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The nurse gathers a health history from a 58-year-old male client with acute urinary retention. Which of the following questions should the nurse ask to aid in assessing for benign prostatic hyperplasia? Select all that apply. 1. "Do you feel the need to urinate again immediately after urinating?" 2."Do you have to strain to begin your stream of urine?" 3."How often do you engage in sexual intercourse?" 4."How often do you wake at night with the urge to urinate?" 5."Is your stream of urine weak or intermittent?"

1. "Do you feel the need to urinate again immediately after urinating?" 2."Do you have to strain to begin your stream of urine?" 4."How often do you wake at night with the urge to urinate?" 5."Is your stream of urine weak or intermittent?"

Which instructions should the nurse include when providing discharge teaching to a client with peptic ulcer disease due to Helicobacter pylori infection? Select all that apply. 1."Avoid foods that may cause epigastric distress such as spicy or acidic foods." 2."It is best if you refrain from consuming alcohol products." 3."Report black tarry stools to your health care provider immediately." 4."Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days." 5."You may take over-the-counter drugs such as aspirin if you have mild epigastric pain."

1."Avoid foods that may cause epigastric distress such as spicy or acidic foods." 2."It is best if you refrain from consuming alcohol products." 3."Report black tarry stools to your health care provider immediately." 4."Take your amoxicillin, clarithromycin, and omeprazole for the next 14 days."

The nurse is preparing to use an automated external defibrillator to defibrillate a client who is experiencing ventricular fibrillation and is unconscious. Which of the following actions should the nurse take? Select all that apply. 1.Apply the defibrillator pads to the client's chest. 2.Ensure that adequate IV sedation has been administered. 3.Call out and look around to ensure that staff members are all clear. 4.Continue chest compressions until the defibrillator is ready to analyze the rhythm. 5.Remove transdermal medication patches from the client's chest and cleanse the skin. 6.Ensure that the synchronization button is tuned on

1.Apply the defibrillator pads to the client's chest. 3.Call out and look around to ensure that staff members are all clear. 4.Continue chest compressions until the defibrillator is ready to analyze the rhythm. 5.Remove transdermal medication patches from the client's chest and cleanse the skin.

The nurse is preparing to administer medications to a client with a myocardial infarction. Which of the following medications are appropriate for the nurse to administer? Vital signs at 0800Temperature98.4 F (36.9 C) Blood pressure126/81 mm Hg Heart rate49/minRespirations16/min Click on the exhibit button for additional client information. Select all that apply. 1.Aspirin 2.Atorvastatin 3.Docusate sodium 4.Lisinopril 5.Metoprolol

1.Aspirin 2.Atorvastatin 3.Docusate sodium 4.Lisinopril

The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which of the following foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply. 1.Black beans and rice 2.Fortified breakfast cereal and milk 3.Medium baked sweet potato 4.Peanut butter on whole wheat toast 5.Raw carrots with cheese dip

1.Black beans and rice 2.Fortified breakfast cereal and milk 4.Peanut butter on whole wheat toast

The school nurse is teaching a class of 10-year-old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply. 1.Chew sugar-free gum 2.Drink fruit drinks/juices instead of sugary, carbonated beverages 3.Include milk, yogurt, and cheese in dietary intake 4.Minimize consumption of sweet, sticky foods 5.Rinse mouth with water after meals when brushing is not possible

1.Chew sugar-free gum 3.Include milk, yogurt, and cheese in dietary intake 4.Minimize consumption of sweet, sticky foods 5.Rinse mouth with water after meals when brushing is not possible

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply. Click the exhibit button for additional information. 1.Client is taking enoxaparin, and the platelet count is 50,000/mm3 (50 × 109/L) 2.Client is taking newly prescribed lisinopril and is at 8 weeks gestation 3.Client is taking nitroglycerin (patch) for heart failure, and blood pressure is 84/56 mm Hg 4.Client is taking phenytoin for epilepsy, and the nurse notes gingival hyperplasia 5.Client is taking warfarin for atrial fibrillation, and the INR is 5.2

1.Client is taking enoxaparin, and the platelet count is 50,000/mm3 (50 × 109/L) 2.Client is taking newly prescribed lisinopril and is at 8 weeks gestation 3.Client is taking nitroglycerin (patch) for heart failure, and blood pressure is 84/56 mm Hg 4.Client is taking phenytoin for epilepsy, and the nurse notes gingival hyperplasia 5.Client is taking warfarin for atrial fibrillation, and the INR is 5.2 (Option 4)Gingival hyperplasia or hypertrophy is a common adverse effect of phenytoin and is not an indication to stop the medication. Warfarin is an anticoagulant used to prevent clot formation in clients with atrial fibrillation. To determine whether the client is receiving an appropriate dose, the nurse should regularly check the INR. A therapeutic INR for a client with atrial fibrillation is 2.0-3.0. An INR >5.0 places the client at risk for severe bleeding

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. 1.Difficult to awaken 2.Dry skin . 3.Frequent, loose stools 4.Hoarse cry 5.Tachycardia

1.Difficult to awaken 2.Dry skin . 4.Hoarse cry Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1) Dry skin due to alterations in skin function (Option 2) Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4) Constipation due to slowed metabolism Bradycardia due to the effect of TH on cardiac function

The nurse is caring for an 11-month-old child in the pediatric hospital. Which of these child's findings would be a common criterion to activate the rapid response team? Select all that apply. 1.New-onset right-sided paralysis of extremities 2.Pulse rate sustained at 120/min 3.Respirations continued at 38/min 4.Sudden inability to be aroused to an awake state 5.Temperature of 101.3 F (38.5 C)

1.New-onset right-sided paralysis of extremities 4.Sudden inability to be aroused to an awake state (Option 2) Normal heart rate for an infant (1-12 months) is 100-160/min. (Option 3) Normal respiration rate for an infant (1-12 months) is 30-60/min. (Option 5) A fever is ordinarily not an emergency situation that meets the criteria to activate the rapid response team. It can signal a serious condition in infants who are age <1 month or in children age <2 years who have a temperature >104 F (40 C) without a localized source (due to an immature immune system).

