a. "I can remove the cast in 4 weeks using industrial scissors." b. "I should avoid moving my fingers until the cast is removed." c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours." d. "I can use a cotton-tipped applicator to rub lotion on any dry areas under the cast.:

c. "I will apply an ice pack to the cast over the fracture site off and on for 24 hours."

. The adult daughters of an older adult client inform the nurse that they fully expect their father to be combative after surgery. Preoperatively, they request that the nurse put all four side rails up and use restraints to keep him safe. What should the nurse tell the daughters? a. "Certainly; we will want to be sure to keep your father safe, too." b. "We will call the health care provider to get a prescription right away." c. "We will first try to keep him safe without restraint." d. "Restraint use is prohibited at our hospital at all times."

c. "We will first try to keep him safe without restraint."

Which statement would be included in the nurse's teaching plan regarding phantom pain after amputation? a. "The pain will disappear soon." b. "It's likely that you will have only a tingling sensation." c. "Your pain will gradually become less severe." d. "Phantom pain is mostly psychological."

c. "Your pain will gradually become less severe."

Which patient would be at greatest risk for developing osteoporosis? a. A 73-year-old man who has 5 alcoholic drinks per week and limits sun exposure to prevent recurrence of skin cancer. b. An 84-year-old man who has recently been diagnosed with hypothyroidism and is prescribed levothyroxine (Synthroid). c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection. d. A 55-year-old woman who recently had a hysterectomy with bilateral salpingo-oophorectomy and refuses estrogen therapy.

c. A 69-year-old woman who had a renal transplant 5 years ago and has been taking prednisone to prevent organ rejection. Risk factors for osteoporosis include advanced age (greater than 65 years), female gender, low body weight, white or Asian ethnicity, current cigarette smoking, nontraumatic fracture, inactive lifestyle, family history of osteoporosis, diet low in calcium or vitamin D deficiency, excessive use of alcohol (greater than 2 drinks per day), postmenopausal, including premature or surgical menopause, and long-term use of corticosteroids, thyroid replacements, heparin, long-acting sedatives, or antiseizure medications.

A 91 year old female comes into the emergency room with symptoms of delirium. Which of the following would NOT be a possible cause of her condition? a. Urinary tract infection b. Dehydration c. Alzheimer's disease d.Hypothyroidism

c. Alzheimer's disease

What should the nurse include when teaching older adults at a community recreation center about ways to prevent fractures? a. Tack down scatter rugs on the floor in the home b. Expect most falls to happen outside the home in the yard c. Buy shoes that provide good support and are comfortable to wear d. Get instruction in range-of-motion exercises from a physical therapist

c. Buy shoes that provide good support and are comfortable to wear

When conducting the preoperative preparations, the nurse determines that the client does not speak English, and the nurse does not speak the client's language. The surgeon needs to obtain the client's informed consent. What is the best way for the nurse to obtain the client's informed consent? a. Have the client call a family member to act as interpreter. b. Have the client sign the Spanish surgical consent form. c. Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions. d. Notify the surgical charge nurse of the situation.

c. Call the Spanish interpreter to translate the surgeon's explanation of the procedure, risks, and alternatives to obtain the client's consent and to answer the client's questions.

A nurse is planning care for a client who has pelvic fractures and will require bed rest and traction for 4 to 6 weeks. The client is a stay-at-home mother and her husband travels extensively for his job. Which of the following effects should the nurse consider when planning care for the family? a. Loss of privacy b. Decrease in income c. Changes in family members' roles and tasks d. Loss of autonomy for the children

c. Changes in family members' roles and tasks

A nurse is teaching a client who has a prosthetic limb due to a right below-the-knee amputation about prosthesis and stump care. Which of the following instructions should the nurse include in the teaching? a. Keep the prosthesis in direct contact with the residual limb. b. Apply a moisturizing lotion or oil to the stump daily. c. Dry the prosthesis socket completely before applying it to the limb. d. Expect some skin irritation from the prosthesis.

c. Dry the prosthesis socket completely before applying it to the limb

A nurse is caring for a middle-aged adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause? a. Urinary retention b. Decreased blood pressure c. Dryness with intercourse d. Elevation in body temperature above 37.8° C (100° F)

c. Dryness with intercourse

A client in a general hospital is to undergo surgery in 2 days and is experiencing moderate anxiety about the procedure and its outcome. What should the nurse do to help the client reduce anxiety? a. Distract the client with games and television. b. Provide reassurance that the client that will come through surgery without incident. c. Explain the surgical procedure to the client and what happens before and after surgery. d. Ask the surgeon to refer the client to a psychiatrist who can work with the client to diminish anxiety.

c. Explain the surgical procedure to the client and what happens before and after surgery.

