MED SURG CMS
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching? - "It is common for one breast to be larger than the other..," - "It is common for the skin on my breasts to dimple." - "| will perform breast exams the day my period begins." - "| will perform breast exams every other month."
"It is common for one breast to be larger than the other..,"
A nurse is caring for a client in hospice care who is dying. The client's partner expresses concern that the client is sleeping more than in the previous week. Which of the following is an appropriate response by the nurse? - "Encourage your partner to wake up to interact with family members." - "Sitting quietly near the bedside can provide comfort and support." - "| will call the provider to discuss your concerns." - "| can ask the provider to prescribe a medication that will minimize drowsiness."
"Sitting quietly near the bedside can provide comfort and support."
A nurse is caring for a young adult client who has testicular cancer and expresses concern about their sexual function following an orchiectomy of the involved testicle. Which of the following responses should the nurse make? - "I'm sure any partner will understand that you have no control over this." - "There are other ways to express intimacy besides intercourse." - "You should focus on recovering from your cancer right now." - "The removal of a single testicle will not prevent you from having an erection."
"The removal of a single testicle will not prevent you from having an erection."
A nurse is reinforcing teaching about immunizations with an older adult client. Which of the following instructions should the nurse include? - "You should receive the live, attenuated influenza vaccine every other year." - "You should receive the hepatitis A vaccine every 10 years." - "You should receive the human papillomavirus vaccine." - "You should receive one dose of the pneumococcal vaccine."
"You should receive one dose of the pneumococcal vaccine."
A nurse is reinforcing teaching with a client who has diabetes mellitus about reducing the risk for a stroke. Which of the following statements by the client indicates an understanding of the teaching? - "Having a total cholesterol level below 200 mg/dL increases my risk for a stroke." - "My provider might prescribe a glucocorticoid regimen to decrease my risk for a stroke." - "My risk for a stroke increases if my HbA1c level is 6 percent or less." - "| can decrease my risk for a stroke by losing excess weight."
"| can decrease my risk for a stroke by losing excess weight."
A nurse is collecting data from a client who has hyperthyroidism and is taking propylthiouracil. Which of the following statements by the client indicates the medication is effective? - "| no longer feel nervous." - "| no longer take a stool softener." - "| have less oily skin." - "| continue to lose weight."
"| no longer feel nervous."
A nurse is reinforcing teaching about a transcutaneous electrical nerve stimulation (TENS) unit for a client who has a herniated intervertebral disk. Which of the following statements by the client indicates an understanding of the teaching? - "| will need to charge the TENS unit for 2 hours each day." - "The TENS unit administers a continuous dose of pain medication." - "| should adjust the TENS unit until | feel a tingling sensation." - "The TENS unit should be applied at least 6 inches from the actual site of my pain." .
"| should adjust the TENS unit until | feel a tingling sensation."
A nurse is reinforcing teaching about foot care with a client who has diabetes mellitus. Which of the following client statements indicates understanding of the teaching? - "| should put lotion between my toes every day to prevent dryness and cracking." - "| should apply a heating pad to my feet every night to help with circulation." - "| should use my wrist to test the temperature of the water before bathing." - "| should round the corners of my toenails with a nail file to prevent ingrown nails."
"| should apply a heating pad to my feet every night to help with circulation."
A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements by the client indicates an understanding of the teaching? O "| should clean around the stoma with moisturizing soap." O "| should avoid broccoli and chewing gum." O "| should decrease the amount of fresh fruit in my diet." O "| should place an aspirin in the pouch to eliminate odor.
"| should avoid broccoli and chewing gum."
A nurse is reinforcing teaching with a client about menopause. Which of the following statements by the client indicates an understanding of the teaching? - "| will need hormone replacement therapy for the rest of my life." - "| should expect to have an increased risk for breast cancer." - "The use of black cohosh will decrease vaginal bleeding." - "| should use a vaginal douche to prevent dryness."
