Adult Medical Surgical

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching? "I should wait at least 2 hours after eating before going to bed." "I should eat three meals a day without eating snacks between meals." "I should season my food with garlic." "I should drink my liquids through a straw."

"I should wait at least 2 hours after eating before going to bed."

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take? Keep the door of the client's room closed at all times. Remove gloves after leaving the client's room. Wear a mask when working within 1 m (3 feet) of the client. Have a designated stethoscope in the client's room.

Have a designated stethoscope in the client's room.

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side-lying position. Greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity.

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.) Ceftriaxone Diltiazem Pioglitazone Hydrocodone 5 mg/acetaminophen 500 mg

Ceftriaxone

A nurse is reinforcing teaching with the caregiver of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?

Change the sheepskin liner weekly.

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration? Provide small, frequent meals. Tell the client to extend their neck when swallowing. Provide mouth care before meals. Give the client liquids with increased viscosity.

Give the client liquids with increased viscosity.

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make? "You may cross your legs in 60 days." "Avoid lying on your operative side." "Avoid bending your hips more than 90 degrees." "You may sleep on a soft mattress."

"Avoid bending your hips more than 90 degrees."

A nurse is reinforcing teaching with a client who is to begin using an insulin pump. Which of the following instructions should the nurse include? "Insert the infusion needle into intramuscular tissue." "Change the needle every 5 days." "Calculate the insulin for each meal by using an insulin-to-protein ratio." "Use rapid-acting insulin in the infusion device."

"Use rapid-acting insulin in the infusion device."

A nurse is contributing to the plan of care for a client who has Ménière's disease. Which of the following interventions should the nurse include in the plan of care? Increase the client's fluid intake. Assist the client with changing positions often. Encourage the client to rest in a well-lit room. Administer an antiemetic to the client

Administer an antiemetic to the client

A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the following instructions should the nurse include in the teaching?

Avoid eating red meat for 3 days prior to the test because this can lead to a false positive result. It is not required to fast before the guaiac fecal occult blood test. Avoid taking any NSAIDs for 7 days prior to the guaiac fecal occult blood test because this can lead to a false positive result.

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication? Reduces bacteria in the urinary tract Suppresses urge to void Prevents nerve stimulation to the bladder muscle Decreases pain during urination

Decreases pain during urination

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include? Restrict the time pregnant women are allowed in the client's room to 15 min. Pick up a radiation implant with a double-gloved hand if it becomes dislodged. Limit time spent in the client's room to 2 hr during an 8 hr shift. Dispose of radiation implants in a lead container.

Dispose of radiation implants in a lead container.

A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group?

Herpes zoster for 60 years of age and older. Meningococcal vaccine to college students and military recruits who are living in shared housing. HPV vaccine for clients who are 9 to 26 years of age. MMR vaccine to clients who are 62 years of age.

A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot ashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT? Five-year history of menopause manifestations History of treatment for blood clots Topiramate use for migraine headaches Increased serum cholesterol levels

History of treatment for blood clots

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula. Clients who have manifestations of sepsis are often hypoxic, tachypneic, or have a PaCO2 level less than 32 mm Hg. The nurse should provide supplemental oxygen to keep the client's oxygen saturation levels at 95% or greater, which will maximize the ability of the hemoglobin to support the oxygen needs of the body. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria.

A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following foods should the nurse recommend?

Lemon juice

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration? Instill 10 mL of air through the NG tube. Place the client in the supine position. Irrigate the NG tube. Pinch the NG tube.

Pinch the NG tube.

A nurse is reinforcing discharge teaching about wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching? Administer an analgesic following wound care. Irrigate the wound with povidone iodine. Cleanse the wound with a cotton-tipped applicator. Report purulent drainage to the provider.

Report purulent drainage to the provider.

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown? Keep the skin dry and free of perspiration. Use hot water and antibacterial soap to bathe the client. Massage the skin over bony prominences to promote circulation. Limit the use of moisturizers on the skin over bony prominences.

Keep the skin dry and free of perspiration.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors? Visitors should call prior to visiting the client. Visitors must don a gown and gloves prior to entering the client's room. Visitors need to wear a mask when in close proximity to the client. Visitors may not bring fresh flowers into the client's room.

Visitors must don a gown and gloves prior to entering the client's room.

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.7

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care? Apply a mask on the client if the transport is needed. Wear a mask when working within 1.2 m (4 feet) of the client Don a gown when visiting with the client Wear an N95 mask when entering the client's room.

