EVOLVE QUESTIONS
The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?
"I understand that my child needs to wear this brace for 12 hours a day."
The nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide. The nurse reinforces dietary instructions to the client. Which are appropriate instructions? Select all that apply.
Drink at least 2 to 3 L of fluid daily. Increase dietary intake of potassium.
A client in the emergency department is diagnosed with Bell's palsy. The nurse collecting data on this client expects to note which observations? Select all that apply.
Excessive tearing Inability to furrow brow A lag in closing the bottom eyelid
A client is complaining about pain when voiding. The primary health care provider prescribes a clean-catch urine specimen. The nurse should instruct the client to perform which action first when obtaining this specimen?
Instruct the client to wash her hands.
After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which?
Limit bleeding from the biopsy site
The nurse is monitoring a client receiving a blood transfusion for circulatory overload. The nurse understands that which is a clinical indication of circulatory overload?
Moist, productive cough
The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?
Allergy to pollen
The nurse will be caring for several older adults who will be undergoing general anesthesia. Which older adult will require the closest monitoring for a prolonged effect of anesthesia?
An older adult with an increase in liver size
The nurse is preparing to assist in performing a fundal assessment on a postpartum client. The nurse understands that which is the initial nursing action when performing this assessment?
Ask the client to urinate and empty her bladder.
The nurse is planning care for a pediatric client experiencing thyrotoxicosis (thyroid storm). Which prescribed medications should the nurse plan to administer? Select all that apply.
Atenolol Propranolol Methimazole
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply.
Ballottement Chadwick's sign Uterine enlargement Braxton Hicks contractions
The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply.
Bed rest Sitz bath Antibiotics
Which observations by the nurse caring for clients in a hospital medical-surgical unit should be immediately reported to the primary health care provider? Select all that apply.
New confused mental state and pulse rate of 106 beats per minute in a 72-year-old client A volume of 105 mL of urine over 4 hours in the collection bag of a 1-day postoperative client
The nurse is assisting in caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. When collecting data on the client, the nurse checks which first?
Respiratory status
The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply.
Severe burn injury Untreated ketoacidosis
A client is admitted to the hospital with a fever and extreme weakness. Which laboratory studies are likely to be elevated if the client is experiencing an infection? Select all that apply.
White blood cell count (WBC) Erythrocyte sedimentation rate (ESR)
The nurse caring for a client following a craniotomy monitors for signs of increased intracranial pressure (ICP). Which indicates an early sign of increased ICP?
confusion
The nurse is talking with a client who is going to have a radical neck dissection and total laryngectomy. Which client statement indicates a need for further teaching concerning postoperative management?
"I will require a lot of pain med after surgery."
A transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which client statements indicate the need for further teaching? Select all that apply.
"The unit should be turned off if I begin to feel pins and needles." "Needles are inserted in the subcutaneous tissue to stimulate the nerve."
A client with type 1 diabetes mellitus in the first trimester of pregnancy is scheduled for a primary health care provider's visit. The client asks the nurse whether a change in the medication to treat the diabetes will occur at this time. Which statement is true?
"Your normal insulin dosage will have to be decreased."
A primary health care provider is caring for a client who is human immunodeficiency virus (HIV) positive and has delivered a newborn baby. The nurse anticipates which interventions should be employed for the newborn to decrease the risk of HIV. Select all that apply.
-HIV testing of the newborn within 48 hours -Antiretroviral prophylaxis for newborns testing HIV positive. -Periodic testing for HIV at set intervals until the age of 6 months.
The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse should perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed. All options must be used.
-Obtain and label a sterile container. -Have the client brush teeth and rinse mouth with water. -Have the client take several deep breaths before coughing. -Have the client expectorate sputum (not saliva) into sterile container. -Send the specimen immediately to the laboratory. -Administer the prescribed antibiotics.
