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A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? Arterial blood gases Urinary output Chest tube drainage Pain level

Arterial blood gases

A nurse is assessing a client who is taking levothyroxine. The nurse should recognize that which of the following findings is a manifestation do levothyroxine overdose?

Insomnia

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

"I will be certain to take enteric-coated medications."

A nurse is assessing a clients immune function by reviewing the lab values of the cellular response of the T cells. The nurse should recognize that which of the following conditions is affected by the t cells?

transplant rejection

A nurse is a client who is taking metformin XR for type 2 DM. Which of the following instructions should the nurse include in the teaching?

Take the medication with a meal.

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 100/min, respiratory rate 40/min, and blood pressure 140/80 mmHg, HCO₃ mEq/L, and SaO₂ 86%. Which of the following is the priority nursing intervention? a. Prepare for mechanical ventilation b. Administer oxygen via face mask c. Prepare to administer a sedative d. Assess for indications of pulmonary embolism

b. Administer oxygen via face mask

A nurse is creating the plan of care for a client who is immunosuppressed. Which of the following precautions should the nurse include in the plan? (Select all that apply.) a. Limit visitors to 5 min only b. Restrict visitors who have an active cough or runny nose c. Avoid IM injections when possible d. Don a mask, gloves, and gown e. Instruct the client to avoid raw foods, and fresh fruits and vegetable that cannot be washed well.

b. Restrict visitors who have an active cough or runny nose d. Don a mask, gloves, and gown e. Instruct the client to avoid raw foods, and fresh fruits and vegetable that cannot be washed well.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? a. Furosemide b. Dexamethasone c. Heparin d. Atropine

c. Heparin

a nurse is prioritizing client care after recieving change of shift report. Which of the following clients should the nurse plan to see first?

A client who told an assistive personnel he is short of breath

A nurse is caring for a client who is to start taking cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can have an adverse interaction with this medication?

Grapefruit juice

A nurse is caring for a client who just had a flexible bronchoscopy. Which of the following nursing action sis appropriate?

Withhold food and liquids until the clients gag reflex returns

A nurse is caring for a client who has a NG tube. The nurse tests the pH of the secretions to determine if the tube is correctly placed. The nurse should expect to aspirate a sample with a pH of

4.0

A nurse is teaching a client how to do fecal occult blood testing. Of the following statements by the client indicates a need for further teaching

"I will continue taking my Coumadin as prescribed."

A nurse is providing teaching to a client who has oral candidiasis and a new prescription for nystatin suspension. Which of the following statements by the client indicates an understanding of the teaching?

"I will store the medication at room temperature"

A nurse is providing discharge teaching to a client who will be receiving TPN at home.Which of the following should the nurse include?

"Keep the TPN refrigerated when not in use. "Infuse 10% dextrose and water if the solution runs out." "Maintain TPN infusion rate when behind schedule."

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the followingresponses should the nurse make?

-Excessive laxative use may cause an electrolyte imbalance."

A nurse is providing teaching to a client who has a diabetes mellitus about carbohydrate intake needs when exercising. Which of the following foods should the nurse include as containing a 15 g serving of carbohydrates?

1 cup milk

A client is prescribed Lansoprazole 15 mg PO once a day. At which of the following times should the nurse administer the medication?

30 min before breakfast

A nurse is assessing a client who has advanced cirrhosis. Which of the following manifestations should the nurseexpect? A. Petechiae B. Hypertension C. Osteoarthritis D. Peripheral ulcers

A. Petechiae

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. increased respiratory rate of 18 to 44/min B. increased oral temperature of 36.6 C to 37.7 CC. increased blood pressure from 112/68 to 120/72 D. Increased heart rate from 68 to 72

A. increased respiratory rate of 18 to 44/min

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? A. "I will use both medications immediately after exercising." B. "If my breathing begins to feel tight, I will use the cromolyn immediately." C. "I will be sure to take the albuterol before taking the cromolyn." D. "I will administer the medications 10 minutes apart."

B. "If my breathing begins to feel tight, I will use the cromolyn immediately."

A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was A. dysphagia B. hoarseness C. dyspnea D. weight loss

B. hoarseness

A nurse is assessing a client who shows signs of hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

C. Agitation

A nurse is teaching a client who has hepatitis A about preventing transmission of a virus. Which of the following strategies should the nurse include in the teaching?

C. Practice effective hand hygiene

A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Check the client's voice every 2hr

A nurse in a provider's clinic is assessing a client who has cancer and a prescription for methotrexate PO. Which of the following actions should the nurse take when the client reports bleeding gums?

Check the value of the client's current platelet count.

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care?

Check urine specific gravity

A nurse is teaching a client who has a history of ulcerative colitis and a new diagnosis of anemia. Which of the following manifestations of colitis should the nurse identify as a contributing factor to the development of the anemia?

Chronic blood loss

A nurse prepares to replace the nearly empty container of total parenteral nutrition (TPN) for a client when she finds that there has been a delay in receiving the new container of solution from the pharmacy. Which of the following solutions should the nurse infuse until the next container of TPN solution becomes available?

Dextrose 10% in water

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client who has DM. When mixing the 2 types of insulin, which of the actions should the nurse take first?

Inject 20 units of air into the NPH insulin vial

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take?

Keep the collection device below the level of the client's chest

A nurse is caring for a client who has tuberculosis and new prescriptions for rifampin and pyrazinamide. Which of the following laboratory tests should the nurse instruct the client will be required while on this medication regimen?

Live function tests

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Place the client in a private room with a special ventilation system.

A nurse is planning a diet for a client who is iron deficient. Which of the following foods high in iron should the nurse include in the plan?

Red meats

Client is admitted to the emergency room with a respiratory rate of 7 bpm. Arterial blood gases reveal the following values. which of the following is an approproate analysis of the ABGs

Respitory acidosis

a nurse is teaching self-management to a client who has hepatitis B. Which of the following instructions should the nurse include in the self teaching?

Rest frequently throughout the day.

A nurse is caring for a client who is taking asprin for arthritis. The nurse should identify which of the following findings as an adverse effect of this medication?

clay colored stool

A nurse is caring for a client immediately following a procedure that required spinal anesthesia. Which of the following findings indicates the client is experiencing a complication of the anesthesia?

headache

A nurse is monitoring a client following thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

increased heart rate

A nurse is reviewing provider's prescriptions for pt experiencing a paralytic ileus following an appendectomy. which of the following actions should the nurse expect to take?

insert NG tube

A nurse is teaching a client who is receiving treatment for metastatic colorectal cancer about the adverse effects of bevacizumab with. The nurse should instruct the client to report which of the following findings as an adverse effect of the medication?

nosebleeds