The nurse is preparing to administer a preoperative medication that includes a sedative to a client who is having abdominal surgery. What should the nurse do first? a. Have the family present. b. Ensure that the operative area has been shaved. c. Have the client empty the bladder. d. Make sure the client is covered with a warm blanket.

c. Have the client empty the bladder.

For what purpose would the nurse use the Mini-Mental State Examination to evaluate a patient with cognitive impairment? a. It is a good tool to determine the etiology of dementia. b. It is a good tool to evaluate mood and thought processes. c. It can help to document the degree of cognitive impairment in delirium and dementia. d. It is useful for initial evaluation of mental status but additional tools are needed to evaluate changes in cognition over time.

c. It can help to document the degree of cognitive impairment in delirium and dementia.

A nurse is assessing an older adult client who has osteoporosis. Which of the following spinal deformities should the nurse expect to find in this client? a. Lordosis b. Ankylosis c. Kyphosis d. Scoliosis

c. Kyphosis

When Melissa was a small child, she insisted that she was a boy, refused to wear dresses, and wanted to be called Mitch. As Melissa reached puperty, she no longer displayed a desire to be male. This change in identity is considered: a. Gender dysphoria b. Reaction formation c. Normal d. Early transgender syndrome

c. Normal

When the nurse asks the client who is having abdominal surgery today if the client understands the procedure, the client replies, "No, not really; I talked about several different things with my surgeon, and I'm just not sure." What should the nurse do next? a. Teach the client all the details of the planned procedures. b. Utilize a second witness when the client signs for consent. c. Notify the surgeon of the client's expressed lack of understanding. d. Administer the prescribed preoperative narcotics and/or sedatives.

c. Notify the surgeon of the client's expressed lack of understanding.

Vascular dementia is associated with a. transient ischemic attacks b. bacterial or viral infection of neuronal tissue c. cognitive changes secondary to cerebral ischemia d. abrupt changes in cognitive function that are irreversible

c. cognitive changes secondary to cerebral ischemia

The nurse is assessing a client admitted to the hospital for surgery to repair an abdominal aortic aneurysm. Prior to surgery, the nurse should assess the client for which factor that puts the client at risk for rupture? a. anemia b. dehydration c. high blood pressure d. hyperglycemia

c. high blood pressure

A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find a. excessive nighttime sleepiness. b.difficulty eating and swallowing. c. loss of recent and long-term memory. d.fluctuating ability to perform simple tasks.

c. loss of recent and long-term memory.

The nurse is reinforcing health teaching about osteoporosis with a 72-yr-old patient admitted to the hospital. What should the nurse explain to the patient? a. With a family history of osteoporosis, you cannot prevent or slow bone resorption. b. Estrogen therapy must be maintained to prevent rapid progression of the osteoporosis. c. Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis. d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

d. Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.

A client who is to receive general anesthesia has a serum potassium level of 5.8 mEq/L. What does the RN do first? a. Call the operating room to cancel the surgery. b. Send the client to surgery. c. Make a note on the client's record. d. Notify the anesthesiologist.

d. Notify the anesthesiologist.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to a.secure the patient in bed using a soft chest restraint. b.ask the health care provider to order an antipsychotic drug. c. instruct family members to remain with the patient and prevent injury. d.assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

d.assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation.

One benefit of hormone replacement therapy is protection against? a. Bone Cancer b. Colon Cancer c. Lung Cancer d. Brain Cancer

b. Colon Cancer

Hormone Replacement Therapy (HRT) is generally used in menopausal women for.... a. 6 months b. <10 years c. <5 years d. 18 months

c. <5 years

Dementia is defined as a A. syndrome that results only in memory loss. B. disease associated with abrupt changes in behavior. C. disease that is always due to reduced blood flow to the brain. D. syndrome characterized by cognitive dysfunction and loss of memory.

D. syndrome characterized by cognitive dysfunction and loss of memory.

Which statement by a patient scheduled for surgery is most important to report to the health care provider? a. "I had a heart valve replacement last year." b. "I had bacterial pneumonia 3 months ago" c. "I have knee pain whenever I walk or jog" d. "I have a strong history of breast cancer"

a. "I had a heart valve replacement last year."

