ati rn comp learning quiz
Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. The nurse has limited experience with children. Which of the following actions should the nurse manager take? Provide constant supervision for the medical-surgical nurse. Have the medical-surgical nurse provide relief for unit nurses during break and lunch times. Assign a unit nurse to act as a resource for the medical-surgical nurse. Delegate to the medical-surgical nurse tasks that assistive personnel perform.
Assign a unit nurse to act as a resource for the medical-surgical nurse
A nurse is admitting a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take?
Attach a latex allergy alert identification band
A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first?
Attempt to reduce environmental stimuli.
A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? Does your child wear a hat outdoors in cold weather?" Otitis media is an infection of the middle ear. Exposure to cold weather does not cause it. "Does anyone smoke around or in the same house as your child?"
"Does anyone smoke around or in the same house as your child?"
A nurse in a substance use disorder program is interacting with a client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission? "I was just using the medication to help me out during a rough time in my life. I can stop whenever I want." "This all happened because my spouse is unemployed. That puts an enormous amount of stress on me." "I have read that problems with substances can have a variety of predisposing factors." "I just don't want to talk about it. There is nothing you can do about it anyway."
"I have read that problems with substances can have a variety of predisposing factors."
A female client who has recurrent cystitis asks the nurse about preventing future episodes. For which of the following statements should the nurse provide further teaching. "I drink at least 2 liters of fluid per day." "I prefer tub baths to showering." "I urinate before and after sexual relations." "I wipe from front to back after urinating."
"I prefer tub baths to showering."
A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses should the nurse make? "I understand how you feel." "You are young and can have healthy babies when you are older." "Sometimes this is nature's way." "This must be so difficult for you.
"This must be so difficult for you.
A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A small, plastic doll with clothes and accessories Alphabet flash cards A handheld video game A 10-piece wooden puzzle
A 10-piece wooden puzzle
A nurse in the emergency department is assessing a client who has pancreatitis. In which of the following laboratory results should the nurse expect to see an elevation? Amylase Potassium Calcium Hematocrit
Amylase
A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiologic adaptation to pregnancy? Spotting with urination Breast tenderness Thick, white vaginal discharge Facial swelling
Breast tenderness
A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client? Tell the client that the nurse will talk to him at his request. Allow the client to skip group activities if he chooses. Leave the client alone for frequent rest periods throughout the day. Build trust with the client by sitting quietly with him.
Build trust with the client by sitting quietly with him.
A nurse is beginning her shift and reviewing the medication administration records (MARs) for her clients. She notes a dosage of a medication above the safe range and sees that a nurse administered that dosage during the previous shift. Which of the following actions should the nurse take?
Call the provider to clarify the dosage.
A nurse responds to a call from an assistive personnel that a client has had a seizure and is unconscious. Which of the following assessments is the nurse's priority? Measure the client's vital signs. Perform a neurological examination. Check airway patency.
Check airway patency.
A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The nurse notes that her left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first? Obtain an x-ray of the injured leg. Apply ice packs to the affected area. Check neurovascular status distal to the injury. Elevate the affected leg on two pillows.
Check neurovascular status distal to the injury
A nurse is providing teaching to a client who has hypothyroidism and is taking levothyroxine. The nurse should instruct the client that which of the following findings is an indication of thyrotoxicosis? Weight gain Constipation Chest pain Fatigue
Chest pain
A nurse is teaching an assistive personnel (AP) about dietary restrictions for a client who is taking phenelzine to treat depression. The AP's selection of which of the following foods for the client's lunch indicates an understanding of the teaching? Bologna on wheat bread Chicken salad Cheddar cheese and crackers Pizza with pepperoni
Chicken salad MAOI
A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? Collard greens Cottage cheese Orange juice Broccoli
Collard greens
A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? Check the client's name and medical record number on the MAR against the room and bed number. Call the client by name and check the name on her identification band against the MAR. Compare the medical record number and name on the MAR with the client's identification band. Ask the client's visitor to identify the client by name and to state the client's birth date.
Compare the medical record number and name on the MAR with the client's identification band.
A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer? Corticosteroids Antimalarials Antidepressants Opioids
Corticosteroids
A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider? Nausea and vomiting Decreased hemoglobin Decreased appetite Anxiety
Decreased hemoglobin can cause severe anemia and neutropenia from bone marrow suppression resulting in hematologic toxicity.
