Adult Health ATI questions

A nurse is caring for a client who has a serum potassium 5.4. The nurse should assess for which of the following manifestations? a. ECG changes b. constipation c. polyuria d. paresthesia

a. ECG changes

A nurse is completing discharge teaching to a client following middle ear surgery. Which of the following statements by the client indicates understanding of the teaching? a. I should restrict rapid movements and avoid bending from the waist for several weeks b. I should wait until the day after surgery to wash my hair c. I will remove the dressing behind my ear in 7 days d. My hearing should be back to normal right after my surgery

a. I should restrict rapid movements and avoid bending from the waist for several weeks

A nurse is teaching a group of clients about influenza. Which of the following client statements indicates an understanding of the teaching? a. I should wash my hands after blowing my nose to prevent spreading the virus b. I need to avoid drinking fluids if I develop symptoms c. I need a flu shout every 2 years because of the different flu strains d. I should cover my mouth with my hand when I sneeze

a. I should wash my hands after blowing my nose to prevent spreading the virus

A nurse is caring for a client who is scheduled for a thoracentesis. Which of the following supplies should the nurse ensure are in the clients room? (select all that apply) a. Oxygen equipment b. incentive spirometer c. pulse oximeter d. sterile dressing e. suture removal kit

a. Oxygen equipment c. pulse oximeter d. sterile dressing

A nurse is providing discharge teaching for a client who has heart failure and is on a fluid restriction of 2,000 mL/day. The client asks the nurse how to determine the appropriate amount of fluids he is allowed. Which of the following statements is an appropriate response by the nurse? a. Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink b. Each glass contains 8 ounces. There are 30 milliliters per ounce, so you can have a total of 8 glasses or cups of fluid each day c. This is the same as 2 quarts, or about the same as two pots of coffee d. Take sips of water or ice chips so you will not take in too much fluid

a. Pour the amount of fluid you drink into an empty 2-liter bottle to keep track of how much you drink

A nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. The nurse should recognize which of the following data as risk factors for this condition? (select all that apply) a. Surgical repair o an atrial septal defect at age 2 b. measles infection during childhood c. hypertension for 5 years d. weight gain of 10 lb in past year e. diastolic murmur present

a. Surgical repair o an atrial septal defect at age 2 c. hypertension for 5 years e. diastolic murmur present

A nurse is caring for a client who has a new diagnosis of GERD. The nurse should anticipate prescriptions for which of the following medications? (select all that apply) a. antacids b. histamine 2 receptor antagonists c. opioid analgesics d. fiber laxatives e. proton pump inhibitors

a. antacids b. histamine 2 receptor antagonists e. proton pump inhibitors

A nurse is beginning a physical assessment of a client who has anew diagnosis of multiple sclerosis. Which of the following findings should the nurse expect? (select all that apply) a. areas of paresthesia b. involuntary eye movements c. alopecia d. increased salivation e. ataxia

a. areas of paresthesia b. involuntary eye movements e. ataxia

A nurse is having difficulty arousing a client following an esophagogastrodeodenoscopy (EGD). Which of the following is the priority action by the nurse? a. assess the client's airway b. allow the client to sleep c. prepare to administer an antidote to the sedative d. evaluate preprocedure laboratory findings

a. assess the client's airway

A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in the review? (select all that apply) a. avoid overwhelming fatigue b. remove caffeinated products from the diet c. limit looking at flashing lights d. perform aerobic exercise e. limit episodes of hypoventilation f. use of aerosol hairspray is recommended

a. avoid overwhelming fatigue b. remove caffeinated products from the diet c. limit looking at flashing lights

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include in the teaching? (select all that apply) a. avoid the consuming grapefruit while taking this medication b. monitor for the presence of black, tarry stools c. take this medication when you have pain d. schedule a weekly PT test e. limit food sources containing vitamin K while taking this medication

a. avoid the consuming grapefruit while taking this medication b. monitor for the presence of black, tarry stools

