CMS FINAL REVIEWERS FOR ADULT MEDICAL SURGICAL

A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg 100 lb. Which of the following statements by the client indicates an understanding of the teaching?

"I should give my shot in my belly tissue"

A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following statements by the client indicate an understanding of the teaching?

"I should report episodes of diarrhea."

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide overnight."

A nurse is caring for a client who has COPD with copious secretions. Which of the following actions should the nurse take?

Administer high-flow oxygen.

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?

Elevated troponin.

A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?

Encourage reminiscence of past experiences.

A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?

Encourage the client to ambulate with a staff member.

A nurse is reinforcing teaching with a client about heart disease prevention. Which of the following client statements indicates an understanding of the teaching?

I will try to maintain my blood pressure around 116/72.

A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching?

I will use a skin sealant before I apply the bag.

A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Install locks at the top of doors.

A nurse is admitting a client who is suspected of having active tuberculosis TB. Which of the following actions should the nurse take first?

Institue airborne precautions.

A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou Pap test. Which of the following actions should the nurse take?

Instruct the client to avoid sexual intercourse until the cervix is healed.

A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding?

Instruct the client to place their chin to their chest when swallowing.

A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls?

Instructs the client to wear their own socks to the bathroom.

A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

Take calcium supplements with meals.

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine?

Urticaria.

A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?

Urine output is 50 mL/hr.

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure ICP. Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

Use clean technique to collect urine specimens from the drainage system.

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.

A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Use the client's left arm to obtain blood samples.

A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take first?

Verify the client has given informed consent.

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

withhold the dose.

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water."

A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective?

"I no longer feel nervous."

A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicate an understanding of the teaching?

"I should expect to have an increased risk for breast cancer."

A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter."

A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will limit my coffee intake"

A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure"

A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching?

"I will set the suction pressure dial between 80 and 120."

A nurse is reinforcing discharge teaching a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet"

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults.

A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse?

"Sitting quietly near the bedside can provide comfort and support."

A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make?

"The removal of a single testicle will not prevent you from having an erection."

A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following responses should the nurse make?

"The tumor causes obstruction of urine from the urethra."

A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur?

(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans.

A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 mL.

A nurse is preparing to administer subcutaneous enoxaparin. 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.

1st. Check the medication administration record to verify the client's allergies. 2nd. Ensure an air bubble is present in the prefilled enoxaparin syringe. 3rd. Locate the injection site 5 cm 2 inch to the right or left of the umbilicus. 4th. Pinch clean skin at the injection site and dart the needle into the skin fold at a 90% angle. 5th. Slowly inject the medication into the site without aspirating.

A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow.

1st. Lower the client to the floor. 2nd. Place a pad beneath the client's head to protect the client from injury. 3rd. Loosen the clothing around the client's neck. 4th. Time the length of the client's seizure. 5ht. Reorient and reassure the client.

A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1st. Record the client's vital signs. 2nd. Measure the client's abdominal girth. 3rd. Prime the client's catheter tubing with dialysate solution. 4th. Infuse dialysate solution into the client's peritoneal cavity. 5th. Open the client's drainage tubing after 10 min of dwell time.

A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hrs? (Round the answer to the nearest whole number)

864 cal

A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately?

A change in pupil size.

A nurse is receiving a change of shift report about the care of four clients. Which of the following clients should the nurse see first?

A client who displays increased confusion over the past 4 hr.

A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to first?

A client who has Alzheimer's disease and requires assistance to the bathroom.

A nurse is planning care for a group of clients after receiving change of shift report. Which of the following clients should the nurse plan to see first?

A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night.

A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take?

Administer an IV bolus of lorazepam.

An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result?

A client whose injection site has an elevated are measuring 15 mm 0.6 inch.

A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. The nurse tells the client to consume foods containing citrus C when taking the supplement to enhance iron absorption. Which of the following client food choices indicates an understanding of the teaching?

A cup boiled broccoli.

A nurse is monitoring a client who has a nasogastric NG tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report?

Abdominal distention.

A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Absent bowel sounds.

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen.

A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include?

Add a weight-bearing exercise regime.

A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. Which of the following instructions should the nurse include in the teaching?

Add oily fish to your diet twice weekly.

A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take?

Allow space for one finger to be placed under the tube ties.

A nures is delegating the task of repositioning a client who is in the skeletal traction to an assistive personnel AP. Which of the following instructions should the nurse give the AP.

Allow the weights to hang freely.

A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?

Ambulate the client in the hallway.

A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?

Apply a motion sensor mat to the client's bed.

A nurse is reinforcing discharge teaching with a client who had an excision biopsy of the left breast. Which of the following instructions should the nurse include?