A nurse is caring for a client who is taking acarbose to treat type 2 diabetes mellitus. For which of the following adverse effects of this medication should the nurse monitor?
Diarrhea are gastrointestinal. They include diarrhea, abdominal distention and cramping, and flatulence.
A nurse is discussing fire safety with newly hired nurses. The nurse should identify which of the following actions as the priority if a fire occurs in the health care facility? Close the fire doors on the unit. Use a fire extinguisher on the fire. Pull the nearest fire alarm. Evacuate clients from the unit.
Evacuate clients from the unit.
A nurse participating in a community health fair is providing information to a client who has a BP of 150/90 mmHg during a blood pressure screening. Which of the following actions should the nurse take? Give the client a written record of his BP to bring to their provider. Encourage the client to go to the nearest emergency department. Instruct the client to follow up with a provider within 6 months. Explain to the client that he is not at risk unless he has manifestations of hypertension
Give the client a written record of his BP to bring to their provider.
A nurse on the antepartum unit is caring for a client who is at 28 weeks of gestation and reports dizziness when lying on her back. Into which of the following positions should the nurse assist the client? Lateral A lateral, or side-lying position, promotes uteroplacental blood flow and thus helps relieve the symptoms of supine hypotension, including faintness, dizziness, and breathlessness. Lithotomy Trendelenburg Prone
Lateral
A nurse is caring for an infant who is experiencing dehydration. Which of the following assessments is the nurse's priority (urgent vs nonurgent)? Measure the client's weight daily. Check for tears. Palpate the fontanel. Assess skin turgor
Measure the client's weight daily. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight
A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? Ask the client's neighbor to call a family member to interpret. Ask the client's neighbor to translate the information. Obtain the services of an interpreter Document the inability to provide discharge instructions
Obtain the services of an interpreter
A nurse is caring for a client who has pseudomembranous colitis due to a Clostridium difficile infection. Which of the following interventions is the nurse's priority? Performing hand hygiene before and after contact with the client Reducing the client's anxiety due to isolation procedures. Assisting the client in making nutritional choices Monitoring the client's intake and output
Performing hand hygiene before and after contact with the client
A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings should indicate to the nurse that the AAA is expanding? Increased BP and decreased pulse rate Jugular-vein distention and peripheral edema Report of sudden, severe back pain
Report of sudden, severe back pain
A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication? Urine specific gravity Urine output Blood pressure Temperature
Temperature Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.
A nurse is assessing a client who is in the fourth stage of labor and suspects bladder distention. Which of the following findings should the nurse anticipate with bladder distention?
The bladder fluctuates with palpation.
A nurse is planning teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. Which of the following topics should the nurse plan to include? Smoking cessation The benefits of a diet high in cruciferous vegetables New types of ostomy appliances The importance of colonoscopy screening starting at age 50 years old
The importance of colonoscopy screening starting at age 50 years old
A nurse is planning care for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) with mild manifestations. The nurse should expect that the provider will prescribe which of the following medications? Chlorpropamide Tolvaptan Vasopressin Desmopressin
Tolvaptan
A nurse observes tachycardia, dyspnea, a cough, and distended neck veins in a client who is receiving a transfusion of packed red blood cells (RBCs). Which of the following interventions should the nurse use to prevent these manifestations with the client's next transfusion? Warm the unit of blood to room temperature before administering it. Administer acetaminophen prior to the blood transfusion. Give an antihistamine prior to the transfusion. Use a transfusion pump to regulate and maintain the transfusion at a slower rate.
Use a transfusion pump to regulate and maintain the transfusion at a slower rate.
A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take? Verify with the provider about giving insulin glargine at 1700. Ensure the insulin glargine is a cloudy suspension. Request a prescription for giving insulin glargine twice daily. Use separate syringes for administering insulin glargine and NPH insulin.
Use separate syringes for administering insulin glargine and NPH insulin.
include hepatotoxicity and peripheral neuropathy. Yellowing of the sclera is an indication of the jaundice that accompanies liver failure.
isoniazid
A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? Elevate the client's feet and legs Administer epinephrine. Infuse 0.9% sodium chloride. Stop the medication infusion.