Apply a mask on the client if transport is needed. •

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Apply cold packs to the inamed joints. Use both warm and cold packs on inflamed joints to decrease pain. Sleep on a firm mattress to support their joints.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching? Consume a low-purine diet. Avoid stopping this medication suddenly. Use chamomile tea to alleviate insomnia. Take this medication on an empty stomach.

Avoid stopping this medication suddenly. Low-purine diet for a client who has gout and a prescription for colchicine. Avoid chamomile because it can interact with baclofen to increase CNS depression.

A nurse is assisting with the care of a client who has a newly-inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider? Chest drainage is greater than 70 mL/hr. Water fluctuates in the water-seal chamber. Chest drainage is clear in color. Connections of the tubing are secured with tape.

Chest drainage is greater than 70 mL/hr.

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client? Intrauterine device Latex condom Combination oral contraceptives Contraceptive sponge

Combination oral contraceptives

A nurse is caring for a client who has a new cast on their left forearm and reports severe pain in the affected arm with numbness in the ngers. The nurse nds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect? Compartment syndrome Fat embolism Deep-vein thrombosis Osteomyelitis

Compartment Syndrome

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

Consume foods that are low in sodium to reduce the development of edema and ascites. Elevate the head of their bed while sleeping to prevent shortness of breath from the pressure of ascites or hydrothorax. Increase vegetable proteins and reduce animal proteins in their diet to limit the development of encephalopathy. Avoid taking OTC medications, including acetaminophen, which is toxic to the liver.

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure? Sodium 136 mEq/L Potassium 4.8 mEq/L Creatinine 1.9 mg/dL Calcium 10 mg/dL

Creatinine 1.9 mg/dL

A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of sores in their mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make? Drink water before and after each bite. Consume foods that are served hot rather than cold. Rinse with a glycerin-based mouthwash before meals. Eat several, small-portioned meals daily.

Eat several, small-portioned meals daily.

A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?

Eat soft foods to decrease irritation to the oral mucosa. Avoid seasoning foods with salt or spices that can irritate the oral mucosa. Eat foods that are high in protein and calories to increase their caloric intake and nutrition. Choose foods that are a lukewarm or cool temperature to prevent irritation of the client's oral mucosa.

A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?

I will have my HbA1c checked twice per year. An HbA1c test provides the client's average glucose level for the preceding 3 months. The nurse should instruct the client to have their HbA1c tested twice yearly to manage their glucose.

A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include?

Incontinence of the bowel and bladder Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin.

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan? Use a commercial mouthwash before taking the medication. Instruct the client to swish the medication in their mouth. Discontinue the medication as soon as the lesions are healed. Combine the medication with applesauce

Instruct the client to swish the medication in their mouth.

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following? Cirrhosis of the liver Hypermotility of the bowel Intra-abdominal bleeding Acute cholecystitis

Intra-abdominal bleeding

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep? Get out of bed if unable to fall asleep within 60 min. Take a brisk walk before sleeping. Listen to soft music before sleeping. Drink adequate amounts of uids before sleeping.

Listen to soft music before sleeping.

A nurse observes a client who is lying in bed and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck to maintain an open airway and prevent aspiration.

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use? Gown Mask Sterile gloves Protective eyewear

Mask

A nurse is monitoring a client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first? Administer doxazosin. Palpate the abdomen. Insert an indwelling urinary catheter. Notify the provider.

Palpate the abdomen.

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Prealbumin 12 mg/dL Elevated HbA1c levels, WBC count can increase the risk for delayed wound healing.

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism: hypotension, tachycardia, tachypnea

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools Halitosis: bad breath Rebound tenderness: indication of appendicitis

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. After stopping the infusion, which of the following actions should the nurse take next? Collect a urine sample. Take the client's vital signs. Return the blood to the laboratory. Administer an antihistamine.

Take the client's vital signs.

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching? "This type of insulin should be given at the same time every day." "This insulin can be mixed with short-acting insulin in a single syringe." "This type of insulin can be used in a pump." "This insulin has an increased risk for hypoglycemia."

This type of insulin should be given at the same time every day.

A nurse is examining a client's IV site and notes a red line up their arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?

Thrombophlebitis: pain, warmth, and a red streak up the arm Infiltration: swelling + cool skin Hematoma: swelling + bruising Venous spasms: cramping + numbness at site

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration? Allow for 30 min of rest before meals. Provide a straw for drinking liquids. Serve foods at room temperature. Place 2 tsp of food in the client's mouth at a time.

Allow for 30 min of rest before meals.

A nurse is contributing to the plan of care for a client who has COPD and is dyspneic. Which of the following interventions should the nurse include in the plan? Encourage abdominal breathing. Direct the client to inhale with pursed lips. Set the oxygen therapy at 5 L/min. Instruct the client to lean back when coughing.

Encourage abdominal breathing.

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include? Apply hot packs to the client's muscles. Schedule physical therapy in the afternoon Encourage the client to complete ADLs. Administer valerian to promote sleep

Encourage the client to complete ADLs.

A nurse is contributing to the plan of care for a client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis. Massaging bony prominences should be avoided because it can traumatize deep tissues. Caffeine and alcohol intake can increase the client's risk for developing osteoporosis. However, fluid intake does not prevent bone loss.

A nurse is contributing to the plan of care for a client who has partial hearing loss. Which of the following interventions should the nurse include in the plan of care? Face the client while speaking. Use a high-pitched tone when talking to the client. Avoid using gestures when communicating. Repeat misunderstood phrases.

Face the client while speaking.

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hgb 11 g/dL Chronic kidney failure: elevated BUN levels, concentrated urine and elevated specific gravity

A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following?

Hyperactive bowel sounds Normal bowel sounds, the nurse should expect to hear 5-35 gurgles and clicks in 1 min.

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching? "Take the medication on an empty stomach." "Limit contact with large groups of people." "Avoid taking over-the-counter calcium supplements." "Follow a low-protein diet."

"Limit contact with large groups of people."

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include? "Your partner will not require treatment for this infection." "You can resume sexual activity as soon as you begin treatment." "You are at risk for infertility with this infection, regardless of treatment." "You will not be at further risk for this infection following treatment."

"You are at risk for infertility with this infection, regardless of treatment."

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make? "Are you experiencing abdominal pain?" "You should talk about this with the people you're closest to." "Many people who have cancer feel this way." "You feel like you want to discontinue treatment?"

"You feel like you want to discontinue treatment?"

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?

I don't cross my legs anymore. It can impede circulation. Have decreased sensation of the affected extremities. Therefore, they are unable to detect the temperature of the water bottle, which increases the risk for burns. Wool socks can result in perspiration, which puts the client at risk for developing a fungal infection.

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?

I should call my doctor if my ankles swell Swelling of the ankles can indicate heart failure. The client should report this finding to the provider.

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?

I understand that testicular cancer is typically painless. Report pea-sized lumps that are not painful because testicular cancer is typically painless. Perform a testicular self-examination monthly, after warm shower.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following actions should the nurse take first? Collaborate with a dietitian. Ensure that the client is provided with a high-ber diet. Implement recommendations from the speech-language pathologist. Request a referral for an occupational therapist.

Implement recommendations from the speech-language pathologist.

A nurse is reinforcing teaching about the management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching?

Increase intake of fiber-rich foods. Fluid intake of 2,000 mL/day to maintain soft stools. Increase activity to stimulate the evacuation of stool.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma? Scaly patches Silvery white plaques Irregular borders Raised edges

Irregular borders

A home health nurse is reinforcing teaching about preventing asthma attacks with a client who has asthma. Which of the following instructions should the nurse include in the teaching? "Cover the floor of your bedroom with carpet." "Do not allow visitors to smoke cigarettes in your home." "Breathe cold air to ease feelings of shortness of breath." "Open the windows in your home during the spring to increase air flow."

"Do not allow visitors to smoke cigarettes in your home."

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.) "I should expect to feel sleepy after using my albuterol inhaler." "I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming." "I should use my budesonide inhaler before using my albuterol inhaler."

"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming."

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication? Polyuria Abdominal cramps Renal insufficiency Insomnia

Abdominal cramps

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine. Greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.

A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? Monitor the insertion site for bleeding Position the affected extremity at a 45º Restrict the client's fluid intake Maintain the pressure dressing Check the client's peripheral pulses

Monitor the insertion site for bleeding is Maintain the pressure dressing Check the client's peripheral pulses

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?

Bradycardia, caused by a decrease in the client's metabolic rate. Hyperthyroidism: blurred vision, insomnia, weight loss

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will nd hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

C is correct. The nurse should identify that the V1 electrode should be placed in the fourth intercostal space just to the right of the sternum. Correct placement of the electrodes is vital in obtaining accurate information about the electrical activity of the heart.