"| should expect to have an increased risk for breast cancer."
A nurse is reinforcing teaching with a client who is to begin taking lansoprazole. Which of the following statements by the client indicates an understanding of the teaching? - "| should chew the capsule thoroughly." - "| should report episodes of diarrhea." - "| should take the medication following a meal." - "| should expect the medication to cause indigestion."
"| should report episodes of diarrhea."
A nurse is reinforcing teaching with a client who has ovarian cancer and will receive chemotherapy through a peripherally inserted central catheter (PICC) line. Which of the following statements by the client indicates an understanding of the teaching? - "| will wear an arm immobilizer to prevent dislodgement of this device. " - "| will monitor my temperature for fever while | have this device." - "It's okay to get the device wet when i shower." - "| should pull the dressing away from the insertion site when | change it."
"| will monitor my temperature for fever while | have this device."
A nurse is reinforcing discharge teaching with the partner of a client who requires tracheal suctioning. Which of the following statements by the partner indicates an understanding of the teaching? - "| will suction the mouth before inserting the suction catheter into the tracheostomy." - "| will suction for less than 15 seconds while inserting the suction catheter." - "| will set the suction pressure dial between 80 and 120." - "| will wrap the suction catheters in a clean towel to be used again at a later time."
"| will set the suction pressure dial between 80 and 120."
A nurse is reinforcing teaching with a client about heart disease prevention. Which of the following client statements indicates an understanding of the teaching? - "| will increase my dairy intake by drinking whole milk with every meal." - "| will exercise by walking twice a week for 25 minutes." - "| will try to maintain my blood pressure around 116/72." - "| will improve my LDL cholesterol by raising it from 100 to 130."
"| will try to maintain my blood pressure around 116/72."
A nurse is reinforcing teaching with a client who has a new ileostomy. Which of the following statements by the client indicates an understanding of the teaching? - "| will need to empty the bag every 4 to 6 hours." - "| will use moisturizing soap to clean around the stoma before applying the bag." - "| will use a skin sealant before | apply the bag." - "| will cut the wafer opening one-fourth of an inch larger than the stoma."
"| will use a skin sealant before | apply the bag."
A nurse is preparing to administer subcutaneous enoxaparin. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
*Check the medication administration record to verify the client's allergies. *Ensure an air bubble is present in the prefilled enoxaparin syringe. *Locate the injection site 5 cm (2 in) to the right or left of the umbilicus. Pinch clean skin at the injection site and dart the needle into the skinfold at a 90° angle. *Slowly inject the medication into the site without aspirating
A nurse is preparing to assist with the administration of peritoneal dialysis to a client. In which order should the nurse take the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
*Record the client's vital signs. *Measure the client's abdominal girth. *Prime the client's catheter tubing with dialysate solution. *Infuse dialysate solution into the client's peritoneal cavity. *Open the client's drainage tubing after 10 min of dwell time
A nurse is reinforcing teaching about risk factors for colorectal cancer with a client. Which of the following risk factors should the nurse include in the teaching? (Select all that apply.) - High-fiber diet - Physical inactivity - History of diabetes mellitus - Family history of colorectal cancer . - Age over 50 years
- History of diabetes mellitus - Family history of colorectal cancer . - Age over 50 years
A nurse is assisting with the transfer of a client from a medical-surgical unit to an intensive care unit following a change in status. Which of the following information should the nurse include in the transfer documentation? (Select all that apply.) - Primary health problem - Scheduled times for dressing changes - Current medication prescriptions | - Number of family members who have visited - Admission vital signs from 1 week ago
- Primary health problem - Scheduled times for dressing changes - Current medication prescriptions
A nurse is preparing to administer diphenhydramine 25 mg PO every 6 hr to an older adult client who has rhinitis. The amount available is diphenhydramine syrup 12.5 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
10 mL
A nurse is caring for a client who is hypoxic and has a prescription for oxygen therapy at 40% via a venturi mask. Which of the following masks should the nurse identify as a venturi mask?
