Final study guide for nurse exam

Which nursing interventions are beneficial in the event of fire in the hospital? SAA 1. Opening the doors and windows 2. Moving ambulatory clients in wheelchairs to a safe location 3. Putting out the fire first and then removing the clients from fire area 4. Asking ambulatory clients to help push wheelchair clients out of danger 5. Maintaining injured clients' respiratory status manually until removed from the fire area

4,5 4. Asking ambulatory clients to help push wheelchair clients out of danger 5. Maintaining injured clients' respiratory status manually until removed from the fire area

Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is MOST important for the nurse to do? A. Have the prescription renewed every 48 hours B. Assess the client's condition per hospital protocol. C. Provide range of motion to the client's elbows every shift D. Document output from the tube and catheter every two hours

B. Assess the client's condition per hospital protocol. Why: A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints are required to be represcribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown.

Healthcare provider prescribes dietary and medication therapy for a client with a diagnosis of gastroesophageal reflux disease (GERD). What is MOST appropriate for the nurse to teach the client about meal management? A. Snack daily in the evenings B. Divide food into four to six small meals a day C. Eat the last of three daily meals by 8:00pm D. Suck peppermint candy after each meal B. Divide food into four to six small meals a day

B. Divide food into four to six small meals a day Why: The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter.

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (brain attack). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? A. Insert a urinary retention catheter B. Institute measures to prevent constipation C. Encourage an increase in the intake of caffeine D. Suggest that a carbonated beverage be ingested daily

B. Institute measures to prevent constipation A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence. Urinary retention catheters should not be used to manage urinary incontinence initially. The use of a catheter keeps the bladder empty, which promotes atony and incontinence.

A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? A. Oral hydroxyurea B. Vitamin B12 injections C. Oral iron supplements D. Erythropoietin injections

B. Vitamin B12 injections Why: A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200- 835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B 12 deficiency and should be given vitamin B 12 injections. Vitamin B 12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb Vitamin B 12

Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? A. Irish Americans B. African Americans C. Chinese Americans D. Egyptian Americans

C. Chinese Americans Why: Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density.

A nurse is assessing a client's eye and finds the following (see image). Which condition can be identified from the given figure? A. Strabismus B. Keratoconus C. Corneal ulcer D. Retinal detachment

C. Corneal ulcer Why: The condition depicted in the figure is a corneal ulcer. Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi.

A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report? A. Attacks of acute pain B. Constant blurred vision C. Decreased peripheral vision D. Complete loss of central vision

C. Decreased peripheral vision With glaucoma, loss of peripheral vision occurs long before central vision is affected. The client also may complain of seeing halos around lights. Primary closed-angle glaucoma causes pain. Blurred vision may be because of a refractive error. Complete loss of central vision occurs with damage to the central retina.

An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? A. Sees best in dim light B. Sees halos around lights C. Cannot see objects in the periphery D. Cannot see objects in the center of the visual field

D. Cannot see objects in the center of the visual field Why: The macula is the central vision area of the retina; therefore macular degeneration affects central vision and makes it difficult to see objects within direct, central vision.

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal? A. Rest the eye B. Dilate the pupil C. Prevent secondary infections D. Control the intraocular pressure

D. Control the intraocular pressure

A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider MOST desirables? SAA 1. Raw carrots 2. Boiled Spinach 3. Dried apricots 4. Brussels sprouts 5. Asparagus spears

2,3 2. Boiled spinach 3. Dried apricots Why: According to the nutritional table, the food sources highest in iron are, "Liver and muscle meats, dried fruits (apricots), legumes, dark green leafy vegetables (spinach), whole-grain and enriched bread and cereals, and beans."

A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include? A. Avoidance of cholinergics B. Surgical replacement of lens C. Continuation of therapy for life D. Prevention of high blood pressure

C. Continuation of therapy for life Why: Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure.

What is the relationship between steroids and osteoporosis?

The long term effect of steroids increases your chance of getting osteoporosis because when you take steroids it makes your bones smaller. Steroids have major effects on how the body uses calcium and vitamin D to build bones. Steroids can lead to bone loss, osteoporosis, and broken bones. When steroid medications are used in high doses, bone loss can happen rapidly.