A nurse is reviewing bowel prep using polyethylene glycol with a client scheduled for a colonoscopy. Which of the following instructions should the nurse include in the teaching? a. check with the provider about taking current medications when consuming bowel prep b. consume a normal diet until start the bowel prep c. expect the bowel prep to not begin acting until the day after all the prep is consumed d. discontinue the bowel prep once feces start to be expelled

a. check with the provider about taking current medications when consuming bowel prep

A nurse is monitoring a group of clients of increased risk for developing pneumonia. Which of the following cleints hsould the expect to be at risk? (select all the apply) a. client who has dysphagia b. client who has AIDS c. client who was vaccinated for pneumococcus and influenza 6 months ago d. client who is postoperative and has received local anesthesia e. client who has a closed head injury and is receiving ventilation f. client who has myasthenia gravis

a. client who has dysphagia b. client who has AIDS e. client who has a closed head injury and is receiving ventilation f. client who has myasthenia gravis

A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry oral mucous membranes. Which of the following findings should the nurse identify as manifestations of fluid volume deficit? (select all that apply) a. decreased skin turgor b. concentrated urine c. bradycardia d. low-grade fever e. tachypnea

a. decreased skin turgor b. concentrated urine d. low-grade fever e. tachypnea

A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? a. diabetic ketoacidosis b. heart failure c. cushing's syndrome d. thyroidectomy

a. diabetic ketoacidosis

A nurse educator is reviewing expected findings in a client who has right-sided valvular heart disease with a group of nurses. Which of the following findings should the nurse include in the discussion? (select all that apply) a. dyspnea b. client report of fatigue c. bradycardia d. pleural friction rub e. peripheral edema

a. dyspnea b. client report of fatigue e. peripheral edema

A nurse is admitting an older adult client who is experiencing dyspnea, weakness, weight gain of 2lb, and 1+ bilateral edema of lower extremities. The client has temperature 99, pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following manifestations of fluid volume excess should the nurse expect? (select all that apply) a. dyspnea b. edema c. bradycardia d. hypertension e. weakness

a. dyspnea b. edema d. hypertension e. weakness

A nurse is caring for a client following a thoracentesis. Which of the following manifestations should the nurse recognize as risks for complications? (select all that apply) a. dyspnea b. localized bloody drainage on the dressing c. fever d. hypotension e. report of pain a the puncture site

a. dyspnea c. fever d. hypotension

A nurse is reviewing the health recorder of a client who has severe otitis media. Which of the following are expected findings? (select all that apply) a. enlarged adenoids b. report of recent colds c. client prescription for daily furosemide d. ligt reflex visible on otoscopic exam in the affected ear e. ear pain relieved by meclizine

a. enlarged adenoids b. report of recent colds e. ear pain relieved by meclizine

A nurse is preparing to administer a dose of a new prescription of prednisone to a client who has COPD. The nurse should monitor for which of the following adverse effects of this medications? (select all that apply) a. hypokalemia b. tachycardia c. fluid retention d. nausea e. black, tarry stools

a. hypokalemia c. fluid retention e. black, tarry stools

A nurse is providing teaching for a client who has a new diagnosis of dry macular degeneration. Which of the following instructions should the nurse include in the teaching? a. increase intake of deep yellow and orange vegetables b. administer eye drops twice daily c. avoid bending at the waist d. wear an eye patch at night

a. increase intake of deep yellow and orange vegetables

A nurse is completing preprocedure teaching for a client who will undergo a signoidoscopy. Which of the following information should the nurse include in the teaching? (select all that apply) a. increased flatulence can occur following the procedure b. NPO status should be maintained preprocedure c. conscious sedation is used d. repositioning will occur throughout the procedure e. fluid intake is limited the day after the procedure

a. increased flatulence can occur following the procedure b. NPO status should be maintained preprocedure