Stop the medication infusion
(an action to prevent the development of a disease).
primary prevention
is that it changes the color of bodily secretions to red-orange.
rifampin
(an action that promotes early detection of disease).
secondary prevention
(an action to minimize the effects of long-term disease or disability).
tertiary prevention
A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? "I'll drink less water so I don't have to catheterize myself too often." "I must use sterile technique to do each of the catheterizations." "I should stop the catheterization when I have removed 150 mL of urine." "I will perform intermittent self-catheterization every 2 to 3 hours."
"I will perform intermittent self-catheterization every 2 to 3 hours."
A nurse is providing teaching to a school-age child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? "Use a toothbrush to scratch under the cast if your skin itches." "Avoid moving your leg and the joints above and below the cast." "Keep the cast above the level of your heart." "Clean soil from the cast with soapy water."
"Keep the cast above the level of your heart."
A nurse is providing teaching to a client who is scheduled for an electroencephalogram (EEG) in the morning. Which of the following information should the nurse provide the client? "You'll feel some mild electrical sensations, like static electricity, during the procedure." "Do not eat or drink anything except water after midnight." "Shampoo your hair before the procedure, and don't put any styling products on it afterward." "It's common to have a temporary short-term memory loss after the procedure."
"Shampoo your hair before the procedure, and don't put any styling products on it afterward."
A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse provide the client? "If you lose weight, you will need a refitting for your IUD." "An IUD provides protection from certain sexually transmitted infections." "Your risk for ectopic pregnancy increases with an IUD." "You shouldn't use an IUD if you want to have children later on."
"Your risk for ectopic pregnancy increases with an IUD
A nurse on an oncology unit receives report at the beginning of her shift about four clients who are postoperative. Which of the following clients should the nurse see first? A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage. A client who is 2 days postoperative following excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguineous drainage A client who is 1 day postoperative following excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine
A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage.
A nurse in the labor and delivery suite is planning care for a group of four clients. Which of the following clients should the nurse see first? A client who is in active labor and has late decelerations on the fetal heart monitor's strip A client who is in transition and is screaming and disturbing other clients A client who has epidural analgesia and is reporting breakthrough pain A client who has received oxytocin infusion and is experiencing contractions every 2 min lasting 60 seconds
A client who is in active labor and has late decelerations on the fetal heart monitor's strip
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A simple face mask A nonrebreather mask A bag-valve-mask device A nasal cannula
A nasal cannula
A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parent's presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan because it offers which of the following benefits? Decreases the child's fear of the dark Allows the child to manipulate toy medical equipment Provides an opportunity to analyze the child's emotions Encourages parents to engage with their child
Allows the child to manipulate toy medical equipment
A nurse delegates a licensed practical nurse (LPN) to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the LPN should indicate to the nurse that she requires further teaching? Accompanies the client to physical and occupational therapy. Ambulates the client's roommate while the client sleeps. Asks the nurse at lunch time to assign another LPN to perform this task. Remains with the client while family members are visiting.
Ambulates the client's roommate while the client sleeps.
A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The nurse should explain to the client that the goal of this medication therapy is to reduce which of the following outcomes? Bacterial growth Scarring Skin graft size Pain
Bacterial growth
A nurse is admitting a client to the medical unit and asks him if he has advanced directives. The client states, "I have a document with me that names someone who can make health care decisions for me if I am not able." The nurse should identify that the client is referring to which of the following documents? Informed consent form Living will document Do-not-resuscitate directive Durable power of attorney document
Durable power of attorney document
A nurse is caring for a client who had a precipitous delivery. The nurse should identify which of the following assessments as the priority during the fourth stage of labor? Obtaining the client's temperature Inspecting the client's perineum Palpating the client's fundus Checking the client for hemorrhoids
Palpating the client's fundus
A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada." The nurse should make which of the following age assessments for this child? 6 months old 12 months old 18 months old 24 months old
12 months old
A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? "I'll stick with soft foods for now." "My family will be bringing me fresh flowers today." "I'll use a new disposable razor each day."-electric razor "I'll blow my nose more often to avoid nosebleeds."-avoid blowing nose
"I'll stick with soft foods for now." Thrombocytopenia (a low platelet count) is common after a bone marrow transplant. To prevent bleeding until his platelet count improves, the client should avoid hard foods that could cause mouth trauma.
A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP should indicate that further teaching is required? "I should not leave all four side rails up unless there is a prescription for restraints." "An alert client will be safest if I raise the two upper side rails at the head of the bed." "If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself." "If a client is sedated, I should raise all four side rails to prevent a fall out of bed."