The nurse has attended a staff education program about medication administration during pregnancy. Which of the following medications should the nurse recognize are contraindicated during pregnancy? Select all that apply. 1.lisinopril 2.albuterol 3.isotretinoin 4.doxycycline 5.levothyroxine

1.lisinopril 3.isotretinoin 4.doxycycline

The nurse is performing visual acuity screenings on a group of students. Which of the following student comments does the nurse recognize as indicating possible myopia? Select all that apply. 1."I can see my teacher better if I sit in the back of the classroom." 2."I have to hold my book close to my face so that the words are clear." 3."If I squint or close one eye, I can read the road signs when we travel." 4."My parents always tell me that I am sitting too close to the television." 5."Sometimes, I have to ask my parents if I've chosen socks that match."

2."I have to hold my book close to my face so that the words are clear." 3."If I squint or close one eye, I can read the road signs when we travel." 4."My parents always tell me that I am sitting too close to the television."

The nurse is teaching a client with ulcerative colitis who has a new prescription for sulfasalazine. Which of the following information should the nurse include? Select all that apply. 1."Avoid consuming foods high in protein." 2."Take vitamin and mineral supplements daily." 3."Apply a skin barrier cream for perianal irritation." 4."Increase your daily fluid intake to at least 2000 mL." 5."Continue taking sulfasalazine after your symptoms resolve."

2."Take vitamin and mineral supplements daily." 3."Apply a skin barrier cream for perianal irritation." 4."Increase your daily fluid intake to at least 2000 mL." 5."Continue taking sulfasalazine after your symptoms resolve."

The nurse is assessing a client with a brain tumor who has developed diabetes insipidus. Which of the following findings would the nurse expect? Select all that apply. 1.Dark amber urine with sediment 2.High serum osmolality 3.Low urine specific gravity 4.Recent weight gain 5.Reports of excessive thirst

2.High serum osmolality 3.Low urine specific gravity 5.Reports of excessive thirst

A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply. 1.Ask a family member about the client's preferences for room arrangement 2.Offer the client an elbow to hold, and walk a half-step ahead for guidance 3.Say "goodbye" when leaving the room to help orient the client 4.Speak slowly and slightly louder so the client can understand 5.Use a clock-face pattern to explain food arrangement on the client's meal tray

2.Offer the client an elbow to hold, and walk a half-step ahead for guidance 3.Say "goodbye" when leaving the room to help orient the client 5.Use a clock-face pattern to explain food arrangement on the client's meal tray

The nurse is caring for a client who had a transsphenoidal hypophysectomy and developed diabetes insipidus. Which of the following findings would the nurse expect to observe? Select all that apply. 1.decreased serum sodium level 2.excessive thirst 3.increased urine output 4.increased serum osmolality 5.increased urine specific gravity

2.excessive thirst 3.increased urine output 4.increased serum osmolality Polydipsia (ie, increased/excessive thirst) (Option 1) Polyuria (ie, increased urine output) (Option 2) Increased serum osmolality (ie, water-electrolyte balance in the blood) due to dehydration from polyuria (Option 3) (Option 4) Clients with DI experience hypernatremia (ie, increased serum sodium level) due to free water loss in the urine. (Option 5) The client with DI will likely have decreased urine specific gravity (ie, concentration of particles in the urine) due to increased free water loss in the urine.

During assessment of a client with cholelithiasis and acute cholecystitis, which of the following findings should the nurse expect during the health history and physical examination? Select all that apply. 1.Flank pain radiating to the groin 2.High-protein food ingestion before the onset of pain 3.Low-grade fever with chills 4.Pain at the umbilicus 5.Right upper quadrant pain radiating to the right shoulder

3.Low-grade fever with chills 5.Right upper quadrant pain radiating to the right shoulder (Option 1) Flank pain radiating to the groin would be expected in clients with renal calculi (ie, nephrolithiasis). (Option 2) It is not dietary protein but foods with significant fat content (eg, cheese, avocado, fried foods) that signal the gallbladder to contract, emptying bile into the small intestine to help digestion. (Option 4) The initial onset of pain at the umbilicus would be expected in clients with acute appendicitis.

The nurse is teaching a client with atrial fibrillation who has a new prescription for warfarin. The nurse should teach the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply. 1.bananas 2.oranges 3.spinach 4.broccoli 5.kale

3.spinach 4.broccoli 5.kale

Which would be the appropriate client criteria for activating a rapid response team at the hospital? Select all that apply. 1.Glasgow coma scale (GCS) score of 9 throughout shift 2.Heart rate remaining at 58 beats/min for more than 1 hour 3.Postoperative pain rated at 10 4.Respiratory rate maintaining an increase to 30 breaths/min 5.Sustained change in level of consciousness for 10 minutes

4.Respiratory rate maintaining an increase to 30 breaths/min 5.Sustained change in level of consciousness for 10 minutes Recommended criteria to consider according to the Institute for Healthcare Improvement include the following: Any provider worried about the client's condition OR An acute change in any of the following:Heart rate <40 or >130/minSystolic blood pressure <90 mm HgRespiratory rate <8 or >28/min (Option 4)Oxygen saturation <90 despite oxygenUrine output <50 mL/4 hrLevel of consciousness (Option 5)


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