A nurse is assessing a client who has splinter hemorrhages in her mail beds and reports a fever. The nurse should identify these findings as manifestations of which of the following disorders? a. infective endocarditis b. pericarditis c. myocarditis d. rheumatic endocarditis

a. infective endocarditis

A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? a. keep the client in a side-lying position b. document the duration of the seizure c. reorient the client to the environment d. provide client hygiene

a. keep the client in a side-lying position

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? a. morning b. immediately after lunch c. immediately before dinner d. bedtime

a. morning

A nurse in a clinic is caring for a client whose partner states the client woke up this morning, did not recognize him, and did not know where she was. The client reports chills and chest pain that is worse upon inspiration. Which of the following actions is the nursing priority? a. obtain baseline vital signs and oxygen saturation b. obtain a sputum culture c. obtain a complete history from the client d. provide a pneumococcal vaccine

a. obtain baseline vital signs and oxygen saturation

A nurse is planning care for a client who has a new prescription for TPN. Which of the following interventions should be included in the plan of care? (select all that apply) a. obtain a capillary blood glucose four times daily b. administer prescribed medications through a secondary port on the TPN IV tubing c. monitor vital signs three times during the 12 hr shift d. change the TPN IV tubing every 24 hr e. ensure a daily aPTT is obtained

a. obtain capillary blood glucose four times daily c. monitor vital signs three times during the 12 hr shift d. change the TPN IV tubing every 24 hr

A nurse in a clinic is caring for a client who has been on long-term NSAID therapy to treat myocarditis. Which of the following laboratory findings should the nurse report to the provider? a. platelets 100,000 b. serum glucose 110 c. serum creatinine 0.7 d. amino alanine transferase (ALT) 30

a. platelets 100,000

A nurse is caring for a client who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take? a. position the client in an upright position, leaning over the bedside table b. explain the procedure c. obtain ABGs d. administer benzocaine spray

a. position the client in an upright position, leaning over the bedside table

A nurse is assessing a client who has a seizure disorder. The client reports he thinks he is about to have a seizure. Which of the following actions should the nurse implement? a. provide privacy b. ease the client to the floor if standing c. move furniture away from the client d. loosen the client's clothing e. protect the client's head with padding f. restrain the client

a. provide privacy b. ease the client to the floor if standing c. move furniture away from the client d. loosen the client's clothing e. protect the client's head with padding

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo die to benign paroxysmal vertigo for several weeks. Which of the following action should the nurse recommend to help control the vertigo? (select all that apply) a. reduce exposure to bright lighting b. move head slowly when changing positions c. do not eat fruit high in potassium d. plan evenly spaced daily fluid intake e. avoid fluids containing caffeine

a. reduce exposure to bright lighting b. move head slowly when changing positions d. plan evenly spaced daily fluid intake e. avoid fluids containing caffeine

A nurse is caring for a client who is receiving TPN solution. The current bag of solution was 24 hr ago, and 400 mL remains to infuse. Which of the following is the appropriate action for the nurse to take? a. remove the current bag and hang a new bag b. infuse the remaining solution at the current rate and then hang a new bag c. increase the infusion rate so the remaining solution is administering withing the hour and hang a new bag d. remove the current bag and hang a bag of lactated Ringer's

a. remove the current bag and hang a new bag

A nurse in the emergency department is completing an assessment of a cleint who has suspected stomach perforation due to a peptic ulcer. Which of the following findings should the nurse expect? (select all that apply) a. rigid abdomen b. tachycardia c. elevated blood pressure d. circumoral cyanosis e. rebound tenderness

a. rigid abdomen b. tachycardia e. rebound tenderness

A nurse is completing the admission assessment of a client who has suspected pulmonary edema. Which of the following manifestation are expected findings? (select all that apply) a. tachypnea b. persistent cough c. increased urinary output d. thick, yellow sputum e. orthopnea

