Final exam

A nurse cares for a client with colon cancer who has a new colostomy. The client states, "I think it would be helpful to talk with someone who has had a similar experience." How should the nurse respond? a. "I have a good friend with a colostomy who would be willing to talk with you." b. "The enterostomal therapist will be able to answer all of your questions." c. "I will make a referral to the United Ostomy Associations of America." d. "You'll find that most people with colostomies don't want to talk about them."

C

The student nurse is performing a Weber tuning fork test. What technique is most appropriate? a. Holding the vibrating tuning fork 10 to 12 inches from the client's ear b. Placing the vibrating fork in the middle of the client's head c. Starting by placing the vibrating fork on the mastoid process d. Tapping the vibrating tuning fork against the bridge of the nose

b

When teaching the client with gastritis, the nurse should include which of these instructions? a."Drink as much decaffeinated tea and coffee as you like." b."Avoid eating at bedtime." c."Drink only milk products and antacids until the pain subsides." d."Eat anything you want as long as you take your medications on time."

b

Which information will the nurse monitor in order to determine the effectiveness of prescribed calcium carbonate (Caltrate) for a patient with chronic kidney disease (CKD)? a. Blood pressure b. Phosphate level c. Neurologic status d. Creatinine clearance

b

A nurse is reviewing a client's plan of care. Noting the medical diagnosis of endocarditis, the nurse knows that the activity order for this client will be: a. to ambulate three times a day (TID) b. bedrest c. to get out of bed to chair three times a day d. no restrictions

b- bedrest to decrease work load of the heart

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply.1.Provide oral hygiene after each meal.2.Assess swallowing ability frequently.3.Allow the client sufficient time to eat.4. Maintain a suction machine at the bedside.5. Provide a full liquid diet for ease in swallowing.

1234 Rationale:A client who is severely dysphagic is at risk for aspiration. Swallowing is assessed frequently. The client should be given a sufficient amount of time to eat. Semisoft foods are easiest to swallow and require less chewing. Oral hygiene is necessary after each meal. Suctioning should be available for clients who experience dysphagia and are at risk for aspiration.

A client with Parkinson's disease is at risk for falls because of an abnormal gait. The nurse assesses the client, expecting to observe which type of gait? 1. Unsteady and staggering 2. Shuffling and propulsive 3. Broad-based and waddling 4.Accelerating with walking on the toes

2

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for more information if the client makes which statement?1."Here's the Medic-Alert bracelet I obtained." 2."I should take my medications an hour before mealtime." 3."Going to the beach will be a nice, relaxing form of activity." 4."I've made arrangements to get a portable resuscitation bag and home suction equipment."

3 Rationale:Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client must be aware of the lifestyle changes needed to maintain independence. The client should carry medical identification about the presence of the condition. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should avoid situations and other factors, including stress, infection, heat, surgery, and alcohol, that could worsen the symptoms.

A client with a history of myasthenic gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenia crisis is suspected. The nurse assesses the client for which precipitating factor? 1. Getting too little exercise 2. Taking excess medication 3. Omitting doses of medication 4. Increasing intake of fatty foods

3 Rationale:Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis.

The nurse is preparing for the admission of a client with a suspected diagnosis of Guillain-Barré syndrome. When the client arrives at the nursing unit, the nurse reviews the health care provider's documentation. The nurse expects to note documentation of which hallmark clinical manifestation of this syndrome? 1. Multifocal seizures 2. Altered level of consciousness 3. Abrupt onset of a fever and headache 4. Development of progressive muscle weakness

4 Rationale:A hallmark clinical manifestation of Guillain-Barré syndrome is progressive muscle weakness that develops rapidly. Seizures are not normally associated with this disorder. The client does not have symptoms such as a fever or headache. Cerebral function, level of consciousness, and pupillary responses are normal.

The nurse is planning care for the client with a neurogenic bladder caused by multiple sclerosis. The nurse plans for fluid administration of at least 2000 mL/day. Which plan would be most helpful to this client? 1.400 to 500 mL with each meal and 500 to 600 mL in the evening before bedtime 2.400 to 500 mL with each meal and additional fluids in the morning but not after midday 3.400 to 500 mL with each meal, with all extra fluid concentrated in the afternoon and evening 4.400 to 500 mL with each meal and 200 to 250 mL at midmorning, midafternoon, and late afternoon

4 Rationale:Spacing fluid intake over the day helps the client with a neurogenic bladder to establish regular times for successful voiding. Omitting intake after the evening meal minimizes incontinence or the need to empty the bladder during the night.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray

4 Rationale:The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided

The home health nurse has been discussing interventions to prevent constipation in a client with multiple sclerosis. The nurse determines that the client is using the information most effectively if the client reports which action?1.Drinking a total of 1000 mL/day 2.Giving herself an enema every morning before breakfast 3.Taking stool softeners daily and a glycerin suppository once a week 4. Initiating a bowel movement every other day, 45 minutes after the largest meal of the day

4 Rationale:To manage constipation, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL/day is recommended. The client should initiate the bowel program on an every-other-day basis. This should be done approximately 45 minutes after the largest meal of the day to take advantage of the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

A nurse is caring for a client who is to receive a full liquid diet due to dysphagia. Which of the following nursing actions is the highest priority?A. Add thickener to liquids B. Educate the client about acceptable liquids C. Perform a calorie count of consumed liquids D. Offer high protein liquid supplements

A

A nurse is caring for a client who has Alzheimers disease. A family member of the client asks the nurse about risk factors for the disease. Which of the following should be included in the nurses response? SATA A. Exposure to metal waste products B. Long term estrogen hormone therapy C. Sustained use of vitamin E. D. Previous head injury E. History of herpes infection

A D E

A nurse is making a home visit to a client who has Alzheimers disease to assess the home for safety. Which of the following are appropriate suggestions to decrease the clients risk for injury: A. Install childproof door locks. B. Place rugs over electrical cords. C. Mark cleaning supplies with colored tape. D. Place the clients mattress on the floor E. Install light fixtures above the stairs.