Apply an ice pack to the incision site to treat discomfort.

A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan?

Apply foam handles to the client's eating utensils.

A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first?

Assist the client to a nearby common area.

A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit form PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?

Assist the client to change positions at least every 2 hr. Client use the incentive spirometer once per hr while awake during the first 24 hr postoperative to prevent respiratory complications.

A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching?

Avoid direct contact.

A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend?

Bananas.

A nurse is monitoring a client who has a wrist cast reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the case using a blow dryer on a cool setting.

A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching?

Broiled cod with broccoli.

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

Calcitonin will slow the breakdown of bone in your body.

A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection?

Changed mental status.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube.

A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

Check for neck vein distention.

A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?

Decrease in exertion dyspnea.

A nurse is caring for a client who is 2 hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?

Check incisional dressing.

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Check the client for increased hypopigmentation under the patch.

A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include?

Chew food throughly.

A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take?

Clamp the tube for 30 min every 8 hr.

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG.

Cleans the client's skin prior to electrode placement.

A nures is caring for a client who has cancer and has a WBC count of 4,000/mm. Which of the following actions should the nurse take?

Cleanse the client's toothbrush with hydrogen peroxide.

A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take?

Cleanse the drainage plug with alcohol swabs.

A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record?

Client status unchanged throughout shift.

A nurse is caring for a client who has a new cast on her 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 he following fracture complications should the nurse suspect?

Compartment syndrome.

A nurse is caring for a client who is postoperative and has a Jackson-pratt drain. Which of the following actions should the nurse take?

Compress the bulb reservoir and then close the drainage valve.

A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor?

Conjunctiva.

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough.

A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an auathermia pad. Which of the following actions should the nurse take?

Cover the pad prior to use.

A nurse is collecting data from a client who is 2 days postoperative following a colon resection. Which of the following findings indicates the need for nursing intervention?

Dark brown drainage in the NG tube.

A nurse caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?

Decreased blood pressure

A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?

Describe the food placement as though the plate were a clock.

A nurse is caring for 4 clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes mellitus

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath.

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache.

A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes.

A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes shortness of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include?

Drink beverages at the end of meals.

A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take?

Educate the client about choosing low-fat, low-cholesterol foods.

A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?

Elevated serum amylase level.

A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take?

Ensure the weights hang freely from the client's bed.

A nurse is caring for a client who has a prescription for a sequential compression device SCD. Which of the following actions should the nurse take when applying the SCD?

Ensure two fingers fit between the leg and the sleeves.

A nurse is caring for a cliennt who has restricted movement of the chest due to a burn injury. The nurse should anticipated preparing the client for which of the following procedures?

Escharotomy

A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?

Frequent colds.

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain?

Frontal lobe.

A nurse is collecting data about immunizations from a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations?

Herpes zoster.

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosemide.

A nurse is caring for a client who has been admitted with Addison's disease. For which of the following laboratory findings should the nurse plan to monitor and report to the provider?

Glucose 55 mg/dL.

A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should then nurse report to the provider?

Glycosylated hemoglobin 5.2%

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months.

A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heart rate 120/min

A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse included in the plan of care?

Heat food before serving.

A nurse is collecting data from a client who has gastroenteritis with diarrhea and vomiting. Which of the following laboratory values should alert the nurse that the client is at risk for fluid volume deficit?

Hematocrit 56 mg/dL.

A nurse is caring for a client who is 8 hr postoperative following a left hip arthroplasty. Which of the following laboratory values indicate the nurse should notify the provider?

Hemoglobin 8.6 g/dL.

A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? Select all that apply.

History of diabetes mellitus. Family history of colorectal cancer. Age over 50 years.

A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take?

Hold the client's finger in a dependent position.

A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis TB and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?

Household family members should be tested for TB.

A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion?

Hypertension.

A nurse working in a provider's office is caring for a client who received penicillin G potassium 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider?

Hypotension.

A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching?

I can decrease my risk for a stroke by losing excess weight.

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine.

I had a low fever this morning.

A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication?

I have gained 3 pounds since my last appointment.

A nurse in a health clinic is reinforcing teaching a client who has tuberculosis TB about transmission of the disease. Which of the following client statements indicates an understanding of the teaching?

I inhaled the infected droplets that were in the air."

A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation TENS unit for a client who has herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching?

I should adjust the TENS unit until I feel a tingling sensation.

A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching?

I should apply a heating pad to my feet every night to help with circulation."

A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicate an understanding of the teaching?

I should avoid broccoli and chewing gum.

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

I will limit my daily intake of protein.

A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter PICC line. Which of the following statements by the client indicate an understanding of the teaching?

I will monitor my temperature for fever while have this device.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate TURP and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride.

A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?

It is common for one breast to be larger than the other.

A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan?

Keep a stethoscope at the client's bedside for the duration of her hospital stay.

A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow beneath the client's legs.

A nurse is assisting with the development of plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off of the affected areas.

A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse report to the provider immediately?

Lip swelling.

A nurse is reinforcing teaching with the parent of a toddler who has type 1 diabetes mellitus and whose prescription has been changed from regular insulin to lisper insulin. Which of the following information should the nurse include in the teaching?

Lispro should be given before eating.

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include?

Maintain hip flexion to 90 degrees or less when sitting.

A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions?

Monitor blood glucose while taking this medication.

A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?

Muscle spasticity is a manifestation of multiple sclerosis.

A nurse is caring for a client following thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching.

A nurses is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?

My food tastes bland even after I add seasoning.

A nurse is reviewing the medical record for an older adult who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take?

Notify the charge nurse of the client's BUN level.

A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take?

Observe the skin 10 min after the start of treatment.

A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?

Obtain the client's blood pressure.

A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral?

Occupational therapist.

A nurse is contribution to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care?

Occupational therapist.

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime.

A nurse is assisting with an educational program for clients who has been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light.

A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?

Oxygen saturation of 88%.

A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider?

Paco2 55 mm Hg.

A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications?

Palpate the client's brachial pulses and compare bilaterally.

A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image?

Participates in performing ostomy care.

A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat?

Pears.

A nurse is assisting in the care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action?

Perform immediate defibrillation.

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

Perform testicular self-examination after taking a warm shower

A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?

Place the client in a negative-pressure airflow room

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals.

A nurse is reinforcing teaching with a client who is postoperative following aa tympanoplasty. Which of the following information should the nurse include?

Plan to shampoo hair in 1 week.

A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?

Platelets 60,000/mm

A nurse is collecting data from a client prior to administering hydrochlothiazide for mild hypertension. Which of the following findings should the nurse identify as a contraindication to administering the medication?

Potassium 2.8 mEq/L.

A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report?

Potassium level 6.2 mEq/L.

A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which of the following laboratory values should indicate to the nurse that the client is experiencing malnutrition?

Prealbumin 10.5 mg/dL.

A nurses is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her mediation for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis.

Prednisone.

A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? Select all that apply.

Primary health problem. Scheduled times for dressing changes. Current medication prescriptions.

A nurse is assisting with the development of the plan of care for a client who has low WBC count. Which of the following interventions should the nurse include?

Prohibit fresh flowers in the client's room.

A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take?

Provide regular oral care for the client with a moist swab.

A nurse is providing information regarding transmission-based precautions for a client who has clostridium difficile to an assistive personnel AP. Which of the following instructions should the nurse include? Select all that apply.

Provide the client with disposable utensils and dishes for meals. Leave blood pressure equipment in the client's room. Clean contaminated surfaces with a bleach solution.

A nures is reinforcing teaching about purse-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?

Pursed-lip breathing works best for activities like walking up stairs.

A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have which of the following effects?

Relaxes the muscles of the bladder.

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The client received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take?

Reposition the client.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client.

A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify which of the following medications can cause this adverse effect?

Rifampin.

A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take?

Rinse the client's mouth twice daily with an alcohol based mouthwash.

A nurse is caring for a client who has bladder cancer and is 1 day postoperative following placement of an ill conduit. Which of the following information should the nurse report to the provider?

Stoma color. (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client.

Semi-Fowler's with knees flexed.

A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin?

Sildenafil.

A nurses in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress.

A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team members should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist

A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false positive result?

The client takes ibuprofen for headaches.

A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately?

The client's fingers are cool to the touch.

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

The medication should be taken before I eat breakfast every morning.

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include in the teaching?

The virus can be transmitted without lesions present.

A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicate a complication of the procedure?

Tingling of the fingers.

A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding body image changes. Which of the following should the nurse recognize as a physical change caused by this disease?

Truncal obesity.

A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following risk factors should the nurse include?

Ulcerative colitis.

A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?

Upright, leaning forward

A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include?

Urinate before and after sexual intercourse.

A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following?

Wheezes

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin.

A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take?

Withhold the medication if the systolic blood pressure is less than 90 mm Hg.

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend to include in the pamphlet?

Women have a higher risk of contracting STIs than men.

A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following instructions should the nurse include?

You should receive one dose of the pneumococcal vaccine.

A nurse is reinforcing teaching regarding the use of a continuous passive motion CPM machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching. Select all that apply.

Your knee is flexed and extended as prescribed by your provider. The machine is padded with sheep skin-Padding the CPM machine with sheep skin prevents injury to pressure points on the extremity.