Foundation Exam 2 Questions
A client taking newly prescribed gabapentin for persistent neuropathic pain reports dizziness. What is the best nursing response? A. "This is a common side effect of gabapentin and will decrease with use." B. "Stop taking the medication and contact the health care provider." C. "The dizziness is caused by the neuropathic pain, not the medication." D. "The dizziness is likely from another medication, not the gabapentin."
A
A client who has been hiking in the woods comes to the ED with urticaria. After administering an antihistamine as prescribed, what teaching does the nurse provide? A.Avoid outdoor activity. B.Use a sauna to relieve pain. C.Apply tea bags to the lesions. D.Consume 1 to 2 alcoholic beverages.
A
A client who is HIV positive and receiving combination antiretroviral therapy tells the nurse she is now pregnant. Which drug does the nurse expect to be suspended during this patient's pregnancy? A. Abacavir B. Darunivir C. Tripanavir D. Raltegravir
A
How does the corresponding increase in carbon dioxide levels that occurs when arterial pH drops assist in maintaining acid-base balance? A. Carbon dioxide loss through exhalation can raise arterial pH levels. B. Carbon dioxide retention during exhalation can lower arterial pH levels. C. Carbon dioxide is a base that can convert free hydrogen ions into a neutral substance. D. Carbon dioxide is a buffer that can bind free hydrogen ions and form a neutral substance.
A
In the early postoperative phase, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 mm Hg B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing
A
The client on combination antiretroviral therapy calls the nurse to report that he is on vacation and the bag with his drugs was accidentally left on the airplane, so he missed all of yesterday's dosages. What action does the nurse recommend? A. "Take today's dosages as normally prescribed and continue to follow your therapy program." B. "Don't worry. Unless you miss your drugs for 4 days consecutively, there is not a problem." C. "Take double doses of the drugs for the next 2 days and do not have sex for at least 4 days." D. "Go to the nearest emergency department and have an immediate blood test for assessment of viral load."
A
The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she didn't like the way she felt."
A
The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pinprick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present
A
The nurse is caring for a hospitalized client on a medical marijuana plan (MMP) who asks for the nurse to administer cannabis. What is the appropriate nursing action? A."You must administer your own cannabis." B."Nurses need special training to give cannabis." C."I will be right back as soon as I gather up the supplies." D."I can take you to the smoking area to provide the drug."
A
The nurse is teaching a class on pain management strategies. Which client statement requires additional teaching? A. "Persistent pain is a warning in my body that alerts the sympathetic nervous system." B. "Acute pain has a quick onset and is usually isolated to one area of my body." C. "My frozen shoulder causes musculoskeletal or somatic pain." D. "Nociceptive pain follows a normal and predictable pattern."
A
When answering the call light for a client on bedrest, the nurse finds the client's visitor unconscious on the floor with no discernable pulse and not breathing. The nurse estimates that at least 2 minutes have passed since the client's light first came on. What is the nurse's priority action? A. Initiate CPR with chest compressions. B. Perform an abdominal thrust maneuver. C. Assess the visitor for the presence of a head injury. D. Ask the client what event led up to the visitor's fall.
A
Which documentation will the nurse record for a client who had a total knee replacement 2 days ago and reports sharp pain at the surgical site? A. Reports acute pain at the surgical site. B. Persistent pain reported around the surgical site. C. Experiences neuropathic pain near the surgical site. D. Discomfort has progressed to chronification of pain.
A
Which precaution is a priority for the nurse to teach a client prescribed the gene therapy combination of ivacaftor/tezacaftor in order to prevent harm from this therapy? A. Examine your skin and the whites of your eyes daily for a yellow appearance. B. Apply ice to the injection site for 30 minutes after each dose to keep bleeding to a minimum. C. Wait at least 15 minutes after using other inhaled drugs before inhaling this drug combination. D. Go to your primary health care provider immediately if you develop a fever or other signs of infection.
A
Which statement about the genetics of cystic fibrosis is true? A. Recessive disorder affecting chloride transport B. Recessive disorder affecting alpha1-antitrypsin levels C. Dominant disorder inhibiting alveoli formation D. Dominant disorder increasing production of interleukin-5
A
Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed? A. "When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank." B. "Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself." C. "Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen." D. "If my shortness of breath becomes worse or if I have chest pain I will contact my primary health care provider immediately."
A
While applying compression stockings and pneumatic compression devices, a client questions the purpose of these devices. What is the appropriate nursing response? A."These will help to prevent blood clots." B."They make your legs feel more comfortable." C."These prevent skin breakdown from immobility." D."The use of these right after surgery makes is easier to start to ambulate."
A
To advocate for safe transition in care, for which process will the nurse advocate? Select all that apply. A.Providing patient history and current assessment information B.Communicating updates and changes in condition C.Verbally verifying that the receiving nurse understands the report D.Using a standardized hand-off communication tool E.Encouraging the receiving nurse to interrupt to ask questions during report
A, B, C, D
A client who was bitten by a spider develops cellulitis of the left lower arm. What assessment findings will the nurse expect when caring for this client? Select all that apply. A. Fever B. Pain C. Redness around the spider bite D. Warmth in the affected arm E. Swelling of the affected arm
A, B, C, D, E
The nurse takes a history for a client admitted to the hospital. Which factors in the nursing history indicate that the client is at risk for infection? Select all that apply. A. Diabetes mellitus type 2 for 20 years B. 52-pack year history of cigarette smoking C. Admitted from a long-term care facility D. Has a history of multiple urinary tract infections E. Is 84 years of age
A, B, C, D, E
Which statements by assistive personnel indicate understanding regarding infection control measures needed to care for a client who has possible Clostridium difficile infection? Select all that apply. A. "I'll wear an isolation gown when providing direct care." B. "I'll wear gloves when providing direct care." C. "I'll wear a mask each time I enter the client's room." D. "I'll use a hand sanitizer when I can't wash my hands." E. "I'll wear goggles to protect my eyes."
A, B, D
The nurse teaching clients precautions to use with drug therapy for primary pulmonary arterial hypertension (PAH) instructs the female clients to use two reliable forms of contraception while taking which drugs? Select all that apply. A. ambrisentan B. bosentan C. epoprostenol D. iloprost E. macitentan F. riociguat G. selexipag H. sildenafil I. tadalafil J. treprostinil
A, B, E, F
The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor <3 seconds C. Blood pressure 160/100 mm Hg D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment
A, C, D
The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.
A, C, D, E
When preparing to discharge a client who has a history of pediculosis, what teaching will the nurse provide? Select all that apply. A. Nits can be removed with a fine-tooth comb. B. Parasites eventually die off without treatment. C. Wash bed linens in hot water to remove lice and eggs. D. Lice can live on clothing items and any surface that is covered by fabric. E. Lice can infest any place on the body with hair, including eyelashes and axillae.
A, C, D, E
A client who has been taking the four first-line drugs for tuberculosis treatment for a month reports all of the following changes. Which changes would cause the nurse to collaborate quickly with the health care provider? Select all that apply. A. Blurry vision B. Constipation C. Difficulty sleeping D. Nausea when drinking beer E. Red-tinged urine F. Sunburn with minimal sun exposure G. Yellowing of the sclera
A, G
A client has been receiving the same dose of an intravenous opioid for 2 days to manage postsurgical pain. The client reports that the drug is no longer controlling the pain. What does the nurse suspect? A. There is likely a history of addiction. B. Tolerance to the opioid is developing. C. Physical dependence is developing. D. The client is opioid naïve.
B
A client is diagnosed with C. difficile infection. What nursing action is the priority for the client? A. Provide meticulous skin care. B. Place the client on Contact Precautions. C. Give the client an antipyretic medication. D. Encourage the client to drink extra fluids.
B
A client newly diagnosed with stage I nonsmall cell lung cancer (NSCLC) who is getting ready for curative surgery asks the nurse whether the oncologist might consider this new drug he has seen on television, pembrolizumab, instead of surgery. What is the nurse's best response? A. "This drug will only work on those lung cancers that have the right target and your tumor does not have it." B. "This drug is approved for use in clients whose lung cancer has metastasized not for early-stage cancers." C. "Why would you want to take a drug for months when you may be cured by surgery alone?" D. "You need to talk about this with your oncologist and your surgeon."
B
A client who underwent radical neck surgery for head and neck cancer 5 days ago tells the nurse that he is worried because his right shoulder is lower than the left and does not go back into place when he tries to raise it. What is the nurse's best response? A. "I will notify the surgeon right away because some leftover tumor must be pressing on the nerve." B. "The nerve to the shoulder was removed during surgery. Physical therapy will help you to use other muscles to regain some motion." C. "This problem is not related to your surgery. If it persists after you go home you will need to see your primary health care provider about it." D. "Your time under anesthesia was long and you are not yet fully recovered. It is likely you will regain full motion in that shoulder by the end of the week."
B
A client who was in a skiing accident has been diagnosed with paraplegia. Which nursing intervention is appropriate to address the client's psychosocial needs? A.Contact a spiritual leader to talk with the client. B.Perform a thorough assessment to determine the client's needs. C.Ask the family to give the client extra support during this difficult time. D.Request a prescription for antidepressants from the health care provider.
B
A client with COPD has just been reclassified for disease severity from a GOLD 2 to a GOLD 3. Which client statement about changes in management or lifestyle indicate to the nurse that more teaching is needed to prevent harm? A. "This year I will get the pneumonia vaccination in addition to a flu shot." B. "Now I will try to rest as much as possible and avoid any unnecessary exercise." C. "Maybe drinking a supplement will help me retain weight and have more energy." D. "Perhaps using a spacer with my metered dose inhaler will make the drug work better."
B
A client with a history of chronic obstructive pulmonary disease is admitted with shortness of breath. Which nursing action is appropriate? A. Do not administer oxygen. B. Administer oxygen via Venturi mask. C. Use nasal cannula to administer high flow oxygen. D. Administer oxygen at 6L per simple face mask.
B
A nurse assessing an older adult client with pneumonia notes the client is now confused and the oxygen saturation has dropped since the last assessment 1 hour ago from 90% to 84%. The nurse also notes the respiratory rate has increased from 26 to 32. What is the nurse's best first action? A. Encourage the client to use the incentive spirometer hourly. B. Increase her O2 flow rate by 2 L and reassess in 5 minutes. C. Increase the flow rate of the IV antibiotic. D. Document the changes as the only action.
B
A nurse interviewing an 82-year-old, somewhat confused client who is becoming a nursing home resident today asks the client's daughter if she would consent for the client to receive an influenza vaccination today. The daughter replies "she had one 2 years ago and doesn't need another." What is the nurse's best response? A. "Your mother is older now and is more fragile, so she should have one this year, too, as a booster." B. "The virus causing influenza often changes each year, and a new influenza vaccination is needed every flu season." C. "The "flu shot" she had 2 years ago will still protect her this year, but if she has not had a previous pneumonia vaccination, she should have one now." D. "If you are worried that she is afraid to have an injection, we could use the nasal mist vaccination this year."
B
As the nurse evaluates a laboratory report for a client scheduled for surgery, which finding requires nursing intervention? A.Hemoglobin 10.4 g/dL B.Serum potassium 2.5 mEq/L C.Serum sodium level 145 mEq/L D.Fasting blood glucose 110 mg/dL
B
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first? A. Immediately notify either the Rapid Response Team or the thoracic surgical resident. B. Assist the client to a side-lying position and reassess the water seal chamber for bubbling. C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system. D. No action is needed because these responses are normal for the first postoperative day after lobectomy.
B
The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-to-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."
B
The nurse is preparing to discharge a client who has been prescribed an opioid analgesic after knee replacement surgery. What teaching will the nurse provide? A.Do not take with grapefruit juice B.Eat plenty of foods that are high in fiber C.Take entire prescription even if pain is gone D.Only take 1-2 pills to avoid becoming addicted
B
The nurse on a postoperative unit is caring for four clients. Which client does the nurse discuss with the surgeon that may benefit from PCA? A.37-year old who broke both arms in skiing accident B.47-year old who underwent bariatric surgery for weight loss C.59-year-old with temperature of 103° following surgery for bowel obstruction D.66-year old with cognitive deficit who had hip replacement
B
The surgery for a client scheduled for an 8:00 a.m. procedure is delayed until 11:00 a.m. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 a.m. as originally prescribed. B. Adjust the administration time to be given at 10:00 a.m. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.
B
When caring for a client with MRSA, which precaution will the nurse institute? A.Droplet B.Contact C.Airborne D.Neutropenic
B
When caring for four clients, which client does the nurse identify at highest risk for infection? A.20-year-old with stomach pain B.31-year-old with chronic kidney disease C.44-year-old using a 10-day steroid taper 62-year-old with history of prostate hyperplasia
B
Which dietary change does the nurse suggest for the client who has esophageal candidiasis? A. "Avoid drinking alcoholic beverages." B. "Eat soft, cool food such as pudding and smoothies." C. "Limit your intake of fluid to no more than 1 L daily." D. "Increase your intake of cooked leafy green vegetables."
B
Which part of the HIV infection process is disrupted by the antiretroviral drug class of entry inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane
B
Which specific information will the nurse teach to the client with eosinophilic asthma newly prescribed benralizumab therapy? A. Avoid breathing into the inhaler or getting it wet. B. The drug can only be given by a health care professional. C. Do not chew, crush, or split the tablet containing this drug. D. The drug must be taken at bedtime because of the extreme drowsiness it causes.
B
Which activities can the nurse postpone or eliminate for the client who has extreme fatigue today? Select all that apply. A. Administering prescribed drug therapy B. Ambulating in the hall C. Culturing suspected infectious drainage D. Performing pulmonary hygiene E. Performing oral care F. Providing a complete bed bath G. Teaching about nutrition therapy
B ,F, G
Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply. A. The client has a fever. B. Crackles and wheezes are heard on auscultation. C. The client requests that suctioning be performed. D. Suctioning was last performed more than 3 hours ago. E. The tracheostomy dressing has a moderate amount of serosanguineous drainage. F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.
B, C
Which adults are at higher risk for development of active tuberculosis? Select all that apply. A. 21-year-old college student living in a dorm at a Canadian university B. 38-year-old with HIV-III (AIDS) who stopped taking antiretroviral therapy C. 42-year-old injection drug user D. 50-year-old Guatemalan migrant farm worker E. 62-year-old incarcerated in prison for 20 years F. 70-year-old with moderate to severe chronic obstructive pulmonary disease (COPD)
B, C, D, E
Which information is most relevant for the nurse to teach a client about CPAP therapy for OSA? Select all that apply. A. Avoid alcoholic beverages or drugs that make you sleepy within 3 hours of bed time. B. Clean the mask device daily. C. Ensure your mask device fits tightly enough to prevent air leaks. D. Keep open flames such as candles out of the room when CPAP is in use. E. Seal the mask edges to your face with petroleum jelly. F. Use only sterile water in the humidifier tank. G. Use the CPAP during all sleep periods, especially in bed. H. Do not share your mask or tubing system with others.
B, C, G, H
The nurse has discussed rehabilitation goals with a client who is recovering from a mild stroke. Which client statement demonstrates understanding of the rehabilitation process? Select all that apply. A."I am glad that I will be cured through rehabilitation." B."Rehab will help me work to my fullest potential." C."This will keep me from having more strokes." D."I'll expect to see occupational and physical therapists." E."Rehabilitation will focus on my physical needs only."
B, D
In preparing a client with head and neck cancer (pharyngeal) for radiation therapy, which side effects does the nurse teach the client to expect? Select all that apply. A. Scalp and eyebrow alopecia B. Taste sensation loss or changes C. Bloody and purulent sinus drainage D. Increased risk for skin breakdown E. Moderate weight gain F. Increased risk for cavities G. Gastroesophageal reflux H. A persistent blue tinge to the skin and mucous membranes around the mouth
B, D, F
A client shows the nurse two pictures of the same lesion, taken 1 month apart. Which assessment finding requires nursing intervention? A. The light pink color of the lesion is the same in both photographs. B. The lesion has almost disappeared by the time of the second photograph. C. The lesion borders have expanded and are shaped differently in the second picture. D. The lesion's well-approximated margins and size look no different in either photograph.
C
A client with COPD has all of the following ABG changes from earlier today. Which change alerts the nurse to take immediate action to prevent harm? A. pH from 7.21 to 7.20 B. HCO3- remains the same at 31 mEq/L C. Paco2 from 45 mm Hg to 68 mm Hg D. Pao2 from 88 mm Hg to 86 mm Hg
C
A client with a history of COPD is brought to the ED with respiratory depression. What acid-base imbalance does the nurse anticipate? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
C
A client with a large, irregularly shaped mole on the upper chest expresses concern about the cosmetic appearance of the lesion. What is the priority nursing intervention? A. Refer to a dermatologic health care provider. B. Ask if there are any other lesions that are bothersome. C. Perform a head-to-toe skin assessment and document the findings. D. Teach about the importance of avoiding excessive sun exposure and tanning beds.
C
A client with severe angioedema and tongue swelling from a drug allergy has stridor and an oxygen saturation of 60%. For which type of respiratory support does the nurse prepare? A. Nasal CPAP B. Tracheotomy C. Cricothyroidotomy D. Endotracheal intubation
C
A nursing home client who has completed a 2-week course of antibiotics for bacterial pneumonia asks whether he can go out to a restaurant to celebrate his grandson's high school graduation if he uses a wheelchair. What is the nurse's best response? A. "No, going out now before you have recovered your strength can cause a relapse of the pneumonia." B. "No, the risk that you could spread this disease to other people is much too high." C. "Yes, if you want to and feel that you could tolerate a couple of hours of sitting." D. "Yes, if you agree to wear a face mask to prevent spreading droplets."
C
The SpO 2 of a client receiving oxygen therapy by nasal cannula at 6 L/min has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to improve gas exchange before reporting the change to the primary health care provider? A. Tighten the straps on the nasal cannula B. Increase the oxygen flow rate to 8 L/min C. Check the tubing for kinks, leaks, or obstructions D. Check to determine whether the oxygen delivery system is adequately humidified
C
The handgrasp strength of a client with metabolic acidosis has diminished since the previous assessment 1 hour ago. What is the nurse's best first action? A. Measure the client's pulse and blood pressure B. Apply humidified oxygen by nasal cannula C. Assess the client's oxygen saturation D. Notify the Rapid Response Team
C
The nurse is caring for a client who has been on biologic therapy for plaque psoriasis. Which assessment finding requires immediate nursing intervention? A. Increased itching B. Temperature of 100°F C. Presence of new plaques on leg D. Expression of impaired self-image
C
The nurse is conducting a handwashing refresher session. For which situation will the the nurse remind all staff that cleansing hands with an alcohol-based hand rub is appropriate? A.After using the bathroom B.To cleanse visibly soiled hands C.After handing oral medications to a client D.After caring for a client with Clostridium difficile
C
The spouse of a 78-year-old client who was discharged to home 1 day ago after hospitalization for seasonal influenza calls to report the fever has returned and is now 103.4°F (39.7°C). What is the nurse's primary concern for this client? A. The client may not be taking the prescribed antiviral drug correctly B. A second strain of influenza is likely C. Pneumonia may be present D. The client may be dehydrated
C
Upon removing a dressing from a wound, the nurse notices a strong odor. What is the appropriate nursing action? A.No action is necessary at this time. B.Notify the health care provider of a possible wound infection. C.Clean the wound and reassess for presence of infection. D.Culture the wound and anticipate an order for antibiotics.
C
What is the most important question for the nurse to ask before giving the first dose of fosamprenavir to a client newly prescribed this drug? A. "Do you have glaucoma or any other problem with your eyes?" B. "Do you take medications for a seizure disorder?" C. "Are you allergic to sulfa drugs?" D. "Are you a diabetic?"
C
When performing a medication reconciliation for a newly admitted client before planned abdominal surgery, the nurse notes that the client is prescribed salmeterol and fluticasone daily for asthma control. What is the priority action for the nurse to take regarding this information to prevent harm? A. Record and display the information in a prominent place within the client's medical record. B. Ask the client how long the drugs have been prescribed and how well the asthma is controlled. C. Collaborate with the surgeon to arrange for continuation of this therapy in the perioperative period. D. Ensure that parenteral forms of these drugs are prescribed for use while the client remains NPO after surgery.
C
Which action does the nurse take care to avoid while suctioning a client's tracheostomy tube? A. Twirling the catheter while applying suction B. Applying suction only when withdrawing the catheter C. Performing oral suctioning before suctioning the artificial airway D. Lubricating the suction catheter with sterile saline before insertion
C
Which client statement regarding treatment of a skin infection requires intervention by the nurse? A. "I am not going to share my clothes with anyone else." B. "Because I am over 60, I am going to get the shingles vaccine." C. "It is important to keep my skin very moist, so I will use lotion." D. "If I get a fever or chills, I will contact my primary health care provider."
C
Which normal physiologic process contributes most to the need for acid-base balance? A. Continuous organ production of bicarbonate from carbonic acid B. Continuous alveolar exchange of oxygen and carbon dioxide C. Continuous metabolic production of free hydrogen ions D. Continuous kidney formation of urine from blood
C
Which part of the HIV infection process is disrupted by the antiretroviral drug class of protease inhibitors? A. Activating the viral enzyme "integrase" within the infected host's cells B. Binding of the virus to the CD4+ receptor and either of the two co-receptors C. Clipping the newly generated viral proteins into smaller functional pieces D. Fusing of the newly created viral particle with the infected cell's membrane
C
Which statement made by the client with stage HIV-III disease (AIDS) whose CD4+ T-cell count has increased from 125 cells/mm3 (0.2 × 109/L) to 400 cells/mm3 (0.2 × 109/L) indicates to the nurse that more teaching is needed? A. "Now my viral load is also probably lower." B. "I am so relieved that my drug therapy is working." C. "Although I am still HIV positive, at least I no longer have AIDS." D. "This change means I am less likely to develop an opportunistic infection."
C
The nurse is caring for a client who is to undergo surgery at 6:00 a.m. today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 mm Hg B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food or water since 9:00 p.m. last night
C, D
With which clients does the nurse remain alert for the possibility of metabolic alkalosis? Select all that apply. A. Client who has been NPO for 36 hours without fluid replacement B. Client receiving a rapid infusion of normal saline C. Client who has been self-managing indigestion with chronic ingestion of bicarbonate D. Client who has had continuous gastric suction for 48 hours E. Client having a sudden and severe asthma attack F. Client with uncontrolled diabetes mellitus
C, D
The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."
C, D, E
The nurse is caring for a client with a traumatic brain injury who is currently unconscious. Which rehabilitative nursing intervention is appropriate? Select all that apply. A.Consult with a recreational therapist. B.Perform active range of motion exercises. C.Delegate hygiene care to assistive personnel. D.Perform turning and repositioning every 1-2 hours. E.Collaborate with the RDN to assess nutrition needs.
C, D, E
A client has just come to the floor after undergoing inner maxillary fixation for a mandibular fracture with wiring of the jaws. As the nurse raises the head of the bed, the client starts to vomit a large amount of liquid vomitus. What is the nurse's priority action? A. Administer the prescribed antiemetic by the intravenous or rectal route. B. Immediately notify the surgeon, the anesthesiologist, or the rapid response team. C. Cut the wires holding his jaws together, and carefully remove them from the mouth. D. Reposition the client to the side and suction the mouth with a large-bore catheter.
D
An older adult client with a long history of congestive heart failure is being treated for a pressure injury over the coccyx that is 4 cm wide and 5 cm long, with eschar present. Which technique does the nurse anticipate will be used to remove the necrotic tissue? A.Surgical removal B.Biologic dressing C.Continuous dry gauze dressing D.Dressings along with a topical enzyme preparation
D
What teaching will the nurse provide when educating about carbon monoxide prevention? A. "Carbon monoxide is only dangerous if accompanied by fire." B. "Black smoke can be seen when carbon monoxide is in the air." C. "Your skin will turn a blue color if you have carbon monoxide poisoning." D. "Put carbon monoxide detectors in your home, because this is an odorless gas."
D
When making rounds, the nurse observes that a cognitively impaired client has a partial airway obstruction from inspissation. What is the nurse's priority action? A. Place the bed in reverse Trendelenburg position and apply humidified oxygen by nasal cannula. B. Check the flow sheet to assess for trends in the client's oxygen saturation patterns. C. Determine which assistive personnel (AP) provided this client's morning care today. D. Immediately provide complete oral care to this client.
D
When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."
D
Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy? A. Providing meticulous oral care every 8 hours B. Deflating the cuff for 15 minutes every 2 hours C. Feeding the client liquids rather than solid foods D. Maintaining cuff inflation pressure less than 25 cm H2O
D
Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately? A. The oxygen flow rate is set at 12 L/min. B. The exhalation ports are open during exhalation. C. The exhalation ports are closed during inhalation. D. The reservoir bag is not inflated during inhalation.
D
Which food, drink, or herbal supplement does the nurse teach the client taking tipranavir to avoid? A. Caffeinated beverages B. Grapefruit juice C. Dairy products D. St. John's wort
D
Which nursing action has the highest priority when caring for a client with any type of facial or laryngeal trauma? A. Managing pain B. Providing nutrition C. Assessing self-image D. Maintaining a patent airway
D
Which set of client arterial blood gas (ABG) values indicates to the nurse that some mechanisms are working to partially compensate for an acid-base imbalance? A. pH 7.42; Pao2 92 mm Hg; CO2 41 mm Hg; HCO3 − 28 mEq/L (mmol/L) B. pH 7.46; Pao2 98 mm Hg; CO2 38 mm Hg; HCO3 − 30 mEq/L (mmol/L) C. pH 7.22; Pao2 60 mm Hg; CO2 80 mm Hg; HCO3 − 22 mEq/L (mmol/L) D. pH 7.29; Pao2 78 mm Hg; CO2 82 mm Hg; HCO3 − 36 mEq/L (mmol/L)
D
A client with primary pulmonary arterial hypertension (PAH) receiving treprostinil by continuous IV infusion now has a fever of 101.6°F (38.7°C). Which actions will the nurse perform to prevent harm? Select all that apply. A. Administer the prescribed antipyretic B. Ask the client whether a productive cough is present C. Apply oxygen by nasal cannula D. Culture the IV site E. Determine whether a durable power of attorney has been signed F. Increase the treprostinil flow rate G. Initiate a second IV access and administer prescribed antibiotic H. Place the client in protective isolation
D, F, G
Which statements about oxygen and oxygen therapy are true? Select all that apply. A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air. B. Clients must provide informed consent to receive oxygen therapy. C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease. D. In nonemergency situations, a health care provider's prescription is needed for oxygen therapy. E. Oxygen can explode when handled improperly. F. Oxygen is a beneficial element but can harm lung tissue. G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element. H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
D, F, H
