Cms

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 1) I should wait at least 2 hours after eating before going to bed 2) I should eat three meals a day without eating snacks in between meals 3) I should season my food with garlic 4) I should drink my liquids throughout a straw

1) I should wait at least 2 hours after eating to go to bed

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 1) Mohs surgery is a horizontal shaving of thin layers of the tumor 2) Mohs surgery uses liquid nitrogen to destroy the cancerous tissue 3) Mohs surgery is the preferred treatment for melanoma skin cancer 4) Mohs surgery is a palliative treatment for metastatic skin cancer

1) Mohs surgery is a horizontal shaving of thin layers of the tumor

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? 1) administer epinephrine 2) monitor the clients vitals 3) monitor the clients o2 sats 4) administer an antihistamine

1) administer epinephrine -the greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchosoasms and laryngeal edema

A nurse is caring fir a client who had an acute ischemic stroke 1 day ago. Which action should the nurse take to reduce aspiration 1) allow 30 min rest before meals 2) provide a straw for drinking liquids 3) serve foods at room temp 4) place 2 tsp of food in the clients mouth at a time

1) allow 30 min rest before meals

A nurse is planning to implement droplet precautions for a client who is has pertussis. Which of the following interventions should the nurse include when contributing to the plan of care 1) apply a mask on the client if transport is needed 2) wear a mask when working within 1.2 m (4ft) of the client 3) don a gown when visiting the client 4) wear an n95 mask

1) apply a mask to patient if transportation 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? 1) apply cold packs to the inflamed joints 2) participate in high impact exercise 3) carry a hand purse rather than a shoulder bag 4) sleep on a soft foam mattress

1) apply cold packs to the inflamed joints -the nurse should instruct the client to use both warm end cold packs on inflamed joints to decrease pain

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 1) chest drainage greater than 70 ml/he 2) water fluctuations in the water seal chamber 3) chest drainage is clear in color 4) connections of the tubing are secured with tape

1) chest drainage is greater than 70 ml/hr

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 fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect 1) compartment syndrome 2) fat embolism 3) deep vein thrombosis 4) osteomyelitis

1) compartment syndrome Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a vast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities, a delay in capillary refill, without immediate treatment, can cause nerve damage and necrosis

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 1) determine the clients understanding of the procedure 2) encourage the client to express their feelings 3) allow the clients partner to stay with them 4) provide music as a distraction

1) determine the clients understanding of the procedure When using the nursing process, the first action the nurse should take us to collect data from the client. Therefore, the nurse should determine the clients understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety.

A nurse is caring for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make 1) "eat soft foods" 2) " season foods with salt" 3) "select foods that are low in protein" 4) "choose foods that are served hot"

1) eat soft foods - the nurse should instruct a client with stomatitis to eat soft, nourishing foods to decrease irritation to the oral mucosa

A nurse is contributing to the plan of care for a client who has COPF and is dyspneic. Which of the following interventions should the nurse include in the plan? 1) encourage abdominal breathing 2) direct the client to inhale with pursed lips 3) set the o2 therapy at 5 L/min 4) instruct the client to lean back when coughing

1) encourage abdominal breathing This reduces the workload on the accessory muscles of respiration during dyspneic episodes

A nurse is reinforcing teaching with the caregiver of the client of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include? 1) incontinence of the bowel and bladder 2) increase in HR 3) warm ness of the skin 4) hypertension

1) incontinence of the bowel and bladder - the nurse should inform the caregiver that incontinence is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following instructions should the nurse include in the teaching 1) increase intake of fiber rich foods 2) take a laxative every morning 3) maintain a fluid intake of 1,200 ml/day 4) limit activity to preserve energy

1) increase intake of fiber rich foods - the nurse should instruct the client to increase the amount of fiber rich foods in their diet. Foods like dried beans and brown rice are good examples

A nurse is caring for a client who is in bucks traction. Which intervention should the nurse perform to reduce skin breakdown 1) keep the skin dry and free of perspiration 2) use hot water and antibacterial soap to bathe the client 3) massage the skin over the bony or eminences to promote circulation 4) limit the use of moisture on the skin over body prominences