a. tachypnea b. persistent cough e. orthopnea

A nurse is discharging a client who has COPD. Upon discharge, the client is concerned that he will never be able to leave his house now that hie his on continuous oxygen. Which of the following is an appropriate response by the nurse? a. there are portable oxygen delivery systems that you can take with you b. when you go out, you can remove the oxygen and then reapply it when you get home c. you probably will not be able to go out as much as you used to d. home health services will come to you so you will not need to get out

a. there are portable oxygen delivery systems that you can take with you

A nurse is caring for a client who has a serum sodium level of 133 and serum potassium level of 3.4. The nurse should recognize that which of the following treatments can result in these laboratory findings? a. three tap water enemas b. 0.9% sodium chloride solution IV at 50 mL/hr c. 5% dextrose with 0.45% sodium chloride solution with 20 of K IV at 80 mL/hr d. antibiotic therapy

a. three tap water enemas

A nurse is providing education to a client who is to undergo an electroencephalogram (EEG) the next day. Which of the following information should the nurse include in the teaching? a. "Do not wash your hair the morning of the procedure." b. "Try to stay awake most of the night prior to the procedure." c. "The procedure will take approximately 15 minutes." d. "You will need to lie flat for 4 hours after the procedure."

b. "Try to stay awake most of the night prior to the procedure."

A nurse is completing discharge teaching with a client who has heart failure and is encouraged to increased potassium in his diet. Which of the following food selections should the nurse include as having the highest source of potassium? a. 1 medium apple b. 1 medium baked potato c. 1 slice toast with 1 tbsp peanut butter d. 1 large scrambled egg

b. 1 medium baked potato

A nurse is assessing a client for changes in the level of consciousness using the Glasgow coma scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a. E2 + V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8

b. E3 + V4 + M4 = 11

A nurse is completing discharge teaching with a client who had a surgical placement of a mechanical heart valve. Which of the following statements by the client indicates understanding of the teaching? a. I will be gland to get back to my exercise routine right away b. I will have my prothrombin time checked on a regular basis c. I will talk to my dentist about no loner needing antibiotics before dental exams d. I will continue to limit my intake of foods containing potassium

b. I will have my prothrombin time checked on a regular basis

A nurse is providing teaching for a client who has a new diagnosis of hypertension and new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? a. I should eat a lot of fruits and vegetables, especially bananas and potatoes b. I will report any changes in heart rate to my provider c. I should replace the salt shaker on my table with a salt substitute d. I will decrease the dose of this medication when I no longer have headaches and facial redness

b. I will report any changes in heart rate to my provider

A nurse is caring for a client who has pneumonia. Assessment findings include temperature 37.8 (100), respirations 30/min, blood pressure 130/76, heart rate 100/min, and SaO2 91% on room air. Prioritize the following nursing interventions. a. administer antibiotics b. administer oxygen therapy c. perform a sputum culture d. administer an antipyretic medication to promote client comfort

b. administer oxygen therapy c. perform a sputum culture a. administer antibiotics d. administer an antipyretic medication to promote client comfort

A nurse is providing care to a client who is 1 day postoperative following a paracentesis. The nurse observes clear, pale-yellow fluid leaking from the operative site. Which of the following is an appropriate nursing intervention? a. place a clean towel near the drainage site b. apply a dry, sterile dressing c. apply direct pressure to the site d. place the client in a supine position

b. apply a dry, sterile dressing

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following action should the nurse take? a. elevate the legs for 10 min, two to three times daily while wearing stockings b. apply the stockings in the morning upon awaking and before getting out of bed c. roll the stockings down to the knees to relieve discomfort on the legs d. remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest

b. apply the stockings in the morning upon awaking and before getting out of bed

A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the clients oxygen per protocol. Which of the following actions should the nurse take first? a. obtain the client's weight b. assist the client into high-fowler's position c. auscultate lungs sounds d. check oxygen saturation with pulse oximeter

b. assist the client into high-fowler's position

A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (select all that apply) a. use the Glasgow coma scale when assessing the client b. assist the client to a supine position c. administer an opioid medication d. encourage the client to increase fluid intake e. instruct the client to perform deep breathing and coughing exercises

b. assist the client to a supine position c. administer an opioid medication d. encourage the client to increase fluid intake

