Adaptive quizzing

Before major abdominal surgery for cancer, a client says to a nurse, "I really don't think this is cancer at all. I'll bet they won't find anything." Which is the most appropriate initial response by the nurse?

"I can understand why you'd like to believe that."

The client is admitted to the emergency department with burns on the anterior part of both arms, from the shoulders to the hands, and the anterior part of the head. The nurse uses the Rule of Nines to assess the percentage of total body surface area burned. What percent should the nurse document in the client's hospital record?

13.5%

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. A nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer rounding to one decimal place. ___%

22.5%

An adult client sustains partial- and full-thickness burns of the left thigh, left arm, and head. Using the Lund-Browder chart, the nurse calculates that the percentage of total body surface area burned is:

23.5%

How many inches should the nurse insert a catheter into the stoma when performing a transverse colostomy irrigation?

8 cm (3 inches)

A client is admitted to the hospital with the diagnosis of a right-sided brain attack (stroke). The client is right-handed. Which task will be most difficult for this client?

Dressing every morning

The nurse is creating a discharge teaching plan for a client that had a subtotal gastrectomy. The nurse should include what instructions about minimizing dumping syndrome? Select all that apply.

Eat small frequent meals Lie down for one hour after eating

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education?

Elevated blood pressure

A client with a supratentorial tumor is scheduled for external radiation therapy to the brain. What should the nurse plan to teach the client?

Feelings of extreme tiredness will occur.

A nurse is concerned about the public health implications of gonorrhea diagnosed in a 16-year-old adolescent. Which should be of most concern to the nurse?

Finding the client's sexual contacts

A client with an acute attack of cholecystitis has a cholecystectomy with a choledochostomy. The client returns from surgery with a T-tube connected to a drainage bag. The nurse concludes that the purpose of the T-tube is to:

Permit drainage of bile

When the exposure method of treatment is used for burns, the nurse explains to the client that:

Isolation precautions will be required while hospitalized

Several days after a client had a total laryngectomy, the health care provider prescribes a progressive diet as tolerated. What should the nurse do?

Keep suction apparatus readily available in case excessive respiratory secretions occur

In which positions should the nurse place a client who has just had a right pneumonectomy?

Supine or right side-lying

A client who is to receive radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." The best response by the nurse is:

"A localized skin reaction usually occurs."

The health care provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of:

70 to 105 mg/dL of blood

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply.

Hyperthermia Splenomegaly

After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse expects that manifestations of excessive levels of antidiuretic hormone are:

Hyponatremia and decreased urine output

A client who had a recent brain attack (cerebrovascular accident, CVA) has not had a bowel movement for five days. After addressing this problem, what does the nurse anticipate will be prescribed daily to prevent this from occurring in the future?

Mild stool softener to make stool easier to pass

A client newly diagnosed with human immunodeficiency virus (HIV) comments to a nurse, "There are so many rotten people around. Why couldn't one of them get HIV instead of me?" What is the nurse's best response?

"It seems unfair that you contracted this disorder?"

After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. What nursing action is the priority?

Monitor for bright red blood in the drainage bag

A client is admitted with a closed head injury sustained in a motor vehicle accident (MVA).The nursing assessment indicates increased intracranial pressure (ICP). Which intervention should the nurse perform first?

Place the head and neck in alignment

Which is an important intervention that the nurse should include in the plan of care that is specific for a client with Addison disease?

Protecting the client from exertion

After a subtotal gastrectomy (Billroth I), a client begins to eat more food in varied forms. After meals, the client experiences a cramping discomfort, a rapid pulse, and waves of weakness, which often are followed by nausea and vomiting. What does the nurse conclude is the cause of this response?

Quick passage of hyperosmolar food solution into the small intestine.

A client is admitted to the hospital with a diagnosis of intestinal obstruction. The health care provider prescribes intestinal suction via a nasoenteric decompression tube. The loss of which constituents associated with intestinal suctioning is most important to consider when caring for this client?

Water and electrolytes

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is:

"All family members, including your child, need to wash their hands after using the bathroom."

A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, the nurse should teach the client to:

Advance the cane and the affected extremity simultaneously

The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? Select all that apply.

Amenorrhea Flushed appearance Short attention span

After several years of unprotected sex, a client is diagnosed as having acquired immunodeficiency syndrome (AIDS). The client states, "I'm not worried because they have a cure for AIDS." The best response by the nurse is:

"There is no cure for AIDS but there are drugs that can slow down the virus."

A client who was a passenger in an automobile collision is admitted to the emergency department with rhinorrhea and bleeding from the ear. The health care provider determines that the client has a basilar head injury. What should the nurse anticipate is the initial focus of care for this client?

Antimicrobial administration

A nurse is taking care of a client with cirrhosis of the liver. For which clinical manifestations should the nurse assess? Select all that apply.

Ascites Pruritus Jaundice

A client is admitted for an exacerbation of emphysema. The client has a fever, chills, and difficulty breathing on exertion. What is the priority nursing action based on the client's history and present status?

Encouraging increased fluid intake

A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? Select all that apply.

Fatigue Weakness Nervousness Increased perspiration

The primary health care provider prescribes contact precautions for a client with hepatitis A. What nursing interventions are required for contact precautions?

Gown and gloves when handling articles potentially contaminated by urine or feces

A nurse is caring for a client who is scheduled to have a pigskin graft applied to a burned area. Which type of graft is going to be applied by the health care provider?

Heterograft

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

Hirsutism Buffalo hump Dependent edema

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. When suctioning the endotracheal tube, the nurse should:

Hyperoxygenate with 100% oxygen before and after suctioning

A nurse administers sodium polystyrene sulfonate (Kayexalate) to a client. What should the nurse monitor to evaluate the effectiveness of the Kayexalate?

Serum potassium

When teaching about the dietary control of gout, the nurse evaluates that the dietary teaching is understood when the client states; "I will avoid eating:

Shellfish."

A client with an acute exacerbation of rheumatoid arthritis is in severe pain and tells the nurse, "The only time I am pain free is when I lie perfectly still." What complication should the nurse explain can be prevented by exercising every day?

Shortening of the muscles

In teaching a class about sexually transmitted diseases, the nurse discusses signs and symptoms associated with each and effects of delaying treatment. During the discussion, gummas, which are tumors that break and ulcerate, and mental and physical disability were described. Which disease is associated with this process?

Syphyllis

A client is admitted with a diagnosis of Cushing syndrome. For which clinical manifestations should the nurse observe when assessing this client? Select all that apply.

Weakness Hypertension Truncal obesity

A construction worker fell off the roof of a two-story building and was taken to the hospital in an unconscious state. During the initial assessment, what clinical finding should the nurse report immediately?

Bleeding from the ears

A nurse is teaching a client about a sodium-restricted diet. What foods should the nurse encourage the client to avoid? Select all that apply.

Cold cuts Processed foods

A nurse expects a client with a herniated intervertebral disk to report a sudden increase in pain with which activities? Select all that apply.

Coughing or sneezing Straining when having a bowel movement

A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms?

Cystitis

The nurse reviews teaching with a client with cancer of the larynx who is scheduled for a total laryngectomy and radical neck dissection. The nurse concludes that the teaching is effective when the client states, "After surgery, I will still be able to:

Chew and swallow food"

The nurse understands that the best way to reduce catheter associated urinary tract infections (CAUTIs) in long term indwelling catheters is to do what?

Replace the catheter on a routine basis