1) keep the skin dry and free of perspiration

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? 1) minimize the time the head of bed is elevated 2) apply a sterile gauze dressing to the site 3) massage the site with moisturizing lotion 4) place a donut shaped cushion under the clients sacral area

1) minimize the time the head of the bed is elevated

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? 1) perform pin site care daily 2) remove the overbed trapeze 3) remove the boot every 2 hours 4) keep the weights on a stable, flat surface

1) perform pin site cafe daily -a nurse should perform a pin site cafe daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin site for signs of infection -make sure 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 heals and elbows with client repositioning. -there is no boot with this -make sure the weights hand freely at all times

A nurse is caring for a client who is at risk for developing pressure insurers. Which of the following actions should the nurse take 1) position pillows between the body prominences 2) check fir incontinence every 3 hours 3) massage areas indicating potential breakdown of the skin 4) elevate the head of the bed to 45 degrees

1) position pillows between the bony prominences

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. 1) this type of insulin should be given at the same time every day 2) this insulin can be mixed with short acting insulin in a single syringe 3) this type of insulin can be used in a pump 4) this insulin has an increased risk for hypoglycemia

1) this type of insulin should be given at the same time every day

A nurse is examining a clients IV site and notes a red line up the arm. The client reports a throbbing, burning pain at the site. The nurse should identify this as which complication 1) thrombophlebitis 2) infiltration 3) hematoma 4) venous spasm

1) thrombophlebitis

A nurse is assisting with the care of a client who had a cardiac catheterization bus the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications 1) monitor the insertion site for bleeding 2) position the affected extremity at a 45 degree angle 3) restrict the clients fluid intake 4) maintain the pressure dressing 5) check the clients peripheral pulses

1,4,5 1) the nurse should monitor the insertion site for signs of hemorrhaging 4) maintaining pressure prevents hemorrhaging and allow for for the cannulation site to heal 5) the nurse should assess the clients peripheral isles to identify signs of arterial occlusion

A nurse is caring for a client who is 1 day post op following a hip arthroplasty. The client is exhibiting hypotension, tachycardia and tachypnea. The nurse recognizes that these indicate which complication? 1) wound infection 2) pulmonary embolism 3) thrombophlebitis 4) paralytic lieu's

2) pulmonary embolism

A nurse is reinforcing teaching about home cafe with a client who had knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present 1) the client asks questions each time the nurse stops talking 2) the client stops the nurse and asks for pain meds 3) while the nurse is speaking , the silent refers to written material 4) a caregiver who is present asks the client to repeat important points

2( the silent stops and ask for pain meds

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving sporting Alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective 1) BUN 40mg/dL 2) HGB 11 g/dL 3) urine specific gravity 1.035 4) blood glucose 105 mg/dL

2) HGB 11 - epoetin Alfa stimulated the production of erythropoietin and red blood cells, resulting in increased HMG levels.

A nurse is monitoring a client taking a carbide. Which of the following findings should the nurse identify as an adverse effect of the meds 1) polyuria 2) abdominal cramps 3) renal insufficiency 4) insomnia

2) abdominal cramps Acarbose affects the gastrointestinal system. Therefore, the nurse should monitor the client for abdominal cramping, rumbling bowel sounds, and diarrhea as adverse effects of this medication

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 1) consume a low purine diet 2) avoid stopping this medication suddenly 3) use chamomile tea to alleviate insomnia 4) take this medication on an empty stomach

2) avoid stopping meds suddenly This can result in adverse reactions including seizures, paranoia, and hallucinations

A nurse is caring for a client who has a methicillin resistant staphylococcus aureus (MRSA) infection in a surgical wound. Which information should the nurse share to visitors 1) call prior to visiting client 2) don a gown and gloves prior to entering the clients room 3) they need to wear a mask when close to the client 4) they can't bring fresh flowers into clients room

2) don a gown and gloves prior to entering the clients room MRSA is a contact precaution and visitors should put in gloves and a gown prior to entering the room

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? 1) cover the floor of your bedroom with carpet 2) do not allow visitors to smoke cigarettes in your home 3) breathe cold air to ease feelings of shortness of breath 4) open the windows in your home during the spring to increase air flow

2) don't allow people to smoke in your house

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority 1) muscle weakness 2) dysrthythmia 3) abdominal pain 4) lethargy

2) dysrhythmia

A nurse is participating in a health fair for older adults. Which vaccine should the nurse recommend 1) meningococcal 2) herpes zoster 3)HPV 4)mmr

2) herpes zoster - the nurse should recommend this fir adults 60 years or older

A nurse is collecting data from a 55 year old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT 1) five year history of menopause manifestations 2) history of treatment for blood clots 3) topi ram are use for migraine headaches 4) increased serum cholesterol levels

2) history of treatment for blood clots Estrogen increases the risk for blood clots. Therefore a female client who has a history of blood clots should not received HRT

A nurse is contributing to the plan if 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 1) use a commercial mouthwash before taking meds 2) instruct client to swish meds in mouth 3) discontinue the meds as soon as lesions heal 4) combine meds with applesauce

2) instruct client to swish meds in mouth This allows the meds the coat the entire oral mucosa

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 1) store the CPM machine on the floor when it is not in use 2) keep a sheepskin pad between the clients extremity and the CPM machine 3) check the cycle end range of motion settings at least every 12 hours 4) align the frame joint of the CPM machine with the middle of the clients calf

2) keep a sheepskin pad between the clients extremity and the CPM machine The nurse should plan to keep a sheepskin pad between the clients extremity and the CPM machine to protect the salients skin. The nurse should check the clients skin condition frequently while using the machine

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is starting methyl prednisone orally. Which statement should be included 1) take this in an empty stomach 2) limit contact with large groups of people 3) avoid taking over the counter calcium supplements 4) follow a low protein diet

2) limit contact with large groups Glucocorticoids cause immunosuppressive and can mask infection. The client should limit contact with sources of possible infections. Such as large groups of people

A nurse is caring for a client with meningococcal pneumonia. What PPE is required 1) gown 2) mask 3) sterile gloves 4) protective eyewear

2) mask This is a droplet precaution

A nurse is monitoring a client who has a history of enlarged prostate she is experiencing suprapubic discomfort. What action should be taken first 1) administer doxazosin 2) palpate the abdomen 3) insert an indwelling urinary catheter 4) notify the provider

2) palpate the abdomen

A nurse is reinforcing discharge teaching for a caregiver of a client who ha sparks sons disease. Which of the following information should the nurse include in the teaching 1) place the client on a low calorie diet to prevent weight gain 2) remind the client to avoid watching their feet when walking 3) use a small area rugs in the clients home for traction 4) instruct the client to take tub baths instead of showers

2) remind the client to avoid watching their feet when walking

A nurse is reinforcing teaching with a client with asthma. Which indicated and understanding of the use of budesimide and albuterol inhalers 1) I should expect to feel sorry after using my albuterol 2) I never forget to rinse my mouth after using budesonide inhaler 3) between office visits, I keep a record of how many times I use my albuterol 4) I use my albuterol inhaler before I go swimming 5) I should use my budesonide before my albuterol

2,3,4. 2- rinsing after use reduces oral thrush 3- recording the use of inhaler can assist the provider to determine the effectiveness 4- using inhaler before I exercise help exasperation

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 1) "I will perform the exam before I shower 2) " I will check my test Ocala every 6 months" 3) "I understand that testicular cancer is typically painless" 4) "I understand that pea size lumps are normal"

3) " I understand that testicular cancer is typically painless"

A nurse is reinforcing teaching about glucosylated hemoglobin (HbA1c) feasting with a client who has diabetes Milpitas. Which of the following statements indicates that the client understand? 1)the test should be done 2 hours after I eat a meal high in carbs 2) the test can help detect the presence of ketones in my body 3) I will have my HbA1c checked twice a year 4) I will fast before I am tested