A nurse is caring for four clients. Which of the following clients should the nurse identify as being at risk for acquiring rheumatic endocarditis? a. older adult who has chronic obstructive pulmonary disease b. child who has streptococcal pharyngitis c. middle age adult who has lupus erythematosus d. young adult who recently received a body tattoo

b. child who has streptococcal pharyngitis

A nurse in a provider's office is obtaining a health history form a client who has cluster headaches. Which of the following are expected findings? (select all that apply) a. pain is bilateral across the posterior occipital area b. client experiences altered sleep-wake cycle c. headache occurs at approximately at the same time of the day d. client describes headache pain as dull and throbbing e. nasal congestion and drainage occur

b. client experiences altered sleep-wake cycle c. headache occurs at approximately at the same time of the day e. nasal congestion and drainage occur

A nurse is screening a male client for hypertension. The nurse should identify which of the following actions by the client increase his riks for hypertension? (select all that apply) a. drinking 8 oz nonfat milk daily b. eating popcorn at the movie theater c. walking 1 mile daily at 12 min/mile pace d. consuming 36 oz beer daily e. getting a massage once a week

b. eating popcorn at the movie theater d. consuming 36 oz beer daily

A nurse is assessing a client who has history of asthma. Which of the following factors should the nurse identify as a risk for asthma? a. gender b. environmental allergies c. alcohol use d. race

b. environmental allergies

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (select all that apply) a. gender b. genetic predisposition c. hypertension d. age e. diabetes mellitus

b. genetic predisposition c. hypertension d. age e. diabetes mellitus

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? a. hypercalcemia b. hyponatremia c. hyperphosphatemia d. hyperkalemia

b. hyponatremia

A nurse is reinforcing teaching with a client on the purpose of taking a bronchodilator. Which of the following client statements indicates an understanding of the teaching? a. this medication can decrease my immune response b. i take this medication to prevent asthma attacks c. i need to take this medication with food d. this medication has a slow onset to treat my symptoms

b. i take this medication to prevent asthma attacks

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a. headache b. infection c. aphasia d. hypertension

b. infection

A nurse is caring for a client who has multiple sclerosis. Which of the following findings should the nurse expect? a. fluctuations in blood pressure b. loss of cognitive function c. ineffective cough d. drooping eye lids

b. loss of cognitive function

A nurse is completing an assessment of a client who has GERD. Which of the following is an expected finding? a. absence of saliva b. loss of tooth enamel c. sweet taste in mouth d. absence of eructation

b. loss of tooth enamel

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? a. cataracts b. open-angle glaucoma c. macular degeneration d. angle-closure glaucoma

b. open-angle glaucoma

A nurse is teaching a client who has hiatal hernia. Which of the following client statements indicates an understanding of the teaching? a. I can take my medications with soda b. peppermint tea will increase my indigestion c. wearing an abdominal binder will limit my symptoms d. I will drink hot chocolate at bedtime to help me sleep e. I can lift weights as a way to exercise

b. peppermint tea will increase my indigestion

A nurse is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances? a. respiratory acidosis b. respiratory alkalosis c. metabolic acidosis d. metabolic alkalosis

b. respiratory alkalosis

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The should recommend that the client avoid which of the following foods? a. baked salmon b. salted cashews c. frozen strawberries d. fresh asparagus

b. salted cashews

A nurse is caring for a 72-year-old client who is to undergo a percutaneous balloon valvuloplasty. The client's daughter asks the nurse to explain the expected outcome of this procedure. Which of the following responses should the nurse give? a. this will improve blood flow in your mother's coronary arteries b. this will permit your mother to resume her activities of daily living c. this will prolong your mother's life d. this will reverse the effects to the damage area

b. this will permit your mother to resume her activities of daily living

A nurse in the emergency department is caring for a client who is having an acute asthma attack. which of the following assessments indicates that the respiratory status is declining? (select all that apply) a. SaO2 95% b. wheezing c. retraction of sternal muscles d. pink mucous membranes e. premature ventricular complexes (PVCs)

b. wheezing c. retraction of sternal muscles e. premature ventricular complexes (PVCs)