Postoperative care for the patient who had an abdominal hysterectomy includes (select all that apply) a. monitoring urine output b. changing position frequently c. restricting all food for 24 hours d. observing perineal pad for pleeding e. encouraging leg exercises to promote circulation

a monitoring urine output b. changing position frequently e. encouraging leg exercises to promote circulation

A patient is discussing with the RN risks versus benefits of estrogen therapy (ET). Which of the following is a risk? a. cardiovascular disease b. reduction in hot flashes c. osteoporosis d. alzheimer's disease

a. cardiovascular disease

A 38 year-old female is admitted for an elective surgical procedure. Which information obtained by the nurse during the preoperative assessment is most important to report to the anesthesiologist before surgery? a. The patient's lack of knowledge about postoperative pain control measures. b. The patient's statement that her last menstrual period was 8 weeks previously. c. The patient's history of a postoverative infection following a prior cholecystectomy. d. The patient's concern that she will be unable to care for her children postoperatively.

b. The patient's statement that her last menstrual period was 8 weeks previously.

The nurse is working with a licensed practical nurse (LPN) and delegating the taking of vital signs for a preoperative client. Upon review of the chart as the client is leaving for the operating room, the nurse notes that the temperature is 101.1°F (38.4°C) and the pulse is 110 bpm. What are the nurse's initial actions? a. Have the LPN take the vital signs again, phone the operating room, and cancel the surgery. b. Take the vital signs, and in the future do not delegate this preoperative responsibility. c. Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs. d. Sign off the chart but flag that vital signs are abnormal; allow the client to go to the operating room.

c. Notify the surgeon and await the surgeon's decision; reinforce with the LPN the importance of reporting abnormal preoperative vital signs.

The RN is interviews a preop pt who had a total hip replacement 3 yrs ago.Why should the RN tell this to the circulator? a. Prosthesis may cause a prob w/the electrosurgical unit b. The perioperative RN can inform the rest of the team about the total hip c. The pt should not have her hip externally rotated when she is positioned d. There isn't enough time to notify the surgeon & note this on the chart

c. The pt should not have her hip externally rotated when she is positioned

A nurse is teaching a client about preventing osteoporosis. Which of the following statements by the client indicates a need for further teaching? a. "I will reduce my intake of sodium." b. "I will decrease my intake of caffeine." c. "I will limit my intake of soft drinks." d. "I will reduce my intake of vitamin K-rich foods."

d. "I will reduce my intake of vitamin K-rich foods."

A nurse is assessing a client who has COPD. The nurse should expect the client's chest to be which of the following shapes? a. Pigeon b. Funnel c. Kyphotic d. Barrel

d. Barrel

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan? a. Restrict the client's fluid intake to less than 2 L/day. b. Provide the client with a low-protein diet. c. Have the client use the late afternoon hours for exercise and activity. d. Instruct the client to use pursed-lip breathing.

d. Instruct the client to use pursed-lip breathing

Dementia with Lewy bodies (DLB) is characterized by a. remissions and exacerbations over many years b. memory impairment, muscle jerks, and blindness c. parkinsonian symptoms, including muscle rigidity d. increased intracranial pressure from decreased CSF drainage

c. parkinsonian symptoms, including muscle rigidity

A client says, "I hate the idea of being an invalid after they cut off my leg." Which response by the nurse would be the most therapeutic? a. "At least you'll still have one good leg to use." b. "Tell me more about how you're feeling." c. "Let's finish the preoperative teaching." d. "You're lucky to have a wife to care for you."

b. "Tell me more about how you're feeling."

A nurse is providing discharge teaching to a client following an abdominal hysterectomy. Which of the following information should the nurse include in the teaching? a. "You should refrain from sexual intercourse for at least 4 weeks." b. "You should expect to have burning with urination for the first week." c. "You should soak in a warm tub bath to ease incisional pain." d. "You should limit lifting to objects of 20 pounds or less."

a. "You should refrain from sexual intercourse for at least 4 weeks."