3) "i will have my HbA1 checked twice a year" - this test provides the clients average glucose level for the preceding 3 months. The nurse should instruct the client to have their levels tested twice yearly to manage glucose - fasting isn't required - carbs aren't required -urine testing can detect ketones in the body

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 1) expect decreased sensation for the first postoperative week 2) avoid lying on the operative side 3) obtain a raised toilet seat 4) cross legs at the ankles

3) Obtain a raised toilet seat This way the patient avoids flexing the hip more than 90 degrees and avoids any risk of a dislocation

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 1) you may cross your legs after 60 days 2) avoid lying on your operated side 3) avoid ending your hips more than 90 degrees 5) you may sleep on a soft mattress

3) avoid bending 90 degrees

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate? 1) blurred vision 2) insomnia 3) bradycardia 4) weight loss

3) bradycardia

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? 1) clean the pin sites every 72 hours 2) use the halo ring to reposition the client in bed 3) change the sheepskin liner weekly 4) tighten the traction bars as needed

3) change the sheepskin liner weekly

A nurse is reviewing lab results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following lab findings should be reported 1) sodium 136 2) potassium 4.8 3) creatinine 1.9 4) calcium 10

3) creatinine This isn't within the normal range

A nurse is contributing to the plan if care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should be included 1) place moist heat pads on extremities 2) perform manual massage to affected extremities 3) dangle extremities off side of the bed 4) apply support stockings before getting out of bed

3) dangle extremities off the side of the bed This reduces pain by increases arterial blood flow.

A nurse is preparing to administer furosemide to a client who has HF. Which findings should the nurse report before administration. 1) elevated sodium 2) elevated BP 3) decreased potassium 4) decreased urine output

3) decreased potassium This should be reported because potassium is lost when a diuretic is administered which can lead to hypokalemia

A nurse is contributing to the plan if 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 1) apply hot packs to the clients muscles 2) schedule physical therapy in the afternoon 3) encourage the client to complete ADLs 4) administer valerian to promote sleep

3) encourage the client to complete ADLs

A nurse is contributing to the plan it care of a client who is having difficulty eating after a stroke. What actions should the nurse take 1) collaborate with dietitian 2) ensure that the client is provided with a high fiber diet 3) implement recommendations from the speech language pathologist 4) request a referral for an occupational therapist

3) implement recommendations from the speech language pathologist The greatest risk to the client following a stroke is aspiration. The first intervention should include a plan of care implementing recommendations from the speech language pathologist this person can conduct a swallow study to determine the clients risk for aspiration.

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observed ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following 1) cirrhosis of the liver 2) hypermotility of the bowel 3) intra-abdominal bleeding 4) acute cholecystitis

3) infra-abdominal bleeding

A nurse is collecting data from a. Client who ha a heart failure and is taking digoxin. Which of the following outcomes form the medication should the nurse expect 1) increased weight 2) increased heart rate 3) decreased urinary output 4) decreased shortness of breath

4) decreased shortness of breath The nurse should expect the client to have decreased shortness of breath. Digoxin increases the contractility of the heart, which decreases pulmonary congestion.

A nurse is assisting in the cafe of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first 1) collect a sputum culture 2) administer ceftriaxone by intermittent IV bolts 3) initiate O2 at 4 L/min via nasal cannula 4) obtain blood cultures

3) initiates oxygen at 4l/min via nasal cannula - when using the airway, breathing, circulation approach to client care, the first action the nurse should take is to initiate oxygen. Clients who have manifestations of sepsis are often hypoxia, tachyonealic, or have PaCO2 level less than 32 mm hg. The nurse should provide supplemental oxygen to keep the clients oxygen saturation levels at 95% or higher. Which will maximize the ability of the hemoglobin to support the oxygen needs of the body

A nurse is contributing the the plan of care of a client who was admitted to the neurological unit following a stroke 3 hours ago. Which of the following interventions should the nurse identify as priority? 1)encourage patient to participate in self care 2)assist client with active ROM exercises 3)keep client in a side laying position 4)maintain the clients body alignment