A nurse in a clinic is teaching a client who has a history of migraine headaches about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of the teaching? a. "this medication will relieve my symptoms by causing my blood vessels to dilate" b. "I should take this medication daily to prevent the headache from occurring" c. "I should except facial flushing when I take this medication" d. "this medication will lower my sensitivity to food triggers"

c. "I should except facial flushing when I take this medication"

A nurse is completing discharge teaching to a client who has seizures and receiving a vagal nerve stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? a. "It is safe to use microwaves that are 1,200 watts or less." b. "You should avoid the use of CT scans with contrast." c. "You should place a magnet over the implantable device when you feel an aura occurring." d. "It is recommended that you use ultrasound diathermy for pain management."

c. "You should place a magnet over the implantable device when you feel an aura occurring."

A nurse is completing the admission physical assessment of client who has a history of mitral valve insufficiency. Which of the following findings should the nurse expect? a. S4 heart sounds b. Petechiae c. Crackles in lung bases d. Splenomegaly

c. Crackles in lung bases

A nurse is providing discharge teaching to a client who has COPD and a new prescription for albuterol. which of the following statements by the client indicates an understanding of the teaching? a. this medication can increase my blood sugar levels b. this medication can decrease my immune response c. I can have an increase in my heart rate while taking this medication d. I can have mouth cores while taking this medication

c. I can have an increase in my heart rate while taking this medication

A nurse is completing discharge teaching to a client who is postoperative following fundoplication. Which of the following statements by the client indicates understanding if the teaching? a. when sitting in my lounge chair after a meal, I will lower the back of it b. I will try to eat three large meals a day c. I will elevate the head of my bed on blocks d. when sleeping, I will lay on my left side

c. I will elevate the head of my bed on blocks

A nurse is completing discharge teaching for a client who has an infection due to H. pylori. Which of the following statements by the client indicates understanding of the teaching? a. I will continue my prescription for corticosteroids b. I will schedule a CT scan to monitor improvement c. I will take a combination of medications for treatment d. I will have my throat swabbed to recheck for this bacteria

c. I will take a combination of medications for treatment

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (select all that apply) a. eye pain b. floating spots c. blurred vision d. white pupils e. bilateral red relfexes

c. blurred vision d. white pupils

A nurse is reviewing the health record of a client who has a suspected tumor of the jejunum. The nurse should anticipate a prescription for which of the following tests? (select all that apply) a. serum alpha-fetoprotein b. endoscopic retrograde cholangiopancreatography (ERCP) c. grastrointestinal x-ray with contrast d. small bowel capsule endoscopy e. colonoscopy

c. grastrointestinal x-ray with contrast d. small bowel capsule endoscopy

A nurse is providing discharge teaching to a client who has a new prescription for prednisone for asthma. Which of the following client statements indicates an understanding of the teaching? a. i will decrease my fluid intake while taking this medication b. i will expect to have black, tarry stools c. i will take my medication with meals d. i will monitor for weight loss while on this medication

c. i will take my medication with meals

A nurse is caring for a client who has a deep-vein thombosis and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescriber warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? a. I will remind your provider that you are already receiving heparin b. your laboratory findings indicated that two anticoagulants were needed c. it takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued d. only one of these medications is being given to treat your deep-vein thrombosis

c. it takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued

A nurse is caring for a client hwo is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client report a headache and double vision. The client states that she ran out of her diltiazem 3 days ago, and is unable to purchase more. Which of the following actions should the nurse take first? a. administer acetaminophen for headache b. provide teaching regarding the importance of not abruptly stopping an antihypertensive c. obtain IV access and prepare to administer an IV antihypertensive d. call social services for a referral for financial assistance in obtaining prescribed medication

c. obtain IV access and prepare to administer an IV antihypertensive

A nurse is completing discharge teaching with a client who is 3 days postoperative following a transverse colostomy. Which of the following should the nurse include in the teaching? a. mucus will be present in stool for 5 to 7 days after surgery b. expect 500 to 1,000 mL of semi liquid stool after 2 weeks c. stoma should be moist and pink d. change the ostomy bag when it is 3/4 full

c. stoma should be moist and pink

A nurse is planning to instruct a client on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care? a. take a quick breathe upon inhalation b. place you hand over your stomach c. take a deep breath in through your nose d. puff your cheeks upon exhalation

c. take a deep breath in through your nose

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the send time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? a. take psyllium daily as a fiber laxative b. drinks skim milk daily as a bedtime snack c. take metoprolol daily after meals d. drinks grapefruit juice daily with breakfast

c. take metoprolol daily after meals

A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? a. consider taking oral contraceptives when on this medication b. watch for receding gums when taking the medication c. take the medication at the same time every day d. provide a urine sample to determine therapeutic levels of the medication

c. take the medication at the same time every day

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. apply a blood pressure cuff to the client's arm b. place the stethoscope bell over the client's carotid artery c. tap lightly on the client's cheek d. ask the client to lower her chin to her chest

c. tap lightly on the client's cheek

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the findings of migraine headaches? a. "do the headaches occur at the same time each day?" b. "is your headache accompanied by profuse facial sweating?" c. "does your headache occur on one of your head?" d. "is there a pattern of headaches among family members?"

d. "is there a pattern of headaches among family members?"

A nurse is teaching a client who has multiple sclerosis and a new prescription for baclofen. Which of the following statements should the nurse include in the teaching? a. "this medication will help you with your tremors" b. "this medication will help you with your bladder function" c. "this medication may cause your skin to bruise easily" d. "this medication may cause you to experience weakness"

d. "this medication may cause you to experience weakness"

A nurse is providing postoperative teaching to a client following cataract surgery. Which of the following statements should the nurse include in the teaching? a. "you can resume playing golf in 2 days" b. "you need to tilt you head back when washing your hair" c. "you can get water in your eyes in 1 day" d. "you need to limit your housekeeping activities"

d. "you need to limit your housekeeping activities"

A nurse is instructing a client on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching? a. I will place the adapter on my finger to read my blood oxygen saturation level b. I will lie on my back with my knees bent c. I will rest my hand over my abdomen to create resistance d. I will take in a deep breath and hold it before exhaling

d. I will take in a deep breath and hold it before exhaling

A nurse is providing discharge instruction to a client who has a new diagnosis of migraine headaches. Which of the following instructions should the nurse include? a. use music therapy for relaxation with the onset of the headache b. increase physical activity when a headache is present c. drink beverages that contain artificial sweeteners to prevent headaches d. apply a cool cloth to the face during a headache

d. apply a cool cloth to the face during a headache

A nurse is caring for a client 2 hr after admission. The client has an SaO2 of 91%, exhibits audilbe wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer? a. antibiotics b. beta-blocker c. antiviral d. beta2 agonist

d. beta2 agonist

A nurse is assess a client following a bronchoscopy. Which of the following findings should the nurse report to the provider? a. blood-tinged sputum b. dry, nonproductive cough c. sore throat d. bronchospasms

d. bronchospasms

A nurse is performing an otoscopic examination of a client. Which of the following is an unexpected finding? a. pearly, gray tympanic membrane b. malleus visible behind the TM c. presence of soft cerumen in the external canal d. fluid bubble seen behind the TM