Which patient is most at risk for developing delirium? a. A 50-yr-old woman with cholecystitis b. A 19-yr-old man with a fractured femur c. A 42-yr-old woman having an elective total hysterectomy d. A 78-yr-old man admitted to the medical unit with complications of heart failure

d. A 78-yr-old man admitted to the medical unit with complications of heart failure

A nurse suspects her patient may be suffering from delirium. What signs does the nurse observe to support this diagnosis? a. Slurred speech and one sided weakness b. Mask-like face and tremors c. Gradual onset of forgetfulness reported by family members d. Confusion and visual hallucinations

d. Confusion and visual hallucinations

Which nursing intervention is most important in preventing postoperative complications? a. progressive diet planning b. pain management c. bowel and elimination monitoring d. early ambulation

d. Early Ambulation

Reloxafine is prescribed for a patient. What information in the patient's history should the nurse question all except? a. History of breast cancer b. History of smoking c. History of a deep vein thrombosis d. History of pregnancy

d. History of pregnancy

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. Prevents osteoporotic fractures

The clinical diagnosis of dementia is based on a. CT or MRS b. brain biopsy c. electroencephalogram d. patient history and cognitive assessment

d. patient history and cognitive assessment

An assistive personnel (AP) reports to the nurse that a client who is 3 days postoperative following an abdominal hysterectomy has a dressing that is saturated with blood. Which of the following tasks should the nurse delegate to the AP? a. Change the abdominal dressing. b. Obtain vital signs. c. Palpate for possible bladder distention. d. Observe the incision site.

b. Obtain vital signs

A client has delirium following a head injury. The client is disoriented and agitated. Which of the following is not a correct action for the nurse to take? a. Assure the client's safety. b. Maintain a quiet environment. c. Administer an antidepressant. d. Aproach the client using short sentences.

c. Administer an antidepressant.

A nurse is reviewing risk factors for osteoporosis with a group of nursing students. The nurse should include that which of the following types of medication therapy is a risk factor for osteoporosis? a. Thyroid hormones b. Anticoagulants c. NSAIDs d. Cardiac glycosides

a. Thyroid hormones

What is most important to include in the teaching plan for a patient with osteopenia? a. Lose weight b. Stop smoking c. Eat a high-protein diet d. Start swimming for exercise

b. Stop smoking

A patient who had an open reduction and internal fixation (ORIF) of left lower leg fractures continues to report severe pain in the leg 15 minutes after receiving the prescribed IV morphine. The nurse determines pulses are faintly palpable and the food is cool to the touch. Which action should the nurse take next? a. Notify the health care provider b. Assess the incision for redness c. Reposition the left leg on pillows d. Check the patient's blood pressure

a. Notify the health care provider Compartment syndrome

A nurse is assessing the elastic bandage on the residual limb of a client who had a right below-the-knee amputation. Which of the following findings should the nurse identify as a complication? a. Pitting edema around the residual limb dressing b. Looseness of the residual limb dressing c. The dressing forms a cone shape over the residual limb. d. Figure-eight wrapping around the residual limb.

a. Pitting edema around the residual limb dressing

A nurse is providing teaching for a client who is preparing for a below the knee amputation. Which of the following statements is true regarding the postoperative placement of a prosthesis? a. "You will do special exercises in advance of getting your prosthesis." b. "You will be fitted for your prosthesis at the time of surgery." c. "A special pressure dressing will remain on to cushion your prosthesis." d. "The prosthesis will be adjustable depending on what shoe you are wearing."

a. "You will do special exercises in advance of getting your prosthesis."

A nurse is teaching a client who is scheduled for dual-energy x-ray absorptiometry (DXA) to screen for osteoporosis. Which of the following instructions should the nurse include in the teaching? a. "You will need to remove all jewelry before the test." b. "You will need to lie flat for 4 hours following the test." c. "You will need to empty your bladder before the test." d. "You will need to fast for 12 hours before the test."

a. "You will need to remove all jewelry before the test."

The surgical unit nurse has just received a patient with a history of smoking from the post anesthesia care unit. Which action is most important at this time? a. Auscultate for adventitious breath sounds. b. Obtain the patient's blood pressure and temperature, c. Remind the patient about harmful effects of smoking. d. Ask the health care provider about prescribing a nicotine patch.

a. Auscultate for adventitious breath sounds

The pt has a latex allergy. What should the nurse teach the client to do before having surgery? Select all that apply a. Determine that there will be a latex-safe environment for surgery. b. Notify the health care providers (HCPs) at the surgery center. c. Ask to have the surgery at a hospital. d. Report symptoms of the latex allergy (rhinitis, conjunctivitis, flushing)

a. Determine that there will be a latex-safe environment for surgery. b. Notify the health care providers (HCPs) at the surgery center. d. Report symptoms of the latex allergy (rhinitis, conjunctivitis, flushing)

The nurse is providing teaching to a group of perimenopausal women. Which herbs and supplements would the nurse include in a discussion about effective alternative therapies for menopausal symptoms? (Select all that apply.) a. Soy b. Garlic c. Gingko d. Vitamin A e. Cinnamon f. Black cohosh

a. Soy f. Black cohosh

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? a. Maintaining a semi-Fowler's position as often as possible b. Administering oxygen via nasal cannula at 2 L/min c. Helping the client select a low-salt diet d. Encouraging the client to drink 2 to 3 L of water daily

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

A patient scheduled for an elective hysterectomy tells the nurse "I am afraid that I will die in surgery like my mother did!" Which response by the nurse is most appropriate? a. Tell me more about what happened to your mother. b. You will receive medications to reduce your anxiety. c. You should talk to the doctor again about the surgery. d. Surgical techniques have improved a lot in recent years.

a. Tell me more about what happened to your mother

Pt is being sent home from same-day surgery.Which statement indicates that the pt doesn't understand postop instructions a. "My husband is taking the day off from work to drive me home." b. "I can drive myself home after surgery." c. "I am taking a taxi home, and my daughter will meet me at home." d. "My son will be here at noon to take me home."

b. "I can drive myself home after surgery."

The RN is discussing teaching on the drug alendronate with a student nurse. Which indicates the correct teaching? a. "This drug is for prevention of pregnancy." b. "It is important to take this drug with a full glass of water." c. "Take this medication with Aspirin to reduce flushing." d. "I don't need to monitor my calcium levels"

b. "It is important to take this drug with a full glass of water."

A nurse in a provider's office is collecting a health history from a client who is at risk for primary osteoporosis. Which of the following findings is a risk factor for the development of osteoporosis? a. Obesity b. Sedentary lifestyle c. Long-term use of diuretics d. Prolonged stress

b. Sedentary lifestyle

Which topic in most important for the nurse to discuss preoperatively with a patient who is scheduled for abdominal surgery for an open cholecystectomy? a. Care for the surgical incision b. Medications used during surgery c. Deep breathing and coughing techniques d. Oral antibiotic therapy after discharge home

c. Deep breathing and coughin techniques

A patient who is scheduled for a therapeutic abortion tells the nurse, "Having an abortion is not right." Which functional health pattern should the nurse further assess: a. Value-belief b. Cognitive-perceptual c. Sexuality-reproductive d. Coping-stress tolerance

a. Value-belief

An 80 year old client with an indwelling urinary catheter suddenly becomes confused and combative towards staff. Which intervention is appropriate when providing care for this client? a. Initiate restraints until the client calms down b. Move the client to a room closer to the nurse's station for observation c. Order a psychiatric consult to evaluate the client d. Have a calendar, clock, and schedule for the day clearly visible to the client

d. Have a calendar, clock, and schedule for the day clearly visible to the client

A nurse is caring for a client who is 2 days postoperative following an above-the knee-amputation. Which of the following is an appropriate nursing intervention for this client at this time? a. Elevate the foot of the bed. b. Encourage the client to sit up as much as possible. c. Elevate the client's residual limb on a pillow. d. Have the client lie prone every 2-3 hours for 20 minutes at a time.

d. Have the client lie prone every 2-3 hours for 20 minutes at a time

A patient undergoing an emergency appendectomy has been using Garlic to help treat hypercholesterolemia. Which complication would the nurse expect in the post-anesthesia care unit? a. Increased pain b. Hypertensive episodes c. Longer time to recover from anesthesia d. Increased risk for bleeding

d. Increased risk for bleeding

Because of the risks, a 50-yr-old patient does not want hormone replacement therapy for perimenopausal symptoms. She asks the nurse how to minimize hot flashes and night sweats. What should the nurse recommend first? a. Increase warmth to avoid chills. b. Good nutrition to avoid osteoporosis c. Vitamin B complex and vaginal lubrication d. Keep the bedroom cool and limit alcohol use.

d. Keep the bedroom cool and limit alcohol use.

A total abdominal hysterectomy is scheduled for a 42-year-old woman with multiple leiomyomas. What would be appropriate for the nurse to include during preoperative teaching? a. She will need to take hormone therapy postoperatively to prevent symptoms of menopause. b. Correct use of the patient-controlled analgesia (PCA) machine to prevent postoperative pain. c. A retention catheter will be used to help her maintain bed rest during the first 2 postoperative days. d. Leg exercises and early, frequent ambulation help to prevent common complications of hysterectomy.

d. Leg exercises and early, frequent ambulation help to prevent common complications of hysterectomy.