3) keep client in a side lying position -the r free eatery risk to the client following a stroke is aspiration. The nurse should position the client in a lateral position to allow any secretions to drain from the mouth, decreasing the risk of aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommended to promote sleep. 1) get out of bed if unable to fall asleep within 69 minutes 2) take a brisk walk before sleeping 3) listen to soft music before sleeping 4) drink adequate fluid before sleeping

3) listen to soft music before sleeping

A nurse is caring for a client who is 3 days post op following a totally right hip arthroplasty. What action should the nurse take 1) use a traction boot to keep the clients right leg internally rotated 2) have the client sit ins reclining chair when out of bed 3) maintain abduction of the clients right leg while in bed 4) encourage the client to perform passive FOM

3) maintain abduction

A nurse is caring for a client who has a history of breast cancer. The client asks about birth control. What method of BC is contraindicated 1) intrauterine device 2) latex condom 3) combination oral contraceptives 4) contraceptive sponge

3) oral contraceptive This may increase estrogen levels which can stimulate cancer growth

A nurse is assisting in the plan if care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan 1) observe for impulsive behavior 2) approach the client from the right side 3) use simple verbal cues when directing tasks 4) place client in low Fowler position during meals

3) use simple verbal cues when directing tasks - the nurse should expect a client who had a left hemispheric stroke to manifest some degree of expensive and/or receptive aphasia. Using simple verbal cues will assist the client in understanding spoken communication. A client who had a left hemisphere stroke might have deficits such as impaired vision in the right side of the body, so the nurse should approach from the unaffected side of the body. The left side

A nurse is preparing to suction a client who has a tracheostomy. What action is done first 1) insert the suction catheter into the tracheostomy 2) rinse the catheter with sterile sodium chloride 3) ventilate the client with 100% o2 4) occlude the vent on the Catherine 10 seconds

3) ventilate client with 100% o2

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include 1) your partner will not require treatment for this infection 2) you can resume sexual activity as soon as you begin treatment 3) you're at risk for infertility with this infection, regardless of treatment 4) you will not be at further risk for this infection following treatment

3) you're at risk for infertility with this infection, regardless of 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 nurses instructions 1) "I apple rubbing alcohol to my feet every day to prevent infection" 2) "I will wear clean, high knee wool socks every day to help improve my circulation 3) "I use hot water bottles to keep my feet warm at night" 4) "I don't cross my legs anymore

4) "I don't cross my legs anymore" -clients who have peripheral vascular disease should NOT cross their legs because it can impede circulation

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 1) "I should call my doctor if I get a headache" 2) "I might develop gastric reflux" 3) "I might develop excessive bruising" 4) "I should cal my doctor if my ankles swell"

4) "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 contributing to the plan if care for a client who has ménierès disease. What should the nurse include 1) increase clients fluid intake 2) assist the client with changing positions often 3) encourage the client to rest in a well lit room 4) administer an antiemetic

4) administer an antiemetic

A nurse is reinforcing teaching with it's a client who is scheduled for a guac decal occult blood test. Which of the following instructions should the nurse include in the teaching? 1) do not eat or drink 6 hours prior to the test 2) ensure that the stool specimen is obtained in the morning 3) take ibuprofen for mild pain until test is complete 4) avoid eating red meat for 3 days prior to the test

4) avoid eating red meat for 3 days prior to the test -the nurse should instruct the client to avoid eating red meat for 3 days prior to the test because this can lead to a false positive result

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include 1) you can take acetaminophen for pain 2) consume a diet that is high in animal protein 3) sleep lying flat on your back 4) consume foods that are low in sodium

4) consume foods low in sodium - this reduces the development of edema and ascites

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 effects of the medication 1) reduces bacteria in the urinary tract 2) suppresses urge to void 3) prevents nerve stimulation to the bladder muscle 4) decreases pain during urination

4) decreases pain during urination

A nurse is assisting the charge nurse with developing an in-service about caring for the clients who have internal sealed radiation implants. Which of the following information should the nurse include 1) restrict the time pregnant women are allowed in the clients room to 15 min 2) pick up a radiation implant with a double gloves hand if it becomes dislodged 3) limit time spent in the clients room to 2 hours during an 8 hour shift 4) dispose of radiation implants ima lead container

4) dispose of radiation implants in a lead containers

A nurse is caring for a client who is receiving chemotherapy. The client mentions that they have a loss of appetite because of the sores in their mouth and that food no longer taste good. Which of the following suggestions to the client should the nurse make 1) drink water before wnd after each bite 2) consume foods that are served hot rather than cold 3) rinse with glycerin based mouth wash before meals 4) eat several small portioned meals

4) eat several small portioned meals a day

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 1) increase fluid intake 2) encourage range of motion exercises 3) massage boney prominences 4) encourage weight bearing exercises

4) encourage weight bearing exercises - weight bearing exercises, such as walking, can maintain bone mass by reducing bone demineralization, thus helping to prevent osteoporosis

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration 1) provide small, frequent meals 2) tell the client to extend their neck when swallowing 3) provide mouth care before meals 4) give the client liquids with increased viscosity

4) give the client liquids with increased viscosity Thickened liquid are easier for the client to swallow and can prevent asliration

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. 1)scaly latches 2) silvery white plaques 3)irregular borders 4) raised edges

4) irregular borders

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 should the nurse recommend 1) ketchup 2) Mayo 3) soy sauce 4) lemon juice

4) lemon juice This is low in sodium unlike the other options

A nurse observed a client who is lying in bed and experiencing a tonic-clinic seizure. Which of the following actions should the nurse take 1) lower the side rails on the bed 2) apply wrist restraints 3) position the client in a semi-Fowler's position 4) loosen clothing around the clients neck

4) loosen clothing around the patients neck - this helps maintain an open airway and prevent aspiration. The nurse should also place the patient in a lateral position to prevent any aspiration of oral drainage or secretions.

A nurse is preparing to remove a clients NG tube. Which of the following interventions should the nurse take to decrease the risk for aspiration 1) instill 10 mL of the air through the NG tube 2) place the client in the supine position 3) irrigate the NG tube 4) pinch the NG tube

4) pinch the NG tube The nurse should pinch the NG tube to prevent secretions from draining into the clients throat, which can cause aspiration.

A nurse is reinforcing discharge teaching about a wound care with the caregiver of a client who is postoperative. Which of the following instructions should the nurse include in the teaching m 1) administer an analgesic following wound care 2) irrigate the wound with providing iodine 3)cleanse the wound with a cotton tipped applicator 4)report purple to drainage to the provider

4) report purple to drainage to the provider The nurse should remind the caregiver to report manifestations of infection, including outliner drainage, to the provider

A nurse in a long care facility is collecting data from a client who reports fullness in the recruitment and abdominal cramping. Which findings indicates to the nurse they the client has fecal impacts on 1) halitosis 2) hemorrhoids 3) rebound tenderness 4) small liquid stools

4) small liquid stools This can be a result of decal material being expelled around an impaction - rebound tenderness is an indication of appendicitis -halitosis is bad breath

A nurse reinforcing teaching with a client who is using an insulin limo. Which instruction should be included 1) insert infusion needle into intramuscular tissue 2) change the needle every 5 days 3) calculate the insulin for each meal by using an insulin to protein ratio 4) use rapid acting insulin in the infusion device

4) use rapid acting insulin -use an insulin to carb ratio fir calculating doses -change the needle every 3 hours

A nurse is caring for a client who has terminal pancreatic cancer. The client states "I don't think I can go any longer" which or the following responses should the nurse make 1) are you experiencing abdominal pain 2) you should talk about this with the people you're close to 3) many people who have cancer feel this way 4) you feel like you want to discontinue treatment

4) you feel you want to discontinue treatment

A nurse is discussing health screening guidelines with an older adult client. Which statement should be included 1) you should have a screening for glaucoma every 5 years 2) you should have a physical examination every other year 3) you should have your hearing checked every 2 years 4) you should have a pneumococcal immunization every 10 years

4) you should have a pneumococcal immunization every 10 years