A D E Do not cover electrical cords with rugs

The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease (select all that apply)?A. Urinalysis B. MRI of the head C. Liver function tests D. Neuropsychologic testing E. Blood urea nitrogen and serum creatinine

A,B,C,D,EBecause there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.

A nurse is caring for a client who has Parkinson's disease and displays manifestations of bradykinesia. Which of the following is an appropriate action by the nurse? A. Allow client extra time for verbal responses to questions. B. Complete passive range-of-motion exercises. C. Provide an alternate form of communication. D. Assist with hygiene as needed.

A. INCORRECT: The nurse should allow extra time for the client who has PD to express herself verbally, but this is not related to bradykinesia. B. INCORRECT: The nurse should encourage active, not passive, range-of-motion exercises to promote mobility in the client who has PD and is displaying bradykinesia. C. INCORRECT: The nurse may provide an alternate form of communication for the client who has PD, but this is not related to bradykinesia. D. CORRECT: Bradykinesia is abnormally slowed movement and is seen in clients who have PD. Therefore, the nurse should assist with hygiene as needed.

A nurse is assisting with a plan of care for the nutritional needs of a client who has stage 4 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Provide three large balanced meals daily. B. Record diet and fluid intake daily. C. Document weight every other week. D. Add thickener to liquids. E. Offer nutritional supplements between meals

A. INCORRECT: The nurse should plan to provide small frequent meals during the day to maintain adequate nutrition and decrease frustration. B. CORRECT: The nurse should record the client's diet and fluid intake daily to check for dietary needs and to maintain adequate nutrition and hydration. C. INCORRECT: The nurse should document the client's weight weekly to identify weight loss and intervene to maintain the client's weight. D. CORRECT: The nurse should add thickener to liquids to prevent aspiration due to pharyngeal muscle involvement, which makes swallowing difficult. E. CORRECT: The nurse should offer nutritional supplements between meals to maintain the client's weight.

A nurse assesses clients at a community health center. Which client is at highest risk for the development of colorectal cancer? a. A 37-year-old who drinks eight cups of coffee daily b. A 44-year-old with irritable bowel syndrome (IBS) c. A 60-year-old lawyer who works 65 hours per week d. A 72-year-old who eats fast food frequently

ANS: D Colon cancer is rare before the age of 40, but its incidence increases rapidly with advancing age. Fast food tends to be high in fat and low in fiber, increasing the risk for colon cancer. Coffee intake, IBS, and a heavy workload do not increase the risk for colon cancer.

A nurse is caring for a client who has Alzheimers disease and is beginning to experience noticeable short term memory loss. When discussing a new prescription for donepezil (Aricept) the nurse should include which of the following in the teaching? A. "You should avoid taking over the counter acetaminophen while on donepezil." B. "You can expect the progression of cognitive decline to slow with donezepil." C. "You will be screened for underlying kidney disease prior to starting donezepil." D. "You should stop taking donezepil if you experience nausea or diarrhea."

B

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

A 26-year-old patient with a family history of stomach cancer asks the nurse about ways to decrease the risk for developing stomach cancer. The nurse will teach the patient to avoid a. emotionally stressful situations. b. smoked foods such as ham and bacon. c. foods that cause distention or bloating. d. chronic use of H2 blocking medications.

B Smoked foods such as bacon, ham, and smoked sausage increase the risk for stomach cancer. Stressful situations, abdominal distention, and use of H2 blockers are not associated with an increased incidence of stomach cancer.

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."

B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

Which medications will the nurse teach the patient about whose peptic ulcer disease is associated with Helicobacter pylori? a. Sucralfate (Carafate), nystatin (Mycostatin), and bismuth (Pepto-Bismol) b. Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec) c. Famotidine (Pepcid), magnesium hydroxide (Mylanta), and pantoprazole (Protonix) d. Metoclopramide (Reglan), bethanechol (Urecholine), and promethazine (Phenergan)

B The drugs used in triple drug therapy include a proton pump inhibitor such as omeprazole and the antibiotics amoxicillin and clarithromycin. The other combinations listed are not included in the protocol for H. pylori infection

The nurse suspects a client's heart is failing when which of the following heart sounds is assessed? a. S3 b. S4 c. S2 d. S1

B. An auscultated S 3 is a sign that increased blood volume remains in the ventricle with each beat and that the heart is beginning to fail

A nurse is caring for a client who has AD and falls frequently. Which of the following actions should the nurse take first to keep the client safe? A. Keep the call light near the client. B. Place the client in a room close to the nurses station. C. Encourage the client to ask for assistance. D. Remind the client to walk with someone for support.

B. Using the safety and risk reduction priority setting framework, placing the client in close proximity to the nurses station for close observation is the first action the nurse should take.

The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? A. Treat disruptive behavior with antipsychotic drugs. B. Use a calendar and family pictures as memory aids. C. Use a writing board to communicate with the patient. D. Use a wander guard mechanism to keep the patient in the area.

B.The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.

A nurse is making a home visit to a client who is in the late stage of Alzheimers disease. The clients spouse, who is the primary caregiver, wishes to discuss concerns about the clients nutrition and the stress of providing care. Which of the following is an appropriate action by the nurse? A. Verify that a concurrent power of attorney document is on file. B. Instruct the clients spouse to offer finger foods to increase oral intake. C. Provide information on resources for respite care. D. Schedule the client for placement of an enteral feeding tube.

C

The client's chart indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?a. "Do you feel like something is in your ear?" b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"

C. Sensorineural hearing loss can occur from damage to the cochlea, the eighth cranial nerve, or the brain. Exposure to loud music is one etiology. The other questions relate to conductive hearing loss.

A nurse working in a long term care facility is planning care for a client in stage 5 of Alzheimers disease. Which of the following interventions should be included in the plan of care?A. Use a gait belt for ambulation.B. Thicken all liquids.C. Provide protective undergarments.D. Assist with ADLs.

D

A patient who has acute glomerulonephritis is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the prescribed calcium gluconate IV? a. Urine volume b. Calcium level c. Cardiac rhythm d. Neurologic status

Cardiac rhythm

A nurse cares for a client who has a family history of colon cancer. The client states, "My father and my brother had colon cancer. What is the chance that I will get cancer?" How should the nurse respond? a. "If you eat a low-fat and low-fiber diet, your chances decrease significantly." b. "You are safe. This is an autosomal dominant disorder that skips generations." c. "Preemptive surgery and chemotherapy will remove cancer cells and prevent cancer." d. "You should have a colonoscopy more frequently to identify abnormal polyps early."

D

A nurse is reviewing food interactions with a client who is taking levodopa/carbidopa (Sinemet) for Parkinsons Disease. Which of the following instructions should the nurse include? A. Eat large amounts of protein rich foods with the medication. B. May take the medication with whole grain cereal C. Consider eating a banana with the medication. D. May take the medication crushed in grapefruit juice.

D

A 62-year-old man patient who requires daily use of a nonsteroidal antiinflammatory drug (NSAID) for the management of severe rheumatoid arthritis has recently developed melena. The nurse will anticipate teaching the patient about a. substitution of acetaminophen (Tylenol) for the NSAID. b. use of enteric-coated NSAIDs to reduce gastric irritation. c. reasons for using corticosteroids to treat the rheumatoid arthritis. d. misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa.

D Misoprostol, a prostaglandin analog, reduces acid secretion and the incidence of upper GI bleeding associated with NSAID use. Enteric coating of NSAIDs does not reduce the risk for GI bleeding. Corticosteroids increase the risk for ulcer development, and will not be substituted for NSAIDs for this patient. Acetaminophen will not be effective in treating the patient's rheumatoid arthritis.

A nurse is planning care for a client who has dysphagia and has a new dietary prescription. Which of the following should the nurse include in the plan of care? SATA A. Have suction equipment available for use. B. Use thickened liquids. C. Place food on the clients unaffected side of her mouth. D. Assign as assistive personnel to feed the client slowly. E. Teach the client to swallow with her neck flexed.

Do not allow UAP to feed client

The nurse determines that a client diagnosed with pericarditis is demonstrating the classic signs of the Beck triad. What are the signs of the Beck triad? (Select all that apply.) a. Hypotension b. Muffled heart sounds c. Fever d. Abdominal pain e. Dyspnea f. Elevated jugular vein pressure

Hypotension Elevated jugular vein pressure Muffled heart sounds

A nurse is reinforcing teaching with a client who has Parkinson's disease and has received a prescription for bromocriptine (parlodel). Which of the following instructions should the nurse include in the teaching? A. Rise slowly when standing. B. Increase carbohydrate intake C. Limit exposure to heat. D. Report any skin discoloration.

a. bromocriptine causes ortho static hypotension.

A nurse is caring for four patients. Which one would the nurse see first? a.Patient who had a first dose of captopril (Capoten) and needs to use the bathroomb.Patient who needs pain medication prior to a dressing change of a surgical woundc.Hypertensive patient with a blood pressure of 188/92 mm Hgd.Patient who needs a beta-blocker, and has a blood pressure of 92/58 mm Hg

a

The nurse is caring for four hypertensive patients. Which drug-laboratory value combination would the nurse report immediately to the healthcare provider? a.Furosemide (Lasix)/potassium: 2.1 mEq/L b.Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c.Torsemide (Demadex)/sodium: 142 mEq/L d.Spironolactone (Aldactone)/potassium: 5.1 mEq/L

a

A nurse plans care for a client who has chronic diarrhea. Which actions should the nurse include in this client's plan of care? (Select all that apply.) a. Using premoistened disposable wipes for perineal care b. Turning the client from right to left every 2 hours c. Using an antibacterial soap to clean after each stool d. Applying a barrier cream to the skin after cleaning e. Keeping broken skin areas open to air to promote healing

a b d

A 25-year-old male patient has been admitted with a severe crushing injury after an industrial accident. Which laboratory result will be most important to report to the health care provider? a. Serum creatinine level 2.1 mg/dL b. Serum potassium level 6.5 mEq/L c. White blood cell count 11,500/µL d. Blood urea nitrogen (BUN) 56 mg/dL

b

A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that one arm feels like "pins and needles" and that the neck is very painful since returning from surgery. What action by the nurse is best? a.Document the findings in the client's chart. b.Notify the provider immediately. c.Assist the client to change positions. d.Encourage range of motion of the neck.

b

A nurse cares for a patient with infective endocarditis. Which infection control precautions would the nurse use? a. Bleeding precautions b. Standard precautions c. Reverse isolation d. Contact isolation

b

A patient with acquired immune deficiency syndrome is hospitalized and has weeping Kaposi's sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important? a.Adhering to Standard Precautions b.Disposing of soiled dressings properly c.Performing hand hygiene before and after care d.Assessing tolerance to dressing changes

b

A client is admitted with diverticulitis of 1 day's duration. Which of these nursing interventions should be included in the client's plan of care? a. Ambulate ad lib. b. Keep the client in a private room. c. Maintain NPO. d. Offer oral fluids frequently.

c

A nurse caring for a patient with sickle cell disease (SCD) reviews the patient's laboratory work. Which finding should the nurse report to the provider? a.Sodium: 147 mEq/L (147 mmol/L) b.Hematocrit: 30% c.White blood cell count: 12,000/mm3 (12 ´ 109/L) d.Creatinine: 2.9 mg/dL (256 mcmol/L)

c

A nurse is caring for a client who displays signs of stage 3 Parkinson's disease. Which of the following actions should the nurse include in the plan of care? A. Recommend a community support group. B. Integrate a daily exercise routine. C. Provide a walker for ambulation. D. Consultation with a dietician.

c

Before administration of calcium carbonate (Caltrate) to a patient with chronic kidney disease (CKD), the nurse should check laboratory results for a. potassium level. b. total cholesterol. c. serum phosphate. d. serum creatinine.

c

The nurse is evaluating a 3-day diet history with a patient who has an elevated lipid panel. What meal selection indicates that the patient is managing this condition well with diet? a.Spaghetti with meat sauce, garlic bread b.Fried catfish, cornbread, peas c.Baked chicken breast, broccoli, tomatoes d.A 4-ounce steak, French fries, iceberg lettuce

c

A patient has been bedridden for several days after major abdominal surgery. What action does the nurse delegate to the unlicensed assistive personnel (UAP) for deep-vein thrombosis (DVT) prevention? (Select all that apply.) a.Teach leg exercises. b.Encourage coughing and deep breathing. c.Assist with ambulation. d.Apply compression stockings. e.Offer fluids frequently.

c d e

A nurse assessing a client with colorectal cancer auscultates high-pitched bowel sounds and notes the presence of visible peristaltic waves. Which action should the nurse take? a. Ask if the client is experiencing pain in the right shoulder. b. Perform a rectal examination and assess for polyps. c. Contact the provider and recommend computed tomography. d. Administer a laxative to increase bowel movement activity.

c (partial obstruction)

A client is admitted with the diagnosis Rule out appendicitis. Which nursing action is MOST important? a.assessing the client's pain threshold b.monitoring laboratory reports c.avoiding administering analgesics d.encouraging the family to visit

c- if the appendix bursts, they wouldn't be able to feel it

The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?

control inflammation

A nurse assesses a client with a mechanical bowel obstruction who reports intermittent abdominal pain. An hour later the client reports constant abdominal pain. Which action should the nurse take next? a. Administer intravenous opioid medications. b. Position the client with knees to chest. c. Insert a nasogastric tube for decompression. d. Assess the client's bowel sounds.

d

A nurse works in the rheumatology clinic and sees clients with rheumatoid arthritis (RA). Which client should the nurse see first? a.Client who reports jaw pain when eating b.Client with a worse joint deformity since the last visit c.Client who has a puffy-looking area behind the knee d.Client with a red, hot, swollen right wrist

d

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

d

A nurse is making a home visit to a client who has AD. The clients partner states that the client is often disoriented to time and place, is unsteady on his feet, and has a history of wandering. Which of the following safety measures should the nurse review with the partner? SATA A. Remove floor rugs B. Have door locks that can be easily opened. C. Provide increased lighting in the stairwells. D. Install handrails in the bathroom. E. Place the mattress on the floor.

everything but b remove floor rugs!

The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus?

middled aged Native american man

The nurse has given instructions to a client with Parkinson's disease about maintaining mobility. Which action demonstrates that the client understands the directions? 1.Sits in soft, deep chairs to promote comfort. 2.Exercises in the evening to combat fatigue. 3.Rocks back and forth to start movement with bradykinesia. 4. Buys clothes with many buttons to maintain finger dexterity.

3 Rationale:The client with Parkinson's disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self. The nurse has given suggestions to a client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs further education if the client makes which statement?1."I will wash my face with cotton pads."2."I'll have to start chewing on my unaffected side."3."I'll try to eat my food either very warm or very cold."4."I should rinse my mouth if toothbrushing is painful." 3 Rationale:Facial pain can be minimized by using cotton pads to wash the face and using room temperature water. The client should chew on the unaffected side of the mouth, eat a soft diet, and take in foods and beverages at room temperature. If toothbrushing triggers pain, an oral rinse after meals may be helpful instead.

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective?1.Eating large, well-balanced meals 2.Doing muscle-strengthening exercises 3.Doing all chores early in the day while less fatigued 4. Taking medications on time to maintain therapeutic blood levels

4

The nurse will anticipate preparing a 71-year-old female patient who is vomiting "coffee-ground" emesis for a. endoscopy. b. angiography. c. barium studies. d. gastric analysis.

A Endoscopy is the primary tool for visualization and diagnosis of upper gastrointestinal (GI) bleeding. Angiography is used only when endoscopy cannot be done because it is more invasive and has more possible complications. Barium studies are helpful in determining the presence of gastric lesions, but not whether the lesions are actively bleeding. Gastric analysis testing may help with determining the cause of gastric irritation, but it is not used for acute GI bleeding.

Which action should the nurse in the emergency department anticipate for a 23-year-old patient who has had several episodes of bloody diarrhea? a. Obtain a stool specimen for culture. b. Administer antidiarrheal medication. c. Provide teaching about antibiotic therapy. d. Teach about adverse effects of acetaminophen (Tylenol).

A Patients with bloody diarrhea should have a stool culture for E. coli O157:H7. Antidiarrheal medications are usually avoided for possible infectious diarrhea to avoid prolonging the infection. Antibiotic therapy in the treatment of infectious diarrhea is controversial because it may precipitate kidney complications. Acetaminophen does not cause bloody diarrhea.

Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)? a. "Ranitidine absorbs the gastric acid." b. "Ranitidine decreases gastric acid secretion." c. "Ranitidine constricts the blood vessels near the ulcer." d. "Ranitidine covers the ulcer with a protective material."

B Ranitidine is a histamine-2 (H2) receptor blocker, which decreases the secretion of gastric acid. The response beginning, "Ranitidine constricts the blood vessels" describes the effect of vasopressin. The response "Ranitidine absorbs the gastric acid" describes the effect of antacids. The response beginning "Ranitidine covers the ulcer" describes the action of sucralfate (Carafate).

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

A 68-year-old patient with a bleeding duodenal ulcer has a nasogastric (NG) tube in place, and the health care provider orders 30 mL of aluminum hydroxide/magnesium hydroxide (Maalox) to be instilled through the tube every hour. To evaluate the effectiveness of this treatment, the nurse a. monitors arterial blood gas values daily. b. periodically aspirates and tests gastric pH. c. checks each stool for the presence of occult blood. d. measures the volume of residual stomach contents.

B The purpose for antacids is to increase gastric pH. Checking gastric pH is the most direct way of evaluating the effectiveness of the medication. Arterial blood gases may change slightly, but this does not directly reflect the effect of antacids on gastric pH. Because the patient has upper gastrointestinal (GI) bleeding, occult blood in the stools will appear even after the acute bleeding has stopped. The amount of residual stomach contents is not a reflection of resolution of bleeding or of gastric pH.

When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (select all that apply)? A. Misplacing car keys B. Losing sense of time C. Difficulty performing familiar tasks D. Problems with performing basic calculations E. Becoming lost in a usually familiar environment

BCDE

Which order from the health care provider will the nurse implement first for a patient who has vomited 1200 mL of blood? a. Give an IV H2 receptor antagonist. b. Draw blood for typing and crossmatching. c. Administer 1000 mL of lactated Ringer's solution. d. Insert a nasogastric (NG) tube and connect to suction.

C Because the patient has vomited a large amount of blood, correction of hypovolemia and prevention of hypovolemic shock are the priorities. The other actions also are important to implement quickly but are not the highest priorities.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Omeprazole (Prilosec) c. Metoclopramide (Reglan) d. Aluminum hydroxide (Amphojel)

C Metoclopramide can cause central nervous system (CNS) side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton-pump inhibitors, mucosal protectants, or antacids.

Which patient should the nurse assess first after receiving change-of-shift report? a. A patient with nausea who has a dose of metoclopramide (Reglan) due b. A patient who is crying after receiving a diagnosis of esophageal cancer c. A patient with esophageal varices who has a blood pressure of 92/58 mm Hg d. A patient admitted yesterday with gastrointestinal (GI) bleeding who has melena

C The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.

After change-of-shift report, which patient should the nurse assess first? a. 42-year-old who has acute gastritis and ongoing epigastric pain b. 70-year-old with a hiatal hernia who experiences frequent heartburn c. 53-year-old who has dumping syndrome after a recent partial gastrectomy d. 60-year-old with nausea and vomiting who has dry oral mucosa and lethargy

D This older patient is at high risk for problems such as aspiration, dehydration, and fluid and electrolyte disturbances. The other patients will also need to be assessed, but the information about them indicates symptoms that are typical for their diagnoses and are not life threatening.

A 50-year-old man vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. To determine possible risk factors for gastritis, the nurse will ask the patient about a. the amount of saturated fat in the diet. b. any family history of gastric or colon cancer. c. a history of a large recent weight gain or loss. d. use of nonsteroidal antiinflammatory drugs (NSAIDs).

D Use of an NSAID is associated with damage to the gastric mucosa, which can result in acute gastritis. Family history, recent weight gain or loss, and fatty foods are not risk factors for acute gastritis.

A nurse assesses a patient who has a history of heart failure. Which question would the nurse ask to assess the extent of the patient's heart failure? a. "Are you able to walk upstairs without fatigue?" b. "Do you have trouble breathing or chest pain?" c. "Do you have new-onset heaviness in your legs?" d. "Do you awake with breathlessness during the night?"

a- newly developed fatigue to normal activities is the greatest indicator of the extent of the patient's heart failure

A 37-yr-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a .Creatinine level b. Glomerular filtration rate (GFR) c. Blood urea nitrogen (BUN) level d. Urine volume

b

A 42-year-old patient admitted with acute kidney injury due to dehydration has oliguria, anemia, and hyperkalemia. Which prescribed actions should the nurse take first? a. Insert a urinary retention catheter. b. Place the patient on a cardiac monitor. c. Administer epoetin alfa (Epogen, Procrit). d. Give sodium polystyrene sulfonate (Kayexalate)

b

The nurse reviews the health care provider's (HCP) prescriptions for a client with Guillain-Barré syndrome. Which prescription written by the HCP should the nurse question? 1.Clear liquid diet 2.Bilateral calf measure 3.Monitor vital signs frequently 4.Passive range-of-motion (ROM) exercises

1 Rationale:Clients with Guillain-Barré syndrome have dysphagia. Clients with dysphagia are more likely to aspirate clear liquids than thick or semisolid foods. Passive ROM exercises can help prevent contractures, and assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Because clients with Guillain-Barré syndrome are at risk for hypotension or hypertension, bradycardia, and respiratory depression, frequent monitoring of vital signs is required.

A client with multiple sclerosis tells a home health care nurse that she is having increasing difficulty in transferring from the bed to a chair. What is the initial nursing action? 1. Observe the client demonstrating the transfer technique. 2. Start a restorative nursing program before an injury occurs. 3. Seize the opportunity to discuss potential nursing home placement. 4. Determine the number of falls that the client has had in recent weeks.

1 Rationale:Observation of the client's transfer technique is the initial intervention. Starting a restorative program is important but not unless an assessment has been completed first. Discussing nursing home placement would be inappropriate in view of the information provided in the question. Determining the number of falls is another important intervention, but observing the transfer technique should be done first.

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate (Cogentin) orally daily. The nurse provides information to the spouse regarding the side effects of this medication and should tell the spouse to report which side effect if it occurs? 1. Shuffling gait 2. Inability to urinate 3. Decreased appetite 4. Irregular bowel movements

2

A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?1.A symmetrical smile2.Difficulty closing the eyelid on the affected side3.Narrowing of the palpebral fissure on the affected side4.Paroxysms of excruciating pain in the lips and cheek on the affected side 2 Rationale:The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia. The nurse is performing an assessment on a client with Guillain-Barré syndrome. The nurse determines that which finding would be of most concern? 1.Difficulty articulating words 2.Lung vital capacity of 10 mL/kg 3.Paralysis progressing from the toes to the waist 4.A blood pressure (BP) decrease from 110/78 to 102/70 mm Hg

2 Rationale:Respiratory compromise is a major concern in clients with Guillain-Barré syndrome. Clients often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg. Options 1 and 3 are expected, depending on the degree of paralysis that occurs. Although orthostatic hypotension is a problem with these clients, the BP drop in option 4 is less than 10 mm Hg and is not significant.

A client with myasthenia gravis is having difficulty with airway clearance and difficulty with maintaining an effective breathing pattern. The nurse should keep which items available at the client's bedside? 1.Oxygen and metered-dose inhaler 2.Ambu bag and suction equipment 3.Pulse oximeter and cardiac monitor 4.Incentive spirometer and cough pillow

2 Rationale:The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside.

The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The client has been taking oxybutynin (Ditropan XL). The nurse evaluates the effectiveness of the medication by asking the client which assessment question? 1."Are you consistently fatigued?" 2. "Are you having muscle spasms?" 3. "Are you getting up at night to urinate?" 4. "Are you having normal bowel movements?"

2. OXYBUTYNIN CAUSES NOCTURIA

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record? 1. Muscle wasting 2. Mild clumsiness 3. Altered mentation 4. Diminished gag reflex

2. mild clumsiness is an INITAL CLINICAL MANIFESTATION

The nurse has provided instructions to a client with a diagnosis of myasthenia gravis about home care measures. Which client statement indicates the need for further instruction? 1. "I will rest each afternoon after my walk." 2. "I should cough and deep breathe many times during the day." 3. "I can change the time of my medication on the mornings when I feel strong." 4. "If I get abdominal cramps and diarrhea, I should call my health care provider."

3

A client has been diagnosed with Alzheimer's disease. The nurse concludes that the client has a pathological condition of which components of the nervous system?1.Glia 2.Peripheral nerves 3. Neuronal dendrites 4. Monoamine oxidase

3 Rationale:Alzheimer's disease is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The components in the other options are not related to the pathology of Alzheimer's disease.

A nurse is providing information about pramipexole (Mirapex) to a client who has early Parkinsons disease. Which of the following possible adverse effects should the nurse include in the information? A. Hallucinations B. Memory loss C. Diarrhea D. Discoloration of urine

A

An example of a proton pump inhibitor is: a. omeprazole b. calcium carbonate c. aluminum hydroxide d. ranitidine

a

A nurse assesses a client who is prescribed 5-fluorouracil (5-FU) chemotherapy intravenously for the treatment of colon cancer. Which assessment finding should alert the nurse to contact the health care provider? a. White blood cell (WBC) count of 1500/mm3 b. Fatigue c. Nausea and diarrhea d. Mucositis and oral ulcers

a

A 58-year-old patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse? a. The patient has been vomiting for 4 days. b. The patient takes antacids 8 to 10 times a day. c. The patient is lethargic and difficult to arouse. d. The patient has undergone a small intestinal resection.

C A lethargic patient is at risk for aspiration, and the nurse will need to position the patient to decrease aspiration risk. The other information is also important to collect, but it does not require as quick action as the risk for aspiration.

In infective endocarditis, what grows in and around the heart valves that causes scar tissue on the valves and allows blood to flow back into the previous chamber? a. abscesses b. vegetations c. fibrinous plaques d. ulcerations

b

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness?1.Giving client full control over care decisions and restricting visitors 2.Providing positive feedback and encouraging active range of motion 3.Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

3 Rationale:The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease?1.Meningitis or encephalitis during the last 5 years 2.Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4.Respiratory or gastrointestinal infection during the previous month

4 Rationale:Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

For which patient should the nurse prioritize an assessment for depression? A. A patient in the early stages of Alzheimer's disease B. A patient who is in the final stages of Alzheimer's disease C. A patient experiencing delirium secondary to dehydration D. A patient who has become delirious following an atypical drug response

A

Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. level of consciousness (LOC).

A

Which statement by the wife of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of her husband's medication regimen? A. "I'm really hoping his medications will slow down his mental losses." B. "We're both holding out hope that this medication will cure his disease." C. "I know that this won't cure him, but we learned that it might prevent a bodily decline while he declines mentally." D. "I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease."

A

Which patient statement indicates that the nurse's teaching following a gastroduodenostomy has been effective? a. "Vitamin supplements may prevent anemia." b. "Persistent heartburn is common after surgery." c. "I will try to drink more liquids with my meals." d. "I will need to choose high carbohydrate foods."

A Cobalamin deficiency may occur after partial gastrectomy, and the patient may need to receive cobalamin via injections or nasal spray. Although peptic ulcer disease may recur, persistent heartburn is not expected after surgery and the patient should call the health care provider if this occurs. Ingestion of liquids with meals is avoided to prevent dumping syndrome. Foods that have moderate fat and low carbohydrate should be chosen to prevent dumping syndrome.

A 50-year-old patient who underwent a gastroduodenostomy (Billroth I) earlier today complains of increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the last hour. The highest priority action by the nurse is to a. contact the surgeon. b. irrigate the NG tube. c. monitor the NG drainage. d. administer the prescribed morphine.

A Increased pain and 200 mL of bright red NG drainage 12 hours after surgery indicate possible postoperative hemorrhage, and immediate actions such as blood transfusion and/or return to surgery are needed. Because the NG is draining, there is no indication that irrigation is needed. Continuing to monitor the NG drainage is not an adequate response. The patient may need morphine, but this is not the highest priority action.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals.

D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

Which assessment should the nurse perform first for a patient who just vomited bright red blood? a. Measuring the quantity of emesis b. Palpating the abdomen for distention c. Auscultating the chest for breath sounds d. Taking the blood pressure (BP) and pulse

D The nurse is concerned about blood loss and possible hypovolemic shock in a patient with acute gastrointestinal (GI) bleeding. BP and pulse are the best indicators of these complications. The other information is important to obtain, but BP and pulse rate are the best indicators for assessing intravascular volume.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure? a. "My shoes fit really tight lately." b. "I wake up coughing every night." c. "I sleep with four pillows at night." d. "I have trouble catching my breath."

a

A nurse assesses a patient with pericarditis. Which assessment finding would the nurse expect to find? a. Friction rub at the left lower sternal border b. Coarse crackles in bilateral lung bases c. Heart rate that speeds up and slows down d. Presence of a regular gallop rhythm

a

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How should the nurse respond? a. "The stool will always be liquid with this type of colostomy." b. "Eating additional fiber will bulk up your stool and decrease diarrhea." c. "Your stool will become firmer over the next couple of weeks." d. "This is abnormal. I will contact your health care provider."

a

A nurse cares for a client who states, "My husband is repulsed by my colostomy and refuses to be intimate with me." How should the nurse respond? a. "Let's talk to the ostomy nurse to help you and your husband work through this." b. "You could try to wear longer lingerie that will better hide the ostomy appliance." c. "You should empty the pouch first so it will be less noticeable for your husband." d. "If you are not careful, you can hurt the stoma if you engage in sexual activity

a

A nurse is teaching a client about ear hygiene and health. What client statement indicates a need for further teaching? a. "A soft cotton swab is alright to clean my ears with." b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my ears."

a

A nurse is teaching a community group about preventing hearing loss. What instruction is best? a. Always wear a bicycle helmet. b. Avoid swimming in ponds or lakes. c. Don't go to fireworks displays. d. Use a soft cotton swab to clean ears.

a

A nurse prepares a patient for a colonoscopy scheduled for tomorrow. The patient states, "My provider told me that the fecal occult blood test was negative for colon cancer. I don't think I need the colonoscopy and would like to cancel it." How would the nurse respond? a. "A negative fecal occult blood test does not rule out the possibility of colon cancer." b. "Your provider would not have given you that information prior to the colonoscopy." c. "The colonoscopy is required due to the high percentage of false negatives with the blood test." d. "I will contact your provider so that you can discuss your concerns about the procedure."

a

An older adult in the family practice clinic reports a decrease in hearing over a week. What action by the nurse is most appropriate? a. Assess for cerumen buildup. b. Facilitate audiological testing. c. Perform tuning fork tests. d. Review the medication list.

a

In GERD, gastric secretions flow upward into the esophagus, damaging the tissues. This is caused by the inability of which of the below to fully close? a. lower esophageal sphincter (LES) b. upper esophageal sphincter (UES) c. epiglottis d. pylorus

a

A nurse is caring for a client who is to start therapy with bromocriptine (Parlodel). For which of the following should the nurse monitor? (Select all that apply.) A. Dyskinesias B. Orthostatic hypotension C. Insomnia D. Constipation E. Darkened urine

a b d

A client has a hearing aid. What care instructions does the nurse provide the unlicensed assistive personnel (UAP) in the care of this client? (Select all that apply.) a. Be careful not to drop the hearing aid when handling. b. Soak the hearing aid in hot water for 20 minutes. c. Turn the hearing aid off when the client goes to bed. d. Use a toothpick to clean debris from the device. e. Wash the device with soap and a small amount of warm water.

a c d e excessive wetting should be avoided

The nurse in the dialysis clinic is reviewing the home medications of a patient with chronic kidney disease (CKD). Which medication reported by the patient indicates that patient teaching is required? a. Multivitamin with iron b. Magnesium hydroxide c. Acetaminophen (Tylenol) d. Calcium phosphate (PhosLo)

b

A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed? a. "I eat small meals during the day and have a bedtime snack." b. "I take antacids between meals and at bedtime each night." c. "I quit smoking several years ago, but I still chew a lot of gum." d. "I sleep with the head of the bed elevated on 4-inch blocks."

a- GERD AND EATING AT NIGHT IS BAD

A 49-year-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which order from the health care provider will the nurse implement first? a. Insert a nasogastric (NG) tube. b. Infuse normal saline at 250 mL/hr. c. Administer IV ondansetron (Zofran). d. Provide oral care with moistened swabs.

b

A 62-year-old female patient has been hospitalized for 8 days with acute kidney injury (AKI) caused by dehydration. Which information will be most important for the nurse to report to the health care provider? a. The creatinine level is 3.0 mg/dL. b. Urine output over an 8-hour period is 2500 mL. c. The blood urea nitrogen (BUN) level is 67 mg/dL. d. The glomerular filtration rate is <30 mL/min/1.73m2.

b

A family member of a 28-year-old patient who has suffered massive abdominal trauma in an automobile accident asks the nurse why the patient is receiving famotidine (Pepcid). The nurse will explain that the medication will a. decrease nausea and vomiting. b. inhibit development of stress ulcers. c. lower the risk for H. pylori infection. d. prevent aspiration of gastric contents.

b

A nurse cares for a client who is recovering from a hemorrhoidectomy. The client states, "I need to have a bowel movement." Which action should the nurse take? a. Obtain a bedside commode for the client to use. b. Stay with the client while providing privacy. c. Make sure the call light is in reach to signal completion. d. Gather supplies to collect a stool sample for the laboratory.

b

A patient with acute kidney injury (AKI) has longer QRS intervals on the electrocardiogram (ECG) than were noted on the previous shift. Which action should the nurse take first? a. Notify the patient's health care provider. b. Document the QRS interval measurement. c. Check the medical record for most recent potassium level. d. Check the chart for the patient's current creatinine level.

b

An emergency room nurse assesses a client after a motor vehicle crash and notes ecchymotic areas across the client's lower abdomen. Which action should the nurse take first? a. Measure the client's abdominal girth. b. Assess for abdominal guarding or rigidity. c. Check the client's hemoglobin and hematocrit. d. Obtain the client's complete health history.

b

Before administration of captopril (Capoten) to a patient with stage 2 chronic kidney disease (CKD), the nurse will check the patient's a. glucose. b. potassium. c. creatinine. d. phosphate.

b

The nurse is planning care for a patient with severe heart failure who has developed elevated blood urea nitrogen (BUN) and creatinine levels. The primary collaborative treatment goal in the plan will be a. augmenting fluid volume. b. maintaining cardiac output. c. diluting nephrotoxic substances. d. preventing systemic hypertension.

b

Which information in a patient's history indicates to the nurse that the patient is not an appropriate candidate for kidney transplantation? a. The patient has type 1 diabetes. b. The patient has metastatic lung cancer. c. The patient has a history of chronic hepatitis C infection. d. The patient is infected with the human immunodeficiency virus.

b

Which item should the nurse offer to the patient who is to restart oral intake after being NPO due to nausea and vomiting? a. Glass of orange juice b. Dish of lemon gelatin c. Cup of coffee with cream d. Bowl of hot chicken broth

b

Which of the following would the nurse most likely assess in a client diagnosed with right-sided heart failure? a. Cough with frothy blood-tinged sputum b. Distended neck veins c. Oliguria d. Syncope

b

The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider? a. The bowel sounds are hyperactive in all four quadrants. b. The patient's lungs have crackles audible to the midchest. c. The nasogastric (NG) suction is returning coffee-ground material. d. The patient's blood pressure (BP) has increased to 142/84 mm Hg.

b The patient's lung sounds indicate that pulmonary edema may be developing as a result of the rapid infusion of IV fluid and that the fluid infusion rate should be slowed

A nurse is collecting data from a client who has Parkinson's disease. Which of the following are expected findings? (Select all that apply.) •A. Decreased vision •B. Pill-rolling tremor of the fingers •C. Shuffling gait •D. Bilateral ankle edema •E. Lack of facial expressions

b c e Bilateral ankle edema is not an expected finding in a client who has PD, but can be an adverse effect of certain medications used for treatment

A 37-year-old female patient is hospitalized with acute kidney injury (AKI). Which information will be most useful to the nurse in evaluating improvement in kidney function? a. Urine volume b. Creatinine level c. Glomerular filtration rate (GFR) d. Blood urea nitrogen (BUN) level

c

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I am awakened by the need to urinate at night." b. "I have experienced blurred vision on several occasions." c. "I must stop halfway up the stairs to catch my breath." d. "I have been drinking more water than usual."

c

A nurse teaches a client who is at risk for colon cancer. Which dietary recommendation should the nurse teach this client? a. "Eat low-fiber and low-residual foods." b. "White rice and bread are easier to digest." c. "Add vegetables such as broccoli and cauliflower to your new diet." d. "Foods high in animal fat help to protect the intestinal mucosa."

c

A patient with diabetes who has bacterial pneumonia is being treated with IV gentamicin (Garamycin) 60 mg IV BID. The nurse will monitor for adverse effects of the medication by evaluating the patient's a. blood glucose. b. urine osmolality. c. serum creatinine. d. serum potassium.

c

A nurse assesses patients on a cardiac unit. Which patient would the nurse identify as being at greatest risk for the development of left-sided heart failure? a. A 42-year-old man with pulmonary hypertension b. A 59-year-old woman who smokes cigarettes daily c. A 36-year-old woman with aortic stenosis d. A 70-year-old man who had a cerebral vascular accident

c Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease, and hypertension. Pulmonary hypertension and chronic cigarette smoking are risk factors for right ventricular failure. A cerebral vascular accident does not increase the risk of heart failure.

The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider? a. Absent bowel sounds b. Complaints of incisional pain c. Temperature 102.1° F (38.9° C) d. Scant nasogastric (NG) tube drainage

c An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

c Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

c- aspiration pneumonia

A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection should the nurse refer to an audiologist as the priority? a. Client with an hour car commute on the freeway each day b. Client who rides a motorcycle to work 20 minutes each way c. Client who sat in the back row at a rock concert recently d. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day

d

An emergency room nurse cares for a client who has been shot in the abdomen and is hemorrhaging heavily. Which action should the nurse take first? a. Send a blood sample for a type and crossmatch. b. Insert a large intravenous line for fluid resuscitation. c. Obtain the heart rate and blood pressure. d. Assess and maintain a patent airway.

d

A 73-year-old patient is diagnosed with stomach cancer after an unintended 20-pound weight loss. Which nursing action will be included in the plan of care? a. Refer the patient for hospice services. b. Infuse IV fluids through a central line. c. Teach the patient about antiemetic therapy. d. Offer supplemental feedings between meals.

d The patient data indicate a poor nutritional state and improvement in nutrition will be helpful in improving the response to therapies such as surgery, chemotherapy, or radiation. Nausea and vomiting are not common clinical manifestations of stomach cancer. There is no indication that the patient requires hospice or IV fluid infusions.

A nursing student is instructed to remove a client's ear packing and instill eardrops. What action by the student requires intervention by the registered nurse? a. Assessing the eardrum with an otoscope b. Inserting a cotton ball in the ear after the drops c. Warming the eardrops in water for 5 minutes d. Washing the hands and removing the packing

d- she should be wearing gloves