"If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself."
A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make? "Have you discussed this with your doctor yet?" "The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." "Women who are already prone to vaginal yeast infections get them during pregnancy." "Why are you concerned about yeast infections during pregnancy?"
"The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common."
A nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? "The doctor will replace the tubes routinely about every 2 years." "Getting water in her ears will not cause any further problems." "The tubes should stay in place until they fall out on their own." "Now that the tubes are in place, she should not have any further problems with hearing."
"The tubes should stay in place until they fall out on their own."
A nurse is talking with a parent of a preschooler. The parent reports that it is very difficult to get her child to go to bed at a consistent time. She tells the nurse that the child gets out of bed, enters her parents' room, and cries when they tell him to stay in bed. Which of the following instructions should the nurse give the parent? "Use a stable, relaxing routine, such as a bath and story time, before bed." "Make sure the room is completely dark when placing your child in bed." "Let your child go to sleep in your lap and then put him in his bed." "Respond consistently if your child cries out for you after putting him to bed."
"Use a stable, relaxing routine, such as a bath and story time, before bed."
A nurse is providing discharge teaching to parents whose infant has had a ventriculo-peritoneal shunt placement for the treatment of hydrocephalus. Which of the following statements by the parents indicates an understanding of the teaching? "We will check his abdomen daily for signs of fluid accumulation." "We will notify the doctor right away if he has a fever." "We should keep a helmet on him when he's awake." "We can expect him to have occasional seizure episodes."
"We will notify the doctor right away if he has a fever." Infection is a risk after a ventriculoperitoneal shunt insertion, especially 1 to 2 months after placement. The parents should report fever, vomiting, seizure activity, and decreases in responsiveness, as these can indicate infection.
A nurse is providing teaching to a client who has type 2 diabetes mellitus. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make? "Let's discuss this with your doctor; it may not be necessary." "Isn't there another favorite dish you can substitute?" "You don't have to give up pasta; just adjust the amount you eat." "You can use no-added-salt tomato products on your pasta."
"You don't have to give up pasta; just adjust the amount you eat."
A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include? "You might need glasses after the surgery." "You may drive home after the procedure." "Continue to wear your contact lenses until the day of the surgery." "Expect complete healing and clear vision in about a week."
"You might need glasses after the surgery."
A community health nurse is planning care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A 1-week-old newborn who needs another phenylketonuria screening test A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy A 10-day-old newborn who is small for gestational age and who requires daily weighing A 2-week-old newborn who was born at 35 weeks of gestation and weighed 2,268 g (5 lb) at discharge
A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy
A nurse is caring for a client who has regular occupational exposure to sunlight and comes to the clinic for evaluation of several skin lesions. Which of the following findings should alert the nurse to the possibility of malignant melanoma? A pearly papule that is 0.5 cm (0.20 in) wide with raised, indistinct borders on the upper right shoulder Several flat, pigmented, circumscribed areas of various sizes over the bridge of the nose A raised, circumscribed lesion on the face that contains yellow-white purulent material An irregularly shaped brown lesion with light blue areas on the neck
An irregularly shaped brown lesion with light blue areas on the neck
glaucoma results from a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. This leads to an acute onset of a severely painful rise in intraocular pressure. is an emergency. Manifestations include a sudden onset of severe pain around the eyes and face, reduced vision, colored halos, and headaches.
Angle-closure (acute)
A nurse is caring for a client who has a platelet count of 50,000/mm3. After discontinuing the client's peripheral IV site, which of the following actions should the nurse take?
Apply pressure to the catheter removal site for 5 min.
A nurse on a mental health unit is caring for a client who has antisocial personality disorder and is becoming increasingly loud and belligerent. Which of the following approaches should the nurse use to manage this client's behavior? Confront the client for breaking the rules. Stand close to the client to offer comfort and support. Speak to the client with clear, calm, caring statements. Escort the client to the nurses' station.
Speak to the client with clear, calm, caring statements.
A nurse is providing teaching to a client who has a new prescription for sertraline. The client asks the nurse if he should continue to take St. John's wort for depression. Which of the following instructions should the nurse give the client?
Stop taking the herbal supplement while taking the medication.
A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? Don a gown before entering the room and remove it before exiting. Wear a mask while in the client's room. Don gloves when entering the room and use hand sanitizer when exiting.