d. fluid bubble seen behind the TM

A nurse is caring for a client who has pericarditis. Which of the following findings should the nurse expect? a. petechiae b. murmur c. rash d. friction rub

d. friction rub

A nurse is teaching a client who has a new diagnosis of dumping syndrome following gastric surgery. Which of the following information should the nurse include in the teaching? a. eat three moderate-sized meals a day b. drink a least one glass of water with each meal c. eat a bedtime snack that contains milk product d. increase protein in the diet

d. increase protein in the diet

A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. The client's temperature is 100.9, pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost 3/4 lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take? a. initiate fluid restrictions to limit intake b. observe for signs of peripheral edema c. encourage the client to ambulate to promote oxygenation d. monitor for orthostatic hypotension

d. monitor for orthostatic hypotension

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? a. edema around the ankles and feet b. ulceration around the medial malleoli c. scaling eczema of the lower legs with stasis dermatitis d. pallor on elevation of the limbs, and rubor when the limbs are dependent

d. pallor on elevation of the limbs, and rubor when the limbs are dependent

A nurse in a clinic is assessing a client who has sinusitis. Which of the following techniques should the nurse use to identify manifestations of this disorder? a. percussion of posterior b. auscultation of the trachea c. inspection of the conjunctiva d. palpation of the orbital areas

d. palpation of the orbital areas

A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? a. wear tightly fitted insulated socks with shoes when going outside b. elevate both legs above the heart when resting c. apply a heating pad to both legs for comfort d. place both legs in dependent position while sleeping

d. place both legs in dependent position while sleeping

A nurse is assessing a client who is dehydrated for fluid volume deficit. Which of the following findings should the nurse expect in the client? a. moist skin b. distended neck veins c. increased urinary output d. tachycardia

d. tachycardia

A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure? a. client report of upper chest pain b. decreased urine output c. pallor d. temperature elevation

d. temperature elevation

A nurse in a clinic is instructing a client about a fecal occult blood test, which requires mailing three specimens. Which of the following statements by the client indicates understanding of the teaching? a. I will continue taking warfarin while I complete these tests b. I'm glad I don't have to follow any special diet at this time c. this test determines if I have parasites in my bowel d. this is an easy way to screen for colon cancer

d. this is an easy way to screen for colon cancer

A nurse is admitting a client who has suspected rheumatic endocarditis. The nurse should anticipate a prescription from the provider for which of the following laboratory tests to assist in confirmation of this diagnosis? a. arterial blood gases b. serum albumin c. liver enzymes d. throat culture

d. throat culture

A nurse is caring for a client who has suspected Meniere's disease. Which of the following is an expected finding? a. presence of a purulent lesion in the external ear canal b. feeling of pressure in the ear c. bulging, red bilateral tympanic membranes d. unilateral hearing loss

d. unilateral hearing loss

A nurse is admitting a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of he following medications? a. propranolol b. metoclopramide c. ranitidine d. vasopressin

d. vasopressin

A nurse is developing a plan of care for a client who scheduled for cerebral angiography with contrast dye. Which of the following statements by the client should the nurse report to the provider? (select all that apply) a. "I think I might be pregnant" b. "I take warfarin" c. "I take antihypertensive medication" d. "I am allergic to shrimp" e. "I ate a light breakfast this morning"

a. "I think I might be pregnant" b. "I take warfarin" d. "I am allergic to shrimp" e. "I ate a light breakfast this morning"

A nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2,000 mg daily. Which of the following foods should the nurse recommend for the client? (select all that apply) a. 1 slice cheddar cheese b. 1 medium beef hot dog c. 3 oz Atlantic salmon d. 3 oz roasted chicken breast e. 2 oz lean baked ham

a. 1 slice cheddar cheese c. 3 oz Atlantic salmon d. 3 oz roasted chicken breast