A nurse is reinforcing discharge teaching for the caregivers of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching? Place the client on a low-calorie diet to prevent weight gain. Remind the client to avoid watching their feet when walking. Use small area rugs in the client's home for traction. Instruct the client to take tub baths instead of showers

Remind the client to avoid watching their feet when walking.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) Notify the charge nurse. Stop the infusion. Elevate the affected arm. Withdraw the IV catheter. Check the IV site.

Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse.

A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include? Place moist heat pads on the extremities. Perform manual massage of the affected extremities. Dangle the extremities o the side of the bed. Apply support stockings before getting out of bed.

Dangle the extremities o the side of the bed.

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication? Elevated sodium Elevated blood pressure Decreased potassium Decreased urine output

Decreased potassium

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect? Increased weight Increased heart rate Decreased urinary output Decreased shortness of breath

Decreased shortness of breath

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first? Determine the client's daily elimination habits. Administer a suppository to the client 30 min prior to defecation time. Offer the client 4 oz of warm prune juice to promote elimination. Provide dietary bulk to the client to ease the passage of stool.

Determine the client's daily elimination habits.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority? Determine the client's understanding of the procedure. Encourage the client to express their feelings. Allow the client's partner to stay with them. Provide music as a distraction.

Determine the client's understanding of the procedure.

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority? Pruritus Nausea Urinary retention Dyspnea

Dyspnea

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority? Muscle weakness Dysrhythmia Abdominal pain Lethargy

Dysrhythmia

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan? Expect decreased sensation for the rst postoperative week. Avoid lying on the operative side. Obtain a raised toilet seat. Cross legs at the ankles

Obtain a raised toilet seat.

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

Perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection. Ensure the client has an overbed trapeze to aid in lifting the upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning.

A nurse is caring for a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take? Position pillows between the bony prominences. Check for incontinence every 3 hr. Massage areas indicating potential breakdown of the skin. Elevate the head of the bed to 45°.

Position pillows between the bony prominences.

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first? Stop the medication infusion. Notify the charge nurse. Administer a PRN dose of diphenhydramine. Follow facility policy for appropriate reporting of the adverse reaction.

Stop the medication infusion.

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present? The client asks questions each time the nurse stops talking. The client stops the nurse and asks for pain medication. While the nurse is speaking, the client refers to the written materials. A caregiver who is present asks the client to repeat important points.

The client stops the nurse and asks for pain medication.

A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first? Insert the suction catheter into the tracheostomy Rinse the catheter with sterile 0.9% sodium chloride. Ventilate the client with 100% oxygen Occlude the vent on the catheter for 10 seconds

Ventilate the client with 100% oxygen

A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure?

intermittent straight catheter (clear tube with blue top)

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care? Store the CPM machine on the floor when it is not in use. Keep a sheepskin pad between the client's extremity and the CPM machine. Check the cycle and range-of-motion settings at least every 12 hr. Align the frame joint of the CPM machine with the middle of the client's calf.

Keep a sheepskin pad between the client's extremity and the CPM machine.

A nurse is caring for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take? Minimize the time the head of the bed is elevated. Apply a sterile gauze dressing to the site. Massage the site with moisturizing lotion. Place a donut-shaped cushion under the client's sacral area.

Minimize the time the head of the bed is elevated.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?

Mohs surgery is a horizontal shaving of thin layers of the tumor. Treat basal and squamous cell carcinoma. The procedure, which involves a horizontal shaving of thin layers of a tumor, has a high success rate. Cryosurgery: uses liquid nitrogen to destroy cancerous tissue. Melanoma: wide, full thickness surgical excision. Radiation: used as a palliative treatment for metastatic skin cancer.

A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?

Use simple verbal cues when directing tasks They manifest some degree of expressive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication Will display slow movement and cautious behavior. A client who has had a right hemisphere stroke, in contrast, will exhibit impulsive and unsafe behavior. Might have deficits, such as impaired vision on the right side of the body. The nurse should approach the client from the unaffected, or left side, of their body. Place the client in high-Fowler's position when eating, drinking, or taking medications to facilitate swallowing.

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?

You should have a pneumococcal immunization every 10 years. Pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia. Physical examination hearing check every year. Screening for glaucoma every 2-3 years along with an annual visual acuity examination.