Don gloves when entering the room and use hand sanitizer when exiting. Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.
A nurse is preparing to administer a feeding via a gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? Warm the feeding in a microwave oven. Elevate the head of the bed. Flush the tube with 0.9% sodium chloride for irrigation.-can use water Verify that the gastric pH is above 4.-below 4
Elevate the head of the bed.
A nurse is caring for a client who has dehydration and has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for this client? BUN 18 mg/dL Capillary refill 1.5 seconds Hct 55% Urine specific gravity 1.001
Hct 55% An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.
A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) Tilt your head back slightly and open your mouth wide Depress the canister while taking a slow deep breath Hold the mouthpiece 1 to 2 inches inf front of your mouth Hold your breath for 10 seconds
Hold the mouthpiece 1 to 2 inches inf front of your mouth Tilt your head back slightly and open your mouth wide Depress the canister while taking a slow deep breath Hold your breath for 10 seconds
A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider? Hypocalcemia Hyperkalemia Anemia Hypoalbuminemia
Hyperkalemia
A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? Call in the clients' family members to provide additional help with moving the clients. Ask clients who are able to ambulate to assist in moving the unstable clients. Instruct clients who are able to ambulate to leave. Direct staff members to close the doors and windows as each room is evacuated.
Instruct clients who are able to ambulate to leave.
A nurse is assessing a client who has multidrug-resistant tuberculosis and takes ethambutol. The nurse should identify which of the following findings as an adverse effect of this medication?
Loss of red/green color discrimination
results in a loss of vision in the center of the visual field (the macula) because of damage to the retina. Manifestations include gradual, mild to moderate reduction of central vision.
Macular degeneration
A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider? Meperidine Amitriptyline Gabapentin Propranolol
Meperidine
A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PaCO2 40, and HCO3- 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
Metabolic acidosis
A nurse is assessing a client who is taking varenicline for smoking cessation. Which of the following findings is nurse's priority? Mood changes Nausea Altered sense of taste Skin rash
Mood changes
A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? Offering the client a diet high in fluid and fiber Encouraging active range of motion of the affected leg Removing the weights prior to repositioning the client Inspecting pin sites every 24 hr for drainage
Offering the client a diet high in fluid and fiber-risk for constipation Encouraging active range of motion of the affected leg-for unaffected limbs Removing the weights prior to repositioning the client-do not move weights Inspecting pin sites every 24 hr for drainage-inspect 8-12 hr
A nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent? Inhaled glucocorticoids are less likely to cause thrush. Oral glucocorticoids are hazardous during times of stress. Oral glucocorticoids are more likely to slow linear growth in children. Inhaled glucocorticoids are more effective for acute bronchospasm.
Oral glucocorticoids are more likely to slow linear growth in children.
A nurse is providing teaching to a client who has a new prescription for doxycycline. The nurse should instruct the client to monitor for which of the following adverse effects? Photosensitivity Constipation Ototoxicity Blurred vision
Photosensitivity
A nurse at a long-term care facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's level of orientation? Encourage the client to make choices about meals and activities. Use written signs to label specific rooms. Post a large calendar on the bulletin board. Place a wander alert electronic alarm bracelet on the client's wrist.
Post a large calendar on the bulletin board.
A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? Finding the bathroom in the dark Driving at night Seeing numbers on highway signs Reading the newspaper
Reading the newspaper
A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? Show the client how to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Assist the client out of bed and to the chair for the first time after surgery. Check the client's abdominal wound dressing.
Record urinary output after emptying the indwelling urinary catheter.
A nurse is assessing a client who reports an acute visual disturbance and describes it as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? Cataracts Angle-closure glaucoma Retinal detachment Macular degeneration
Retinal detachment
A nurse is providing teaching to a client about a surgical procedure that she is scheduled for later in the day. The client states that no one has spoken to her about the procedure before. Which of the following actions should the nurse take? Continue the teaching, but check afterward with the surgeon about informed consent. Stop the teaching and check with the surgeon about informed consent. Stop the teaching and ask the client to sign an informed consent form. Continue the teaching and check the client's medical record afterward for a signed consent
Stop the teaching and check with the surgeon about informed consent.
is a clouding that develops in the lens of the eye over time. Cataracts slowly impair vision and, without treatment, lead to blindness. Manifestations include decreased color perception and blurry vision.
cataract