The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients. staff, and family members? SAA 1. Move bedridden clients via stretcher 2. Place ambulatory clients in 3. Turn off all sources of supplemental oxygen 4. Provide manual respiratory support to critically ill clients 5. Close all windows and doors and use an ABC fire extinguisher

1, 3, 4, 5 1. Move bedridden clients via stretcher 3. Turn off all sources of supplemental oxygen 4. Provide manual respiratory support to critically ill clients 5. Close all windows and doors and use an ABC fire extinguisher

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? SAA 1. Hips 2. Knees 3. Ankles 4. Shoulders 5. Metacarpals

1,2 1. Hips 2. Knees Why: Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first, because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage.

A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? SAA 1. Avoid intramuscular injections 2. Institute neutropenic precautions 3. Monitor the white blood cell count 4. Administer prescribed anticoagulants 5. Examine the skin for ecchymotic areas

1,5 1. Avoid intramuscular injections 5. Examine the skin for ecchymotic areas Why: Intramuscular injections should be avoided because of the increased risk of bleeding and possible hematoma formation. Decreased platelets increase the risk of bleeding, which leads to ecchymoses. thrombocytopenia definition: deficiency of platelets in the blood. This causes bleeding into the tissues, bruising, and slow blood clotting after injury. Signs and symptoms: Easy or excessive bruising (purpura) Superficial bleeding into the skin that appears as a rash of pinpoint-sized reddish-purple spots (petechiae), usually on the lower legs. Prolonged bleeding from cuts.

A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? SAA 1. Clean the eyelid and eyelashes enter 2. Place the dropper against the eyelid 3. Apply clean gloves before beginning the procedure 4. Instill the solution directly onto the cornea 5. Press on the nasolacrimal duct after instilling the solution

1.3.5 1.Clean the eyelid and eyelashes enter 3. Apply clean gloves before beginning the procedure 5. Press on the nasolacrimal duct after instilling the solution Why: Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye.

Following a motor vehicle accident, a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address? A. Glaucoma B. Scleroderma C. Detached retina D. Cerebral concussion

C. Detached retina

A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations are the clients body should the nurse assess? SAA 1. Sclera 2. Nail beds 3. Conjunctivae 4. Palms of hands 5. Bony prominences

2,3,4 2. Nail beds 3. Conjunctivae 4. Palms of hands why: Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids (conjunctiva). Palms of the hands will become pale because of the decreased hemoglobin.

A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? SAA 1. "I may eat potatoes at dinner daily." 2. "I should bring at least six glasses of water every day." 3. "I must eat eggs for breakfast three times a week." 4. "I can include bran muffins in my breakfast daily." 5. "I will walk every day as part of my exercise regiment."

2,4,5 2. "I should bring at least six glasses of water every day." 4. "I can include bran muffins in my breakfast daily." 5. "I will walk every day as part of my exercise regiment." Why: At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation.

The laboratory report of a client reveals that the platelet count is 60,000/microliter (60 x 10^9 /L). Which integumentary changes can be anticipated in this client? SAA 1. Cyanosis 2. Petechiae 3. Varicosity 4. Ecchymosis 5. Hematoma

2,4,5 2. Petechiae 4. Ecchymosis 5. Hematoma Why: Normal blood platelet counts range between 150,000 and 400,000/µL (150-400 x 10 ⁹/L). A count of less than 100,000/µL (100 x 10 ⁹/L) is referred to as thrombocytopenia, which results in prolonged bleeding time. Petechiae, ecchymosis, and the formation of hematoma are the results of bleeding disorders. Cyanosis is caused by cardiorespiratory problems, vasoconstriction, asphyxiation, and deoxygenated blood. Varicosity is caused by interruption of venous return commonly found on lower legs with aging.

A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's BMI. The Client's weight is 65kg, and the height is 1.7 meters. What is the client's BMI?

22.5 BMI 1.7m x 1.7m= 2.8965 kg/2.89= 22.5 formula for BMI is: weight in kg ÷ (height in meters) ^2 The square of the client's height is 1.7 × 1.7 = 2.89; 65 ÷ 2.89 = 22.5. The desirable BMI for adults is 18.5 to 24.9. <br><br><b>STUDY TIP:</b> Develop a realistic plan of study. Do not set rigid, unrealistic goals.</p>

Which term should the nurse use to describe bone loss greater that normal but less than that caused by osteoporosis? A. Osteopenia B. Osteomyelitis C. Osteomalacia D. Osteoarthritis

A. Osteopenia Why: Osteopenia is defined as bone loss that is more than normal but not yet at the level for a diagnosis of osteoporosis. Osteomyelitis is infection of bone or bone marrow. Osteomalacia is softening of bones due to calcium or vitamin D deficiency. Osteoarthritis is cartilage deterioration in the joints.

A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective? A. "I should call the clinic if my eye begins to hurt." B. "I am so glad that I can take a shower tomorrow." C. "There will be bright flashes of light for a few days." D. "My vision should show some improvement by tomorrow."

A. "I should call the clinic if my eye begins to hurt." Why: Pain after a cataract extraction and intraocular lens implant may indicate infection, increased intraocular pressure, or hemorrhage and should be reported immediately.

The nurse understands that the BEST way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? A. Perform catheter care twice a day. B. Replace the catheter on a routine basis C. Administer cranberry tablets three times each day D. Give antibiotics for the duration of catheter placement

A. Perform catheter care twice a day. Why: A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter-associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day.

Which key feature does the nurse associate with a stage 2 pressure ulcer? A. Presence of non-intact skin B. Development of sinus tracts C. Damage to the subcutaneous tissues D. Appearance of a reddened area over a bony prominence

A. Presence of non-intact skin

A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect? A. Retinol (vitamin A) B. Thiamine (vitamin B1) C. Pyridoxine (vitamin B6) D. Absorbic acid (vitamin C)

A. Retinol (vitamin A) Why: Joint pain, hair loss, jaundice, anemia, irritability, pruritus, and enlarged liver and spleen are signs of vitamin A toxicity. Unlike retinol, which is lipid soluble and eliminated by the liver, thiamine, pyridoxine, and ascorbic acid are water soluble, so they are typically excreted in the urine before toxic blood levels can be achieved.

Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? A. Tubing luer-lok port B. Distal end of the tubing C. Urinary drainage bag D. Catheter insertion site

A. Tubing luer-lok port Why: The tubing luer-lok port is the best site for obtaining a urine specimen for a critical care client with an indwelling urine catheter. The nurse applies a clamp to the drainage tubing distal to the luer-lok port, cleans the port with antiseptic, attaches a sterile 5-mL or 10-mL syringe onto the port, and aspirates the urine quantity desired.

What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? A. Urinate small amount, stop flow, fill half a cup B. Collect the las urine sample voided in the night C. Keep the urine sample in dry warm area if delay is anticipated D. Send the urine sample to the laboratory within 6 hours of collection

A. Urinate small amount, stop flow, fill half a cup

The nurse provides information to a client scheduled for a dual x-ray absorptiometry (DEXA) test. Which information should the nurse provide to the client? Select all that apply.

it is a painless test. Metallic objects such as jewelry or belt buckles may interfere with the test and need to be removed. Rationale:The most commonly used screening and diagnostic tool for measuring bone mineral density is the dual x-ray absorptiometry (DEXA) test. It is a painless test that emits less radiation than a chest x-ray. A height is taken before the start of the test. The client stays dressed but is asked to remove any metallic objects such as belt buckles, coins, keys, or jewelry because they may interfere with testing. No special follow-up care for the test is necessary.

A client with GERD receives a prescription for an H2 receptor antagonist. Which medications are within the classification of an H2 receptor antagonist? SAA 1. Nizatidine 2. Ranitidine 3. Famotidine 4. Lansoprazole 5. Metoclopramide

1,2,3 1. Nizatidine 2. Ranitidine 3. Famotidine Nizatidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Lansoprazole is a proton pump inhibitor that inhibits gastric secretion up to 90% with one dose daily and provides for symptomatic improvement in GERD. Metoclopramide is a prokinetic agent that increases the rate of gastric emptying; it has multiple side effects and is not appropriate for long-term treatment of GERD.