?
A nurse is collecting data from a client who had a left hemispheric stroke. Which of the following findings should the nurse report to the provider immediately - Difficulty speaking - A change in pupil size - Right-sided weakness - Inability to follow direction
A change in pupil size
A nurse is receiving a change-of-shift report about the care of four clients. Which of the following clients should the nurse see first? ' - A client who displays increased confusion over the past 4 hr | - A client who has a blood glucose level of 128 mg/dL - A client who has a blood pressure of 138/88 mm Hg ' - A client who reports a pain level of 4 on a scale of 0 to 10
A client who displays increased confusion over the past 4 hr
A nurse is prioritizing care for four clients following a change-of-shift report. Which of the following clients should the nurse attend to first? - A client who has diverticulitis and a temperature of 38.3° C (100.9° F) - A client who has a prescription for a sputum specimen to be obtained before breakfast - A client who sustained a head injury 2 days ago and has a decreased level of consciousness - A client who has Alzheimer's disease and requires assistance to the bathroom
A client who has Alzheimer's disease and requires assistance to the bathroom
An occupational health nurse is interpreting the results of a tuberculin skin test for a group of clients who received the test 48 hr ago. Which of the following clients should the nurse identify as having a positive test result? - A client whose injection site has an elevated area measuring 15 mm (0.6 in) - A client whose injection site is scabbed - A client whose injection site is firm and measures 3 mm (0.1 in) - A client whose injection site is ecchymotic
A client whose injection site has an elevated area measuring 15 mm (0.6 in)
A nurse is monitoring a client who has a nasogastric (NG) tube set to intermittent suction to manage a mechanical intestinal obstruction. Which of the following findings should the nurse report? - Potassium 4.2 mEq/L - BUN 16 mg/dt - Abdominal distention - Bile-colored drainage from the NG tube
Abdominal distention
A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect? - Peripheral edema - Decreased respirations - Absent bowel sounds - Polyuria
Absent bowel sounds
A nurse is reinforcing teaching about decreasing the risk of osteoporosis to a client who is postmenopausal. Which of the following instructions should the nurse include? - Limit vitamin D intake. - Increase daily intake of vitamin E. - Add a weight-bearing exercise regimen. - Take calcium carbonate supplements once a day with breakfast.
Add a weight-bearing exercise regimen.
A nurse is caring for a client who is experiencing a generalized tonic-clonic seizure. Which of the following actions should the nurse take? - Apply restraints to the client. - Insert a tongue blade into the client's mouth. - Administer an IV bolus of lorazepam. - Place the client in the prone position.
Administer an IV bolus of lorazepam.
A nurse is caring for a client who has COPD with copious secretions. Which of the following actions should the nurse take? - Place the client in a prone position. - Administer high-flow oxygen. - Limit fluid intake. - Perform postural drainage.
Administer high-flow oxygen.
A nurse is performing tracheostomy care for a client who has a chronic tracheostomy. Which of the following actions should the nurse take? - Suction the client for 20 seconds with each pass. - Apply suction pressure while inserting the catheter into the trachea. - Sanitize around the stoma with povidone-iodine. - Allow space for one finger to be placed under the tube ties.
Allow space for one finger to be placed under the tube ties.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first? - Administer a glycerin suppository. - Ambulate the client in the hallway. - Offer an analgesic medication. - Request the client to be NPO
Ambulate the client in the hallway.
) A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take? - Raise all four side rails while the client is in bed. - Apply a motion sensor mat to the client's bed. - Leave the television on in the client's room. - Move the overbed table away from the bed.
Apply a motion sensor mat to the client's bed.
A nurse is reinforcing discharge teaching with a client who had an excisional biopsy of the left breast. Which of the following instructions should the nurse include? - Refrain from wearing a bra for 10 days after the surgery. - Apply an ice pack to the incision site to treat discomfort. - Expect numbness to last for up to 4 months. - Use bandages to absorb bleeding at the incision site.
Apply an ice pack to the incision site to treat discomfort.
A nurse is contributing to the plan of care for a client who reports difficulty eating due to chronic arthritis. Which of the following interventions should the nurse include in the plan? - Apply foam handles to the client's eating utensils. - Obtain a referral for physical therapy. - Have an assistive personnel feed the client. - Ask the provider for a prescription for a pureed diet.
Apply foam handles to the client's eating utensils.
A nurse enters a client's room and sees smoke coming from the bathroom. Which of the following actions should the nurse take first? - Activate the fire alarm system. - Use a fire extinguisher at the source of the smoke. - Assist the client to a nearby common area. - Close the doors to the room and to the bathroom
Assist the client to a nearby common area.
A nurse is reinforcing teaching about the care of a client who has tinea corporis with a newly licensed nurse. Which of the following should the nurse include in the teaching? - Avoid direct contact. - Administer a broad-spectrum antibiotic. - Place on airborne precautions. - Isolate for 24 hr after lesions appear
Avoid direct contact.
A nurse is reinforcing discharge teaching about dietary changes with a client who has a new colostomy. Which of the following foods should the nurse recommend? - Asparagus - Bananas - Grapes - Broccoli
Bananas
A nurse is reinforcing teaching about dietary modifications to help control blood pressure with a client who has hypertension. Which of the following food choices by the client indicates an understanding of the teaching? - A ham sandwich on rye bread - Broiled cod with broccoli - Beef bouillon with crackers - Pork sausage with sautéed peppers
Broiled cod with broccoli
A nurse is collecting data from an older adult client. Which of the following findings should indicate to the nurse that the client has a bladder infection? - WBC count 9,000/mm - Changed mental status - Temperature 37.3° ¢ (99.1° F) - Diminished reflexes
Changed mental status
A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care? - Offer oral fluids every 4 hr. - Check for neck vein distention. - Limit oral fluids prior to bedtime. - Monitor pulse pressure every 6 hr
Check for neck vein distention.
A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care? - Advise the client about increased dry mouth. - Check the client for increased hypopigmentation under the patch. - Monitor the client for weight loss. - Inform the client of the adverse effect of diarrhea.
Check the client for increased hypopigmentation under the patch.
) A nurse is reinforcing teaching with a client who has gastroesophageal reflux disease. Which of the following dietary instructions should the nurse include? - Chew food thoroughly. - Use a straw when drinking liquids. - Drink carbonated beverages with meals. - Limit meals to three per day with no snacking in between.
Chew food thoroughly.
A nurse is assisting with the care of a client who has a closed-chest tube drainage system. Which of the following actions should the nurse take? - Replace the unit when the drainage chamber is full. - Clamp the tube for 30 min every 8 hr. - Pin the tubing to the client's bed sheets. - Monitor for at least 150 mL of drainage every hour.
Clamp the tube for 30 min every 8 hr.
A nurse is caring for a client who has cancer and has a WBC count of 4,000/mm°. Which of the following actions should the nurse take? - Cleanse the client's toothbrush with hydrogen peroxide. - Instruct the client to use a disposable razor to shave. - Decrease the client's protein intake. - Encourage the client to eat unpasteurized dairy products.
Cleanse the client's toothbrush with hydrogen peroxide.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following information should the nurse include when documenting in the electronic medical record? - Incision healing well - Client status unchanged throughout shift - Abdominal wound dry, without redness - Client received an adequate amount of fluid
Client status unchanged throughout shift
A nurse is collecting data from a client who is African-American. Which of the following areas should the nurse check to determine the presence of pallor? - Antecubital space - Pinna of the ear - Abdomen - Conjunctiva ??
Conjunctiva ??
A nurse is caring for a client who is experiencing muscle spasms and has a new prescription for an aquathermia pad. Which of the following actions should the nurse take? - Use safety pins to secure the pad in place. - Fill the pad with sterile water. - Apply the pad for 45 min at a time. - Cover the pad prior to use.
Cover the pad prior to use.
A nurse is collecting data from a client who is 2 days postoperative following a colon resection. Which of the following findings indicates the need for nursing intervention? - Mild abdominal pain when coughing 30 min after receiving pain medication - Dark brown drainage in the NG tube - Serosanguineous drainage on the wound dressing - Oxygen saturation 95%
Dark brown drainage in the NG tube
A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take? - Provide the client with small-handled adaptive utensils. - Arrange for an assistive personnel to feed the client. - Describe the food placement as though the plate were a clock. - Discourage conversations during the client's mealtime.
Describe the food placement as though the plate were a clock.
A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement? - Encourage the client to ambulate with a staff member. - Isolate the client in their room. - Apply bilateral wrist restraints to the client. - Administer a prescribed oral dose of trazodone to the client.
Encourage the client to ambulate with a staff member.
A nurse is caring for a client who is in skin traction. Which of the following actions should the nurse take? - Loosen the ropes of the pulleys when repositioning the client in bed. - Inspect the client's skin every 12 hr for signs of breakdown. - Ensure the weights hang freely from the client's bed. - Maintain 6.8 kg (15 Ib) of weight for the client's skin traction
Ensure the weights hang freely from the client's bed.
A nurse is caring for a client who has a prescription for a sequential compression device (SCD). Which of the following actions should the nurse take when applying the SCD? - Ensure two fingers fit between the leg and the sleeve. - Wrap excess tubing to the side of each leg. - Ensure pressure of the device is at 25 mm Hg. - Place each sleeve under each leg with the opening at the calf.
Ensure two fingers fit between the leg and the sleeve.
A nurse is caring for a client who has been admitted with Addison's disease. For which of the following laboratory findings should the nurse plan to monitor and report to the provider? - Glucose 55 mg/dL - Potassium 3.8 mEq/L - Sodium 140 mEq/L - BUN 15 mg/d
Glucose 55 mg/dL
A nurse is caring for a client who has diabetes mellitus. Which of the following laboratory results should the nurse report to the provider? - Glycosylated hemoglobin 5.2% - Urine positive for ketones - Urine negative for bilirubin - Fasting blood glucose 70 mg/dL
Glycosylated hemoglobin 5.2%
A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care? - Offer artificial saliva frequently. - Add honey to sweeten fruit smoothies. - Heat food before serving. - Provide three large meals daily.
Heat food before serving.
A nurse is collecting data from a client who has gastroenteritis with diarrhea and vomiting. Which of the following laboratory values should alert the nurse that the client is at risk for fluid volume deficit? - Hematocrit 56 mg/dl - Creatinine 1.1 mg/dL - Sodium 140 mEq/L - Potassium 4.5 mEq/L
Hematocrit 56 mg/dl
A nurse is caring for a client who is 8 hr postoperative following a left hip arthroplasty. Which of the following laboratory values indicates the nurse should notify the provider? - BUN 18 mg/dt - Potassium 3.6 mEq/L - Blood glucose 98 mg/dL - Hemoglobin 8.6 g/d
Hemoglobin 8.6 g/d
A nurse is collecting data about immunizations from a 65-year-old client who has no identified risk factors for disease. The nurse should identify the client's need for which of the following immunizations? - Inactivated poliovirus - Herpes zoster - Human papilloma virus - Measles, mumps, and rubella
Herpes zoster
A nurse is preparing to obtain a postprandial blood glucose level from a client who has diabetes mellitus. Which of the following actions should the nurse take? - Apply the first drop of blood to the test strip. - Clean the client's finger with hexachlorophene. - Prick the central tip of the client's finger. - Hold the client's finger in a dependent position.
Hold the client's finger in a dependent position.
A nurse is assisting with the care of a postoperative client who is receiving a unit of packed RBCs. Which of the following manifestations should the nurse recognize as an indication of a septic reaction to the blood transfusion? - Hypertension - vomiting - Distended neck veins - Polyuria
Hypertension
A nurse working in a provider's office is caring for a client who received penicillin G potassium 15 min ago to treat strep throat. Which of the following is the priority finding the nurse should report to the provider? - Nausea - Hypotension - Abdominal pain - Arthralgia
Hypotension
A nurse is reinforcing teaching about environmental modifications in the home with a family member of a client who has Alzheimer's disease. Which of the following information should the nurse include in the teaching? - Leave the television on. - Install locks at the top of doors. - Schedule alternate caregivers. - Place throw rugs on the floor.
Install locks at the top of doors.
A nurse is preparing a client for a colposcopy following an abnormal Papanicolaou (Pap) test. Which of the following actions should the nurse take? - Place the client in the Sims' position. - Reinforce teaching that the procedure involves dilation of the cervix. - Insert a tampon following the procedure. - Instruct the client to avoid sexual intercourse until the cervix is healed
Instruct the client to avoid sexual intercourse until the cervix is healed
A nurse is caring for a client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take when assisting the client with feeding? - Offer the client sticky foods such as peanut butter. - Instruct the client to place their chin to their chest when swallowing. - Place food on the affected side of the client's mouth. - Position the client upright for 5 min after eating.
Instruct the client to place their chin to their chest when swallowing.
A charge nurse is observing a newly licensed nurse care for a client who is at risk for falls. Which of the following findings should the nurse identify as a risk factor for falls? - Instructs the client to wear their own socks to the bathroom - Keeps the client's bed in the low position - Positions the bedside table close to the client - Attaches the call light to the side rail of the client's bed
Instructs the client to wear their own socks to the bathroom
A nurse is assisting with the plan of care for a client who requires contact precautions. Which of the following interventions should the nurse include in the plan? - Keep a stethoscope at the client's bedside for the duration of her hospital stay. - Wear an N95 mask when entering the room. - Use an alcohol swab to clean the temperature probe before removing it from the room. - Remove personal protective equipment immediately after leaving the client's room
Keep a stethoscope at the client's bedside for the duration of her hospital stay.
A nurse is collecting data from a client who began taking captopril 2 days ago. Which of the following findings should the nurse report to the provider immediately? - Lip swelling - Dizziness - Joint aches - Metallic taste
Lip swelling
A nurse is reinforcing teaching with a client who is starting to take metformin extended release. Which of the following instructions should the nurse include in the instructions? - Monitor blood glucose while taking this medication. - Chew the medication before swallowing - Expect muscle pain while taking this medication. - Take the medication with breakfast.
Monitor blood glucose while taking this medication.
A nurse is caring for a client who has diabetic neuropathy of the lower extremities and has a new prescription for a heating pad. The prescription reads, "Apply to the left foot for 20 min." Which of the following actions should the nurse take? - Complete Semmes-Weinstein monofilament testing following treatment. - Apply the heating pad as prescribed by the provider. - Clarify the prescription with the provider. - Observe the skin 10 min after the start of treatment
Observe the skin 10 min after the start of treatment
A nurse is caring for a client who has Parkinson's disease. The client displays difficulty using utensils while eating at mealtime. For which of the following interdisciplinary team members should the nurse recommend a referral? - Recreational therapist - Occupational therapist - Physical therapist - Speech therapist
Occupational therapist
A nurse is contributing to the plan of care for a client who has disuse syndrome following cast removal from a lower extremity. Which of the following referrals should the nurse include in the plan of care? - Dietitian - Herbalist - Occupational therapist - Social worker
Occupational therapist
A nurse is caring for an older adult client who has heart failure. Which of the following findings should the nurse report to the provider? - Urinary output of 1,000 mL in 12 hr - Potassium level 4.5 mEq/L - Paco2 55 mm Hg - Chest x-ray showing cardiomegaly
Paco2 55 mm Hg
A nurse is caring for a client who has returned to the unit following a cardiac catheterization using a femoral approach. Which of the following methods should the nurse use to monitor for complications? - Check the client's blood pressure while the client lies supine, sits, and stands. - Palpate the client's brachial pulses and compare bilaterally. - Check for jugular vein distention while the client is supine. - Palpate the client's pedal pulses and compare bilaterally.
Palpate the client's pedal pulses and compare bilaterally.
A nurse is collecting data from a client who has a newly placed colostomy. Which of the following findings should indicate to the nurse the client has accepted their new altered body image? - Denies feelings of sadness about the ostomy - Prefers not to look at the stoma site - Accepts that sexual activity will decrease - Participates in performing ostomy care
Participates in performing ostomy care
A nurse is reinforcing teaching with a client about increasing her intake of fiber. Which of the following foods should the nurse encourage the client to eat? - Cheese - Pears - Yogurt - Eggs
Pears
A nurse is assisting in the care of a client whose cardiac monitor suddenly displays ventricular tachycardia. Which of the following is the priority nursing action? - Determine palpable pulse. - Begin chest compressions. - Perform immediate defibrillation. - Provide pulmonary ventilation.
Perform immediate defibrillation.
A nurse is reinforcing teaching with a client who is postoperative following a tympanoplasty. Which of the following information should the nurse include? - Drink fluids through a straw. - Plan to shampoo hair in 1 week. - Resume exercising in 10 days. - Close mouth when sneezing.
Plan to shampoo hair in 1 week.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider? - Ammonia 55 mcg/dl - Bilirubin 1.0 mg/dL - Platelets 60,000/mm - Aspartate aminotransferase 34 units/L
Platelets 60,000/mm
A nurse is collecting data from a client prior to administering hydrochlorothiazide for mild hypertension. Which of the following findings should the nurse identify as a contraindication to administering the medication? - 2+ pedal edema - Potassium 2.8 meQ/L - Allergy to shellfish - History of GERD
Potassium 2.8 meQ/L
A nurse is reviewing a client's medical record. Which of the following findings is the priority for the nurse to report? - Urine output 200 mL/8 hr - A client's rating of ear pain as 5 on a scale from 0 to 10 - Potassium level 6.2 mEq/L - Abnormal hepatoiminodiacetic acid (HIDA) scan
Potassium level 6.2 mEq/L
A nurse is reviewing the laboratory report of a client who has cancer and is experiencing anorexia. Which of the following laboratory values should indicate to the nurse that the client is experiencing malnutrition? - Prealbumin 10.5 mg/dL - Hematocrit 45% - WBC count 6,000/mm - BUN 15 mg/d
Prealbumin 10.5 mg/dL
A nurse is assisting with the development of the plan of care for a client who has a low WBC count. Which of the following interventions should the nurse include? - Encourage the client to eat a low-protein diet. - Prohibit fresh flowers in the client's room. - Obtain the client's rectal temperature every 4 hr. - Initiate airborne precautions for the client.
Prohibit fresh flowers in the client's room.
A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. Which of the following actions should the nurse take? - Request a prescription for IV fluids. - Ask the client's health care surrogate for permission to withhold nourishment. - Provide regular oral care for the client with a moist swab. - Explain the importance of oral hydration to the client
Provide regular oral care for the client with a moist swab.
A nurse is reinforcing teaching with a client who is taking oxybutynin. The nurse should tell the client that the medication will have the following effects? - Relaxes the muscles of the bladder - Increases venous return to the heart - Relaxes the muscles of the colon - Increases tissue perfusion in the lungs
Relaxes the muscles of the bladder
A nurse is caring for a client who is 24 hr postoperative following abdominal surgery. The client received an opioid analgesic 1 hr ago and now reports a pain level of 2 on a scale of 0 to 10. Which of the following actions should the nurse take? - Reposition the client. - Administer an additional dose of pain medication. - Maintain the client on bed rest. - Apply a warm, moist compress to the incision area.
Reposition the client.
A nurse is reviewing the medical record of a client who reports his urine is red-orange. The nurse should identify which of the following medications can cause this adverse effect? - isoniazid - Metoprolol - Furosemide - Rifampin
Rifampin
A nurse is caring for an older adult client who has stomatitis due to poorly fitting dentures. Which of the following actions should the nurse take? - Rinse the client's mouth twice daily with an alcohol-based mouthwash. - Increase the client's fluid intake to 2,000 mL daily. - Offer the client hot beverages to drink. - Provide the client with a high-protein diet.
Rinse the client's mouth twice daily with an alcohol-based mouthwash.
A nurse is obtaining a medication history from a client who is to start taking nitroglycerin for chest discomfort with activity. Which of the following medications should the nurse instruct the client to avoid taking within 24 hr of using nitroglycerin? - Atorvastatin - Metformin - Sildenafil - Meprazole
Sildenafil
A nurse is caring for a client who has bladder cancer and is 1 day postoperative following placement of an ileal conduit. Which of the following information should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) - Platelet count - Stoma color - Bowel sounds - Urine output
Stoma color
A nurse is reviewing the results of a client's fecal occult blood screening test. Which of the following findings from the client's history should the nurse identify as potentially causing a false-positive result? - The client consumed citrus juice 3 days before the test. - The client has a history of breast cancer. - The client takes ibuprofen for headaches. - The client had a hemorrhoidectomy 1 year ago.
The client takes ibuprofen for headaches.
A nurse is collecting data from a client who had a long arm cast applied 2 hr ago. Which of the following findings of the affected extremity should the nurse report to the provider immediately? - The client reports increased pain at the area of the fracture. - The client reports severe itching under the cast. - The client's capillary refill is 3 seconds. - The client's fingers are cool to the touch.
The client's fingers are cool to the touch.
A nurse is collecting data from a client who underwent a thyroidectomy 4 hr ago. Which of the following client findings indicates a complication of the procedure? - Tingling of the fingers - Report of sore throat - Serosanguineous drainage on the dressing - Soreness at the incision site
Tingling of the fingers
A nurse is reinforcing teaching with a client about colorectal cancer. Which of the following risk factors should the nurse include? - Biliary colic - Duodenal ulcer - Chronic constipation - Ulcerative colitis
Ulcerative colitis
A nurse is reinforcing teaching with a female client who has a history of urinary tract infections. Which of the following instructions should the nurse include? - Use a vaginal douche once a week. - Empty the bladder at least every 6 hr. - Increase milk consumption to make the urine more alkaline. - Urinate before and after sexual intercourse.
Urinate before and after sexual intercourse.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? - Empty urine from the drainage bag every 12 hr. - Secure the catheter tubing to the client's thigh. - Apply topical antimicrobial ointment to the client's urinary meatus following catheter care. - Use clean technique to collect urine specimens from the drainage system.
Use clean technique to collect urine specimens from the drainage system.
A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema? - Keep both arms below the level of the client's heart. - Limit range-of-motion exercises with the affected arm. - Obtain blood pressure readings using the client's right arm. - Use the client's left arm to obtain blood samples.
Use the client's left arm to obtain blood samples.
A nurse is caring for a client who has a prescription for propranolol for the treatment of atrial fibrillation. Which of the following actions should the nurse take? - Request a dosage increase if the apical heart rate is less than 60/min. - Administer the medication with an antacid. - Instruct the client to expect increased hair growth. - Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
Withhold the medication if the systolic blood pressure is less than 90 mm Hg.
A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
apical pulse ?
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication that the client should receive diphenhydramine? - Pulmonary congestion - urticaria - vomiting - Jugular vein distention
urticaria
