Med Surg CMS

B. 100 mL of red drainage

1. A PACU nurse is monitoring the drainage from a client's NG tube following abdominal surgery. Which of the following findings in the first postoperative hour should the nurse report to the provider? A. 200 mL of brown drainage B. 100 mL of red drainage C. 150 mL of serosanguineous drainage D. 75 mL of greenish-yellow drainage

D. Wears clean gloves when caring for the client

1. A charge nurse is observing a newly licensed nurse care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA). Which of the following observations of the newly licensed nurse indicates an understanding of infection control precautions? A. Remains 3 feet away from the client B. Wears an N95 mask when providing wound care C. Disposes of isolation gown outside of the client's room D. Wears clean gloves when caring for the client

C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash.

1. A charge nurse on a neurological unit is for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station? A. A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack. B. A client who has a headache following a grade 1 concussion. C. A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash. D. A client who has experienced brain death and is awaiting organ procurement.

B. A client who reports having fever, night sweats, and cough for 2 days.

1. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room? A. A client who has a compound fracture of the right femur. B. A client who reports having fever, night sweats, and cough for 2 days. C. An older adult client who was admitted with aspiration pneumonia. D. A client who has diabetes mellitus and is presenting with acute ketoacidosis.

D. A client who reports having fever, night sweats, and cough for 2 days.

1. A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room? A. A client who has diabetes mellitus and is presenting with acute ketoacidosis. B. An older adult client who was admitted with aspiration pneumonia. C. A client who has a compound fracture of the right femur. D. A client who reports having fever, night sweats, and cough for 2 days.

C. A DNR prescription will allow you to continue with your current treatment regimen.

1. A client who has a terminal illness asks the nurse, "If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?" Which of the following statements should the nurse provide to explain a DNR prescription? A. A DNR prescription means you will only receive pain medication for your treatments. B. A DNR prescription will limit your current treatment regimen. C. A DNR prescription will allow you to continue with your current treatment regimen. D. A DNR prescription will limit your ability to receive invasive procedures.

B. Request an interpreter during the initial assessment.

1. A client who is deaf and communicates using sign language is being admitted by a nurse who does not know sign language. Which of the following actions should the nurse take? A. Obtain a board that uses colored pictures as communication. B. Request an interpreter during the initial assessment. C. Familiarize themselves with commonly used signed language. D. Ask a family member to be present during the admission.

A. Severe, throbbing headache

1. A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor the client for which of the following manifestations? A. Severe, throbbing headache B. Hypotension C. Fever D. Cyanosis of the head and neck

C. Paresthesia

1. A home health nurse is assessing a client who has pernicious anemia. Which of the following is an expected manifestation that poses a risk to the client's safety? A. Loss of hearing B. Muscle wasting C. Paresthesia D. Changes in vision

A. "This can be part of your plan as long as your provider approves."

1. A home hospice nurse is caring for a client who has end-stage osteosarcoma and informs the nurse that they have been receiving acupuncture treatment to help with the pain. Which of the following responses should the nurse make? A. "This can be part of your plan as long as your provider approves." B. "This can be a good decision to help you meet your behavioral health needs." C. "It's important to avoid acupuncture since complementary therapy is not proven to help with end-stage care." D. "It's important that you choose the type of care that is most effective for you."

B. "We will respect what is important to you."

1. A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the client's and family's cultural beliefs? A. "You should limit discussing past events with the client." B. "We will respect what is important to you." C. "We will arrange all burial services." D. "Grieving should not be done in front of the client."

A. Turn the client on their side.

1. A nurse enters a client's room and observes the client having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Turn the client on their side. B. Perform a neurologic check. C. Obtain the client's vital signs. D. Notify the rapid response team.

A. "Did you decrease your insulin intake before you exercised?"

1. A nurse in a clinic is assessing a client who has type 1 diabetes mellitus. The client is diaphoretic, has a heart rate of 92/min, and reports palpitations. The client states, "I went for my morning run and feel exhausted." Which of the following responses should the nurse make? A. "Did you decrease your insulin intake before you exercised?" B. "It is normal to feel this way after a morning run." C. "Were you careful to not have carbohydrates after the run?" D. "It becomes easier when exercise is a routine."

B. Cough

1. A nurse in a provider's office is evaluating a client who has been taking lisinopril for hypertension. The nurse should identify which of the following findings as an adverse effect of this medication? A. Leukocytosis B. Cough C. Hypokalemia D. Bradycardia

C. Metabolic alkalosis

1. A nurse in an emergency department is caring for a client who is receiving treatment for excessive ingestion of antacids. The nurse should identify that this client is at risk for which of the following acid- base imbalances? A. Metabolic acidosis B. Respiratory alkalosis C. Metabolic alkalosis D. Respiratory acidosis

D. Dyspnea

1. A nurse in the PACU is caring for a client following a thyroidectomy. Which of the following findings should the nurse report to the provider? A. Dry cough B. Temperature 37.2° C (99° F) C. Serosanguineous drainage D. Dyspnea

B. Respiratory status

1. A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority? A. Surgical site B. Respiratory status C. Level of consciousness D. Pain level

A. Gently elevate the client's head and note any nuchal rigidity.

1. A nurse in the emergency department is evaluating a young adult client for bacterial meningitis. Which of the following actions should the nurse take as part of the focused assessment? A. Gently elevate the client's head and note any nuchal rigidity. B. Strike the client's patellar tendon with a percussion hammer and note any increase in response. C. Run a tongue blade on the outside of the client's sole and note any flaring of the toes. D. Tap the client's facial nerve and note any facial twitching.

B. Obtain an ECG.

1. A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first? A. Change dressings over the entrance and exit wounds. B. Obtain an ECG. C. Administer an opioid pain medication. D. Titrate IV fluids to maintain urine output at 75 mL/hr.

B. Blood pressure 90/50 mm Hg

1. A nurse in the emergency department is monitoring a client who is receiving dopamine to treat hypovolemic shock. Which of the following findings should the nurse identify as an indication for increasing the client's dopamine dosage? A. Heart rate 60/min B. Blood pressure 90/50 mm Hg C. Oxygen saturation 95% D. Respiratory rate 14/min

D. Weight loss of 1.8 kg (4lb) in the past 24 hr

1. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? A. Elevation in blood pressure B. Adventitious breath sounds C. Respiratory rate 24/min D. Weight loss of 1.8 kg (4lb) in the past 24 hr

C. Weight loss of 1.8 kg (4 lb) in the past 24 hours

1. A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective? A. Respiratory rate of 24/min B. Adventitious breath sounds C. Weight loss of 1.8 kg (4 lb) in the past 24 hours D. Elevation in blood pressure

C. Stop the infusion.

1. A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first? A. Administer oxygen to the client. B. Collect a urine sample. C. Stop the infusion. D. Check the client's vital signs.

A. Stool for occult blood

1. A nurse is admitting a client who has arthritic pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor? A. Stool for occult blood B. Fasting blood glucose C. Serum calcium D. Urine for white blood cells

B. Photophobia

1. A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect? A. Bradycardia B. Photophobia C. Petechiae on the chest D. Intermittent headache

D. Photophobia

1. A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect? A. Petechiae on the chest B. Bradycardia C. Intermittent headache D. Photophobia

A. Monitor vital signs at least every 4 hr.

1. A nurse is admitting a client who has neutropenia. Which of the following precautions should the nurse take? A. Monitor vital signs at least every 4 hr. B. Insert an indwelling urinary catheter. C. Change the client's linens three times a day. D. Place the client in a room with negative airflow.

B. Eggs

1. A nurse is asking a preoperative client about food allergies. Which of the following food allergies indicates a potential reaction to propofol? A. Shellfish B. Eggs C. Strawberries D. Avocados

C. Stridor

1. A nurse is assessing a client following exudation from a Ventilator. For which of the following findings should the nurse intervene immediately? A. Sore throat B. SaO2 92% C. Stridor D. Rhonchi

B. Laryngeal edema

1. A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response? A. Arrythmia B. Laryngeal edema C. Hypertension D. Fever

A. Laryngeal edema

1. A nurse is assessing a client following the administration of an initial dose of captopril. Which of the following findings indicates an anaphylactic response? A. Laryngeal edema B. Fever C. Hypertension D. