Form A
What is the proper way to use crutches?
1. Place body weight on crutches 2. Advance the UNAFFECTED leg onto the stair 3. Shift weight from the crutches to the unaffected leg 4. Bring the crutches and the affected leg up to the stair
A nurse in an ED is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit? A. HR 110/min B. BP 138/90 C. Urine specific gravity 1.020 D. BUN 15
A. HR 110/min RATIONALE: C- this is within the expected reference range. A client who is dehydrated will have a urine specific gravity >1.030 (normal range is 1.005-1.030)
A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? A. Remain with the client for the first 15min of the infusion B. Prime the blood administration IV tubing with LR solution C. Verify the client's identity by using the client's room number prior to starting the transfusion D. Infuse the unit of packed RBCs within 8hr
A. Remain with the client for the first 15min of the infusion RATIONALE: Hemolytic rxns usually occur during the infusion of the first 50mL of blood; stay with the client for the first 15-30min
A nurse is providing discharge teaching to a client who has HF and a new prescription for a potassium sparring diuretic. Which of the following information should the nurse include in the teaching? A. Try to walk at least 3 times per week for exercise B. To increase stamina, walk for 5 min after fatigue begins C. Take OTC cough medicine for persistent cough D. Use a salt substitute to reduce sodium intake
A. Try to walk at least 3 times per week for exercise RATIONALE: D- salt substitutes contain an increased amount of potassium, which can place the client at an increased risk for hyperkalemia
A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want anymore morphine because I don't want to get addicted". Which of the following actions should the nurse take? A. Administer a placebo to the client without their knowledge B. Instruct the client on alternative therapies for pain reduction C. Tell the client not to worry about addiction to prescribed narcotics D. Suggest the client receive a different opioid for pain reduction
B. Instruct the client on alternative therapies for pain reduction
A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider? A. Restlessness B. T3 level 215 C. BP 170/80 D. Decreased weight
C. BP 170/80 RATIONALE: pt is at risk for thyroid storm
A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take? A. Teach the importance of a clear liquid diet after discharge B. Tell the client to remove the incisional adhesive strips 3 days after discharge C. Demonstrate ways to deep breathe and cough D. Instruct the client to maintain bed rest for 48hr
C. Demonstrate ways to deep breathe and cough
A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication? A. Bradycardia B. Tremors C. Orthostatic hypotension D. Drowsiness
C. Orthostatic hypotension
What medications can alter allergy skin results?
-ACEIs -BB's -Theophylline -Nifedipine (CCB) -Glucocorticoids These meds can diminish the client's rxn to allergens; the nurse should notify the provider & instruct the client to d/c prednisone 2 weeks before allergy skin testing
A nurse is providing dietary teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium in her diet? A. 12 almonds B. One small banana C. 1 tbsp peanut butter D. 1/2 cup tomato juice
A. 12 almonds
A nurse is teaching a class about client rights. Which of the following instructions should the nurse include? A. A client should sign an informed consent before receiving a placebo during a research trial B. A client cannot refuse to sign a consent form for a life-saving treatment C. A client who has mental illness is unable to give informed consent D. An unemancipated minor needs a guardian consent for substance use disorder treatment
A. A client should sign an informed consent before receiving a placebo during a research trial RATIONALE: D- an unemancipated minor has the right to consent to treatment for substance abuse disorder
A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients? A. A client who is receiving postoperative teaching for a right knee arthroplasty B. A client who states they will have difficulty obtaining a walker for home use C. A client who reports an increase in pain following a left arthroplasty D. A client who is having emotional difficulty accepting that they have a prosthetic leg
A. A client who is receiving postoperative teaching for a right knee arthroplasty
A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment? A. History of asthma B. Appendectomy 1 year ago C. Penicillin allergy D. Total knee arthroplasty 6 months ago
A. History of asthma RATIONALE: greater risk of reacting to contrast dye; other conditions that can result in a rxn to contrast include allergies to shellfish, eggs, milk and chocolate
A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client is experiencing excessive stools. Which of the following findings is an adverse effect of this medication? A. Hypokalemia B. Hypercalcemia C. GI bleeding D. Confusion
A. Hypokalemia RATIONALE: lactulose works by stimulating the production of excess stools to rid the body of excess ammonia and can l/t hypokalemia and dehydration
A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? A. I will monitor my BP while taking this medication B. I should take a vitamin D supplement to increase the effectiveness of this medication C. I should inform the provider if I experience an increased appetite while taking this medication D. I will decrease the amount of protein in my diet while taking this medication
A. I will monitor my BP while taking this medication RATIONALE: HTN is a common adverse effect that can l/t hypertensive encephalopathy
A nurse in an ED is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first? A. IV fluids B. Analgesia C. Antibiotics D. Tetanus toxoid
A. IV fluids
A nurse is providing discharge instructions to a client following an upper GI series with barium contrast. Which of the following information should the nurse provide? A. Increase fluid intake B. Take an OTC antidiarrheal medication C. Expect black, tarry stools D. Follow a low-fiber diet
A. Increase fluid intake RATIONALE: to facilitate elimination of the barium used during the test
A nurse in an ED is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? A. It's like a curtain closed over my eye B. This sharp pain in my eye started 2hrs ago C. I've been having more and more difficulty seeing over the past few weeks D. I seem to have more problems seeing different colors
A. It's like a curtain closed over my eye
A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentrations of oxygen? A. Nonrebreather mask B. Venturi mask C. Simple face mask D. Partial rebreather mask
A. Nonrebreather mask RATIONALE: to deliver between 80 and 95% oxygen to the client B- this delivers the most precise amount, but can only deliver oxygen concentration between 24 and 50% C- this is for a client who requires short term supplemental oxygen and can only deliver an oxygen concentration between 40 and 60% . It does not usually fit well and can lead to skin breakdown D- partial rebreather allows a portion of room air to be inhaled along with the oxygen, diluting the oxygen concentration to range between 60 and 75%
A nurse in a provider's office is assessing a client who has HTN and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? A. Report of a night cough B. Report of tinnitus C. Report of excessive tearing D. Report of increased salivation
A. Report of a night cough RATIONALE: A night cough is an early indication of HF
A nurse is assessing a client who has extracorporeal shock wave lithotripsy (ESWL) 6hr ago. Which of the following findings should the nurse expect? A. Stone fragments in the urine B. Fever C. Decreased UO D. Bruising on the lower abdomen
A. Stone fragments in the urine RATIONALE: ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder and through the urethra when voiding; following the procedure, the nurse should strain the client's urine to confirm the passage of stones B- UTI or pyelonephritis C- complication from stone fragments obstructing urine flow D- caused by repeated shock waves directed towards the body
A nurse is preparing to admit a client who has dysphagia. The nurse should place which of the following items at the client's bedside? A. Suction machine B. Wire cutters C. Padded clamp D. Communication board
A. Suction machine
A nurse is caring for a client who has type 1 DM and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? A. Take insulin even if you are unable to eat your regular diet B. It's okay if your ketone levels are temporarily high C. Monitor your blood glucose levels every 12hr D. Call the provider if your glucose levels reach 170
A. Take insulin even if you are unable to eat your regular diet RATIONALE: to prevent hyperglycemia, since BG levels rise when ill C- check q4hr when ill D- notify if greater than 250
A nurse an an AP are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions? A. Wear a mask B. Wear a gown C. Keep the client's room well lit D. Maintain the head of bed at 45° elevation
A. Wear a mask RATIONALE: bacterial meningitis requires droplet precautions; wear mask until 24hr after the client has begun receiving abx therapy D- Maintain at 30°
A nurse has received change of shift report for a group of clients. Which of the following clients should the nurse assess first? A. A client who is 1 day post operative following abdominal surgery and reports pain of 4 on a scale of 0-10 B. A client who had a MI 4 days ago and is asking for PRN sublingual nitroglycerin tablet C. A client who has atopic dermatitis with scaling and excoriation of the skin and reports severe itching D. A client who has pneumonia manifesting with bilateral crackles and diminished breath sounds
B. A client who had a MI 4 days ago and is asking for PRN sublingual nitroglycerin tablet RATIONALE: could be unstable, be experiencing angina or could be having another MI D- bilateral crackles with diminished breath sounds= stable because these are expected findings
A nurse is caring for a client who is receiving total parenteral nutrition. A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take? A. Keep the line open with 0.9% sodium chloride until the new bag arrives q C. Flush the line and cap the port until the new bag arrives D. Decrease the infusion rate until the new bag arrives
B. Administer dextrose 10% in water until the new bag arrives RATIONALE: TPN solutions have a high concentration of dextrose, so administer D10 or D20 in water to avoid hypoglycemia while waiting for the new bag
A nurse in a community clinic is caring for a client who reports an increase in the frequency of migraine HAs. To help reduce the risk of migraine HA's, which of the following foods should the nurse recommend the client avoid? A. Shellfish B. Aged cheese C. Peppermint candy D. Enriched pasta
B. Aged cheese RATIONALE: stay away from foods rich in tyramine, such as aged cheese, sausage, wine, chocolate, yeast, smoked fish & fermented/pickled foods
A nurse is caring for a client 1 hr following cardiac catheterization. The nurse notes formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurses priority? A. Initiate oxygen at 2L/min via nasal cannula B. Apply firm pressure to the insertion site C. Take the client's vital signs D. Obtain a stat order for an aPTT
B. Apply firm pressure to the insertion site
A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonas aeruginosa infection? A. Encourage the client to eat raw fruits and vegetables B. Avoid placing plants or flowers in the client's room C. Limit visitors to members of the client's immediate family D. Wear an N95 respirator mask when providing care to the client
B. Avoid placing plants or flowers in the client's room RATIONALE: Live plants can harbor P. aeruginosa and this bacterium can infect burn wounds and cause life threatening complications
A nurse is caring for a client who has DKA. Which of the following lab findings should the nurse expect? A. Negative urine ketones B. BUN 32 C. pH 7.43 D. HCO3 23
B. BUN 32 RATIONALE: the nurse should expect a client who has DKA to have elevated BUN, creatinine and specific gravity from excess glucose present in urine A- POSITIVE C- <7.35 D. Client with DKA will have HCO3 <15 (normal is 22-26)
A nurse is assessing a client who has had a plaster cast applied to their left leg 2hr ago. Which of the following actions should the nurse take? A. Inspect the cast for drainage once every 24hr B. Check that one finger fits between the cast and leg C. Perform neurovascular checks every 2-3hr D. Make sure the client has a warm blanket covering the cast
B. Check that one finger fits between the cast and leg RATIONALE: It is not uncommon for casts to loosen as swelling subsides, but that shouldn't be an issue 2hr after application C- perform hourly during first 24hr after application D- leave uncovered to allow thorough air drying of the plaster
A nurse is reviewing the lab results of a client who has cirrhosis. Which of the following lab values should the nurse expect? A. Decreased prothrombin levels B. Elevated bilirubin level C. Decreased ammonia level D. Elevated albumin level
B. Elevated bilirubin level RATIONALE: A- increased C- increased D- decreased
A nurse is caring for a client who has chronic glomerulonephritis with oliguria. Which of the following findings should the nurse identify as a manifestation of chronic glomerulonephritis? A. Metabolic alkalosis B. Hyperkalemia C. Increased hemoglobin D. Hypophosphatemia
B. Hyperkalemia RATIONALE: Client's with chronic glomerulonephritis can experience hyperkalemia because kidney failure results in decreased excretion of potassium
A nurse is providing teaching to a client who has CKD and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching? A. I should take calcium supplements so the medication will work better in my system B. I am taking this medication to increase my energy level C. This medication can cause my BP to drop D. I will not need to restrict protein in my diet while taking this medication
B. I am taking this medication to increase my energy level RATIONALE: Used to increase hematocrit in clients with anemia C- INCREASES BP D- restrict protein as needed for CKD, but is not related to this med
A nurse is evaluating a client who has a new diagnosis of type 1 DM. Which of the following client statements indicates the client is successfully coping with the change? A. It is just easier to let my partner administer my insulin B. I used to never worry about my feet. Now, I inspect my feet every day with a mirror. C. I'm concerned I won't be able to read my blood sugar level because the screen is so small D. I know a lot of people who have diabetes and do not take insulin. I wish I didn't have to
B. I used to never worry about my feet. Now, I inspect my feet every day with a mirror.
A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. I will wash the ink markings off the radiation area after each treatment B. I will use my hands rather than a washcloth to clean the radiation area C. I will be able to be out in the sun 1 month after my radiation treatments are over D. I will use a heating pad on my neck if it becomes sore during the radiation therapy
B. I will use my hands rather than a washcloth to clean the radiation area RATIONALE: gently wash the radiation area with hands using warm water and mild soap to prevent further irritation A- the ink markings designate the exact radiation area and should not be removed until radiation tx is complete C- avoid direct sunlight during radiation tx and for 1 year following the conclusion of therapy D- avoid exposure to heat
A nurse is providing teaching to a client who has IBS. Which of the following instructions should the nurse include in the teaching? A. Take an antacid before meals and at bedtime B. Increase fiber intake to at least 30g/day C. Drink ginger tea daily D. Consume no more than 1L of water per day
B. Increase fiber intake to at least 30g/day
A nurse is caring for a client who is experiencing supraventricular tachycardia Upon assessing the client, the nurse observes the following findings: HR 200/min, BP 78/40, RR 30/min. Which of the following actions should the nurse take? A. Defibrillate the client's heart B. Performed synchronized cardioversion C. Begin cardiopulmonary resuscitation D. Administer lidocaine IV bolus
B. Performed synchronized cardioversion RATIONALE: this is the expected action for supraventricular tachycardia A- only for V-tach or V-fib C- only if not breathing D- only for ventricular dysrhythmia
A nurse is teaching a young adult client how to perform testicular self-examination. Which of the following instructions should the nurse include? A. Compare both testicles by examining them simultaneously B. Roll each testicle between the thumb and fingers C. Perform testicular self examination before a warm bath or shower D. Perform self-examination of the testicles every 2 weeks
B. Roll each testicle between the thumb and fingers RATIONALE: roll each testicle horizontally between thumbs and fingers to feel for any lumps deep in the center of the testicle; perform during a warm bath or showing; perform once a month
A home health nurse is assigned to a client who was recently discharged from a rehab center after experiencing a right-hemispheric stroke. Which of the following neurologic deficits should the nurse expect to find when assessing this client? SATA A. Expressive aphasia B. Visual spatial deficits C. Left hemianopsia D. Right hemiplegia E. One-sided neglect
B. Visual spatial deficits C. Left hemianopsia E. One-sided neglect RATIONALE: A- left sided stroke= language D- this would be from a left hemispheric stroke
A nurse is providing discharge teaching to a client who has hypothyroidism and is receiving levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? A. Gingko biloba B. Glucosamine C. Calcium D. Vitamin C
C. Calcium RATIONALE: Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine; avoid taking calcium within 4hr of levothyroxine
A nurse is caring for a client who is on bed rest and has a new prescription for enoxaparin subcutaneous. Which of the following actions should the nurse take? A. Monitor the client's INR daily B. Expel air bubbles when using a prefilled syringe C. Inject the medication into the anterolateral abdominal wall D. Massage the injection site after administration
C. Inject the medication into the anterolateral abdominal wall
A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? A. Obtain ABGs B. Administer propofol to the client C. Instruct the client to allow the machine to breathe for them D. Disconnect the machine and manually ventilate the client
C. Instruct the client to allow the machine to breathe for them RATIONALE: use least restrictive intervention first
A nurse in a provider's office is assessing a client who has migraine HA's and is taking feverfew to prevent HA's. The nurse should identify that which of the following client medications interacts with feverfew? A. Metoprolol B. Bupropion C. Naproxen D. Atorvastatin
C. Naproxen RATIONALE: Naproxen & feverfew both impair platelet aggregation and place the client at risk for bleeding
A nurse is caring for a client who is 12hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? A. Maintain adduction of the client's legs B. Encourage range of motion of the hip up to a 120° angle C. Place a pillow between the client's legs D. Keep the client's hip internally rotated
C. Place a pillow between the client's legs RATIONALE: A- ABDUCTION B- no more than 90° to prevent dislocation D- NO, this can lead to hip dislocation
A nurse is planning to provide discharge teaching for the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include? A. Keep the client's personal care items in the bathroom B. Keep the overhead lights on in the client's bedroom while the client is sleeping C. Remind the client to scan their complete range of vision during ambulation D. Secure the client's extension cords under carpeting
C. Remind the client to scan their complete range of vision during ambulation
A nurse is assessing a client following the administration of magnesium sulfate 1g via IV bolus. For which of the following adverse effects should the nurse monitor? A. Hyperreflexia B. Increased BP C. Respiratory paralysis D. Tachycardia
C. Respiratory paralysis RATIONALE: this is a life threatening adverse rxn of magnesium sulfate
A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure? SATA A. Flat jugular veins B. A Glasgow Coma Scale score of 15 C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing
C. Sleepiness exhibited by the client D. Widening pulse pressure E. Decerebrate posturing
A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatment for chronic kidney disease. Which of the following interventions should the nurse include in the plan? A. Remind the client that dialysis treatments are not difficult to incorporate into daily life B. Inform the client that dialysis will result in a cure C. Tell the client that it is possible to return to similar previous levels of activity D. Begin health promotion during the first dialysis treatment
C. Tell the client that it is possible to return to similar previous levels of activity RATIONALE: help the client develop realistic goals and activities to have a productive life D- begin health and lifestyle teaching in the first weeks after starting the dialysis tx once the client feels better physically and emotionally
A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing? A. WBC count 6,000 B. BMI 24 C. Urine output 25mL/hr D. Albumin 4g/dL
C. Urine output 25mL/hr RATIONALE: UO reflects fluid status. Inadequate UO can indicate dehydration, which can delay wound healing D- this reflects nutritional status and is within the expected reference range of 3.5-5 (same as potassium)
A nurse is planning care for a client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which of the following actions should the nurse include in the client's plan of care? A. Collect and place the client's urine or feces in a biohazard bag B. Limit the client's ambulation to their own room C. Wear a lead apron while providing care to the client D. Limit visitors to 1hr/day
C. Wear a lead apron while providing care to the client RATIONALE: A- with sealed implants, the client's excretions are not radioactive; use standard precautions B- client requires bedrest in a private room and needs to avoid excessive movements while in bed to prevent dislodging the implant D- Visitors should be limited to 30min/day and should stay 6ft away from the client
A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching? A. You will still have the urge to void B. You can apply an aspirin tablet to the pouch to reduce odor C. You should cut the opening of the skin barrier 1/8 in wider than the stoma D. You should use a moisturizing soap when washing the skin around the stoma
C. You should cut the opening of the skin barrier 1/8 in wider than the stoma RATIONALE: to minimize irritation of the skin from exposure to urine A- during the procedure, the client's bladder is removed and the ureters are brought to the skin surface of the abdomen to form a stoma, from which the urine will flow into an external ostomy bag, therefore the client will NOT have the urge to void
A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analgesic for pain management. Which of the following information should the nurse include in the teaching? A. It is an expected effect to sleep through the day when taking this medication B. Your constipation will be lessened as you develop a tolerance to the medication C. You should void every 4hrs to decrease the risk of urinary retention D. If you experience ringing in your ears, your dose will need to be reduced
C. You should void every 4hrs to decrease the risk of urinary retention
A nurse is an ED is reviewing the provider's prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which of the following prescriptions should the nurse expect? A. Apply ice to the clients puncture wounds B. Initiate corticosteroid therapy for the client C. Keep the client's leg above heart level D. Administer an opioid analgesic to the client
D. Administer an opioid analgesic to the client RATIONALE: A- apply ice for a bite from a black widow spider B- initiate antihistamines & corticosteroids for bee and wasp stings C- should be AT heart level, not above or below it
A nurse in an ICU is assessing a client who has a TBI. Which of the following findings should the nurse identify as a component of Cushing's triad? A. Hypotension B. Tachypnea C. Nuchal rigidity D. Bradycardia
D. Bradycardia RATIONALE: The others are hypertension and widened pulse pressure
A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? A. Amylase B. Alkaline phosphatase C. Bilirubin D. Calcium
D. Calcium RATIONALE: a client with pancreatitis is expected to have decreased calcium & magnesium levels due to fat necrosis A- increased B- increased C- increased
A nurse is caring for a client who is undergoing hemodialysis to treat end stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the. nurse plan to administer? A. Epoetin alfa B. Furosemide C. Captopril D. Calcium carbonate
D. Calcium carbonate RATIONALE: Hypocalemia is a manifestation of ESKD and an adverse effect of dialysis
A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment? A. Decreased T cells B. Increased creatinine clearance C. Increased eosinophils D. Decreased viral load
D. Decreased viral load
A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48hr prior to cardioversion? A. Enoxaparin B. Metformin C. Diazepam D. Digoxin
D. Digoxin RATIONALE: Cardiac glycosides, such as digoxin are withheld prior to cardioversion. These meds can increase ventricular instability and put the client at risk for v-fib after the synchronized countershock of cardioversion
A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement? A. Place a padded tongue blade at the clients bedside B. Keep the side rails lowered on the client's bed C. Maintain the client's bed at the hip level or above D. Ensure that the client has a patent IV
D. Ensure that the client has a patent IV
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following lab values should the nurse report to the provider? A. Potassium 4 B. WBC 10,000 C. Hct 45% D. Hgb 8
D. Hgb 8 RATIONALE: indication of postoperative hemorrhage or anemia; normal range is 12-16
A nurse is caring for a client who has a potassium level of 3. Which of the following assessment findings should the nurse expect? A. Positive Trousseau's sign B. 4+ deep tendon reflexes C. Deep respirations D. Hypoactive bowel sounds
D. Hypoactive bowel sounds RATIONALE: hypokalemia decreases smooth muscle contraction in the GI tract leading to decreased peristalsis A- this is regarding hypocalcemia B- DTR's are used to monitor magnesium levels C- shallow respirations occur with hypokalemia due to respiratory muscle weakness
A nurse is caring for a client who has anorexia, low grade fever, night sweats and a productive cough. Which of the following actions should the nurse take first? A. Obtain a sputum sample B. Administer antipyretics C. Provide hand hygiene education D. Initiate airborne precautions
D. Initiate airborne precautions
A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Insert a padded tongue blade B. Apply oxygen C. Restrain the client D. Loosen restrictive clothing
D. Loosen restrictive clothing RATIONALE: B- supplemental oxygen is not usually necessary
A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions? A. Neutralizing gastric acid B. Reducing the growth of ulcer-causing bacteria C. Coating the stomach lining D. Suppressing gastric acid production
D. Suppressing gastric acid production RATIONALE: Omeprazole= PPI
An older adult client is brought to an ED by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? A. Serum sodium level 145 B. Forearm skin tents when pinched C. Respiratory rate decreased D. Urine specific gravity 1.045
D. Urine specific gravity 1.045 RATIONALE: Normal range is 1.005-1.030, this is above the expected range and indicates a decrease in urine volume and an increase is osmolarity A- in normal range B- unreliable in older adult clients because of changes to skin elasticity C- would increase with dehydration
A nurse is providing teaching for a female client who has recurrent UTI's. Which of the following information should the nurse include in the teaching? A. Take tub baths daily B. Drink at least 1L of fluid daily C. Wear underwear made of nylon D. Void before and after intercourse
D. Void before and after intercourse
A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include? A. Change the dressing every 72hr B. Immobilize the hand with a pressure dressing C. Take pain medication 30min after changing the dressing D. Wrap fingers with individual dressings
D. Wrap fingers with individual dressings RATIONALE: to allow for functional use of the hand while healing occurs; the nurse should also instruct the client to perform ROM exercises to each finger every hr while awake
A nurse in a provider's office is caring for a client who requests sildenafil to treat erectile dysfunction. Which of the following statements should the nurse make? A. You might need to take a stool softener while taking this medication B. You will not be able to use sildenafil if you have diabetes C. You will need to limit your caffeine intake if you start taking sildenafil D. You will not be able to use sildenafil if you are taking nitroglycerin
D. You will not be able to use sildenafil if you are taking nitroglycerin RATIONALE: Can cause vasodilation and significant prolonged hypOtension
What should be done if you are performing a cardiac assessment on a client who had a MI 2 days ago and you hear a murmur?
Listen with the client on their left side so it can be heard more clearly
What 2 rhythms is defibrillation used on?
V-tach or V-fib