The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by nursing student indicate effective learning? SAA 1. "I will elevate the head of the client's bed to no more than 30 degrees." 2. "I will ensure that the client is turned and repositioned at least every two hours." 3. "I will advise the client to apply talc directly to the perineum." 4. "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day 5. "I will teach the client to refrain from eating a high-protein and calorie diet

1,2,4 1. "I will elevate the head of the client's bed to no more than 30 degrees." 2. "I will ensure that the client is turned and repositioned at least every two hours." 4. "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day Why: The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure ulcers. Turning and repositioning the client frequently improves circulation, and redistributes body weight over bony prominences, both of which reduce the risk of pressure ulcer formation. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps to nourish the skin.

A client with renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure?SAA 1. Ensure that the consent form is signed 2. Assess the client for iodine sensitivity 3. Have the client remove all metal objects 4. Administer an enema or cathartic to the client 5. Instruct the client to lie still during the procedure

1,2,4 1. Ensure that the consent form is signed 2. Assess the client for iodine sensitivity 4. Administer an enema or cathartic to the client Why: The presence, position, shape, and size of kidneys, ureters, and bladder can be evaluated using an intravenous pyelogram (IVP). The contrast medium used in the procedure may cause hypersensitivity reactions. Therefore, the nurse should assess the client for sensitivity to iodine prior to the procedure. The nurse should use a cathartic or enema to empty the colon of feces and gas.

A registered nurse is teaching a client regarding preventative measures for genital tract infections. Which statement made by the client indicates the need for further education? SAA 1. "I should take frequent bubble baths." 2. "I should decrease the use of dietary sugar." 3. "I should choose hosiery with nylon crotch." 4. "I should use colored and scented toilet tissues." 5. "I should limit the time spent in damp exercise clothes."

1,3,41. "I should take frequent bubble baths." 3. "I should choose hosiery with nylon crotch." 4. "I should use colored and scented toilet tissues." Why: Exposure to bath salts and bubble baths should be limited to prevent genital tract infections. Hosiery with a cotton crotch should be selected to prevent genital tract infections because cotton fabric absorbs wetness. Colored and scented toilet tissues should be avoided because they can increase the risk of genital tract infections.

What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? SAA 1. Encourage motion of the joint 2. Maintain a knee brace on the leg 3. Keep the client on a regimen of bed rest 4. Maintain joints in functional alignment when resting 5. Immobilize the joint with pillows until pain subsides

1,4 1. Encourage motion of the joint 4. Maintain joints in functional alignment when resting

A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? SAA 1. Carrots 2. Oranges 3. Tomatoes 4. Green leafy greens 5. Yellow/orange vegetables

1,4,5 1. Carrots 4. Green leafy greens 5. Yellow/orange vegetables Why: Yellow/orange vegetables, like carrots, contain large quantities of vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin A. Dark-green leafy vegetables contain large quantities of vitamin A in human nutrition.

The nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? SAA 1. Cigarette smoking 2. Moderate exercise 3. Use of street drugs 4. Familial predisposition 5. Inadequate intake of dietary calcium

1,4,5 1. Cigarette smoking 4. Familial predisposition 5. Inadequate intake of dietary calcium Why: Cigarette smoking is a high-risk behavior associated with an increased incidence of osteoporosis in later life. Familial predisposition is considered a risk factor for the development of osteoporosis. Inadequate calcium intake during the premenopausal years is a risk factor for the development of osteoporosis after menopause.

Which client statement indicates to the nurse that a client who is receiving cyanocobalamin (vitamin B12) therapy for an intrinsic factor deficiency understands the treatment? A. "I should have a vitamin b12 injection every month? B. "I'll take my B12 vitamin every morning with my breakfast C. "I'll have a salad every day because vitamin B12 is in green vegetables." D. "I should feel better because my vitamin B12 treatments will improve my aplastic anemia

A. "I should have a vitamin b12 injection every month. Why: Vitamin B 12 is administered via injection on a weekly or monthly basis. Vitamin B 12 is destroyed by stomach acid and therefore cannot be taken in pill form. Vitamin B 12 is found primarily in meat, fish, poultry, and eggs.

A registered nurse is teaching a student nurse about the role of nurses in case of a fire in the hospital. Which statement made by the student nurse indicates an effective learning? A. "I will continue oxygen for all clients, even those who can breathe without it." B. "I will seek to put out the fire by closing doors and windows and use an ABC extinguisher." C. "I will manually maintain the respiratory status for clients on life support until they are removed from the fire area." D. "I will take the help of staff members to move bedridden clients on blankets or carry them from the fire area."

A. "I will continue oxygen for all clients, even those who can breathe without it." Why: In case of fire in a hospital, the role of a nurse is to discontinue oxygen for clients who can breathe without it. An ABC extinguisher should be used to put out the fire after everyone is out of danger. The respiratory status of clients on life support should be maintained manually until they are removed from the fire area. The nurse should employ the help of staff members to move bedridden clients on blankets or carry them from the fire area.

A female client has a history of recurrent urinary track infections. What should the nurse include in the teaching plan when educating the client about the health practices that may help decrease future urinary tract infections? A. "Wear cotton underpants." B. "Void at least every 6 hours." C. "Increase foods containing alkaline ash in the diet." D. "Wipe from back to front after toileting."

A. "Wear cotton underpants." Why: Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments.

A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? A. An increase in the pressure within the eyeball B. An opacity of the crystalline lens or its capsule C. A curvature of the cornea that becomes unequal D. A separation of the neural retina from the pigmented retina

A. An increase in the pressure within the eyeball Why: An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.

A client with GERD is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? A. Apple B. Orange C. Tomato D. Grapefruit

A. Apple Why: Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.

A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the MOST appropriate nursing action? A. Applying cold compress to the affected area B. Ensuring the client keeps the skin clean and dry C. Monitoring for neurological and cardiac symptoms D. Advising the client to launder all clothes with bleach

A. Applying cold compress to the affected area Why: A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client.

Which beta-adrenergic blocker is prescribed to clients with glaucoma? A. Betaxolol B. Carbachol C. Brimonidine D. Methazolamide

A. Betaxolol Why: Betaxolol is a beta-adrenergic blocker that is prescribed for glaucoma. Carbachol is a cholinergic agent that is used to treat glaucoma. Brimonidine is an alpha-adrenergic agonist that is prescribed in glaucoma. Methazolamide is a carbonic anhydrase inhibitor that is used to treat glaucoma.

Which drug is derived from a natural source and may be prescribed for the treatment of osteoporosis? A. Calcitonin B. Raloxifene C. Clomiphene D. Bisphosphonates

A. Calcitonin Why: Calcitonin is derived from natural sources such as fish; this drug may be prescribed to prevent osteoporosis. Raloxifene is prescribed to prevent postmenopausal osteoporosis. Clomiphene is prescribed to induce ovulation. Bisphosphonates are prescribed to treat osteoporosis; this drug is not derived from natural sources.

Which client responses does the nurse determine represent the HIGHEST risk for the development of pressure ulcers? A. Incontinence and inability to move independently B. Periodic diaphoresis and occasional sliding down in bed C. Reaction to just painful stimuli and receiving tube feedings D. Adequate nutritional intake and spending extensive time in a wheelchair

A. Incontinence and inability to move independently Why: Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers.

A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? A. Loss of central vision B. Attacks of acute pain C. Constant blurred vision D. Decreased peripheral vision

A. Loss of central vision Why: age-related macular degeneration is loss of central vision, which is gradual. Primary closed-angle glaucoma causes pain. Blurred vision may be caused by a refractive error. Loss of peripheral vision does not occur with macular degeneration; peripheral vision loss can occur with glaucoma.

After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? A. Monthly injections of cyanocobalamin B. Regular daily use of a stool softener C. Weekly injections of iron dextran D. Daily replacement therapy of pancreatic enzymes

A. Monthly injections of cyanocobalamin Why: Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized

A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance? A. Vitamin C B. Fat content C. Water content D. Vitamin B complex

A. Vitamin C Why: Vitamin C aids the absorption of iron. Fat content, water content, and vitamin B complex are all unrelated to the absorption of iron.

A complete blood count (CBC), urinalysis, and X-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the BEST reply by the nurse? A. "Don't worry; theses tests are routine." B. " They are done to identify other health risks." C. "They determine whether surgery will be safe." D. " I don't know; your healthcare provider prescribed them."

B. " They are done to identify other health risks." Why: Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery.

Which client is MOST at risk for osteoporosis? A. A nonsmoking 60 year old woman, 5ft 7in (170cm) tall and 173 lb (78.5kg) B. A 66 year old white woman, 5ft 1in (155cm) tall and 100 lb (45kg), who is a paralegal C. a 68 year old woman, 5ft 5in (165cm) tall and 140 lb (63.5 kg), who is a retired receptionist D. A 63 year old woman, 5ft 4in (163 cm) and 135 lb (61kg), who takes calcium carbonate daily

B. A 66 year old white woman, 5ft 1in (155cm) tall and 100 lb (45kg), who is a paralegal Why: A postmenopausal woman who is small-boned, thin, and relatively sedentary is at risk for osteoporosis; other risk factors are family history and white or Asian ethnicity.

While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? A. Gray color B. Dark red color C. Deep brown color D. White color

B. Dark red color Why: Dark red skin coloring is identified as ecchymosis. A grayish skin color is due to cyanosis. A deep brown skin coloring is caused by erythema in dark-skinned clients. A white or ashen skin color is found in clients with pallor.

The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? A. Ulnar drift B. Heberden nodes C. Swan-neck deformity D. Boutonniere deformity

B. Heberden nodes Why: Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.

A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals. Which food items will the nurse recommend? A. Meatloaf and tea B. Meatloaf and strawberries C. Chicken soup and baked apple D. Chicken soup and buttered bread

B. Meatloaf and strawberries Why: Meat provides protein, and fruit provides vitamin C; both promote wound healing.

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? A. Takes estrogen therapy B. Receives long-term steroid therapy C. Has a history of hypoparathyroidism D. Engages in strenuous physical activity

B. Receives long-term steroid therapy Why: Increased levels of steroids will accelerate bone demineralization.

A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? A. Pull the fire alarm on the unit B. Remove anyone who is in immediate danger C. Obtain a fire extinguisher and report the fire area D. Close all windows and fire doors and await further instructions

B. Remove anyone who is in immediate danger Why: The nurse is following the standard fire safety procedure RACE: "R" represents removing any clients from immediate danger. In RACE, "A" represents alarming or activating the fire alarm, "C" represents containing the fire source by closing all windows and fire doors, and "E" represents extinguishing the fire and/or evacuating.

Which diagnostic study is used to determine a client's bone density? A. Diskogram B. Standard X-ray C. Computed tomography scan D. Magnetic resonance imaging

B. Standard X-ray Why: A standard X-ray is used to determine bone density. A diskogram is used to visualize abnormalities of the intervertebral disc. A computed tomography scan is used to identify soft tissues, bony abnormalities, and various types of musculoskeletal trauma. Magnetic resonance imaging is used to diagnose avascular necrosis, disc disease, tumors, osteomyelitis, ligament tears, and cartilage tears.

A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? A. Urinary frequency due to bladder spasticity B. Urinary retention due to bladder atony C. Pain due to urinary tract calculi D. Urinary urgency due to urinary tract infections

B. Urinary retention due to bladder atony Why: Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder. Cholinergics will not prevent renal calculi. Urinary tract infections are a secondary gain because cholinergics help prevent urinary retention that can lead to urinary tract infection, but this is not the primary purpose for administering a cholinergic.

The nurse is preparing to initiate intravenous antibiotic therapy for a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intervenous antibiotics, which task should the nurse ensure has been completed? A. Red blood cell count B. Wound culture C. Knee x-ray D. Urinalysis

B. Wound culture Why: A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given.

A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? A. "I will avoid the pooling of urine in the tubing." B. "I will avoid prolonged clamping of the tubing." C. "I will avoid draining urine from the tubing before ambulation." D. "I will avoid raising the drainage tube above the level of the bladder."

C. "I will avoid draining urine from the tubing before ambulation."

A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asked the nurse to describe the procedure. Which is the nurse is MOST appropriate response? A. "It is a computerized scan that outlines the bladder and surrounding tissue." B. "It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." C. "It is the visualization of the inside of the bladder with an instrument connected to a source of light." D. "It is the visualization of the urinary tract through urethral catheterization and the use of radiopaque material."

C. "It is the visualization of the inside of the bladder with an instrument connected to a source of light Why: The response that the procedure is "The visualization of the inside of the bladder with an instrument connected to a source of light" answers the client's question and provides an accurate description of a cystoscopy. Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen. (Usually is a UTI)

Upon assessment the nurse finds to following (See Image). The nurse will prepare the client for which type of surgery? A. Keratoplasty B. Trabeculoplasty C. Cataract removal D. Laser in situ keratomileusis (LASIK)

C. Cataract removal

A thin 24 year old woman who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend? A. Vitamin E and ginseng tea B. Vitamin B and ginkgo biloba C. Vitamin D and calcium citrate D. Vitamin c and glucosamine/chondroitin

C. Vitamin D and calcium citrate Why: All women, except those who are pregnant or lactating, should ingest between 1000 and 1300 mg of calcium daily; if the client is unable to ingest enough calcium in food, supplements of calcium and vitamin D are recommended.

A client diagnosed with GERD is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? A. Antacids should be taken 1 hour before meals B. These should be scheduled at 4-hour intervals C. Antacid tablets are just as fast and effective as the liquid form D. Antacids commonly interfere with the absorption of other drugs

D. Antacids commonly interfere with the absorption of other drugs Why: Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin.

Which nursing intervention is indicated for aging clients with decreased bone density? A. Teaching the client isometric exercises B. Advising the client to take a moist heat shower C. Providing supportive armchairs to the client D. Demonstrating weight-bearing exercises to the client

D. Demonstrating weight-bearing exercises to the client Why: Decreased bone density leads to osteoporosis; weight-bearing exercises help to build and maintain bone density. Isometric exercises are indicated for clients with muscular atrophy. Clients with cartilaginous degeneration are advised to take moist heat showers to increase blood flow to the region. Correction of posture problems by sitting in a supportive armchair provides support to the bony structures for a client with kyphosis.

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do? A. Void after a urinary catheter is removed B. Collect a specimen of urine during midstream C. Attempt to void when a urinary catheter is in place D. Empty the bladder before a urinary catheter is inserted

D. Empty the bladder before a urinary catheter is inserted Why: Emptying the bladder before a urinary catheter is inserted measures how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating. After voiding, the client is catheterized, or a bladder scan can be used.

After surgery to repair a retinal detachment, an older adult client is transferred to the post-anesthesia care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information? A. Has not voided B. Cannot open the eye C. Cannot remember the date D. Has sharp pain in the affected eye

D. Has sharp pain in the affected eye Why: Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye.

An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4hrs. Which diet should the nurse expect the healthcare provider to prescribe to BEST meet this client's immediate nutritional needs? A. Low in fat and vitamin D B. High in calories and fiber C. Low in residue and bland D. High in protein and vitamin C

D. High in protein and vitamin C

Which clinical indicator is the nurse MOST likely to identify when exploring the history of a client with open-angle glaucoma? A. Constant blurring B. Abrupt attacks of acute pain C. Sudden, complete loss of vision D. Impairment of peripheral vision

D. Impairment of peripheral vision

The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? A. Primary B. Secondary C. Superinfection D. Nosocomial

D. Nosocomial Why: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients. A primary infection is synonymous with initial infection. A secondary infection is made possible by a primary infection that lowers the host's resistance and causes an infection by another kind of organism. A superinfection is a new infection caused by an organism different from that which caused the initial infection. The microbe responsible is usually resistant to the treatment given for the initial infection.</p>

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? A. Administer a mineral oil enema B. Offer 1 cup of fluid every hour C. Manually remove fecal impactions D. Offer a cup of prune juice

D. Offer a cup of prune juice Why: Prune juice does not require a primary healthcare provider's order and helps promote bowl movement because it contains sorbitol that increases water retention in feces.

A Client is being discharged from the hospital with an indwelling urinary catheter. The client asked about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? A. Once a day, clean the tubing with mild soap and water, starting at the drainage bag and moving toward the insertion site . B. After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. C. Clean the insertion side daily using a solution of one part vinegar to two parts water D. Replace the drainage bag with a new bag once a week

D. Replace the drainage bag with a new bag once a week Why: It is recommended to change the bag at least once a week. Once a day, the client should wash the first inches of the catheter, starting at the insertion site and moving outward. The foreskin should be pushed forward as soon as the foreskin has been cleaned and dried. The drainage bag, not the insertion site, should be cleaned with the vinegar and water solution.

A client has a pressure ulcer that is full thickness with the crosses into the subcutaneous tissue down to the underlying patient. The nurse should document the assessment finding as which stage of pressure ulcer? A. Stage I B. Stage II C. Stage III D. Unstageable

D. Unstageable Why: A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full-thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed.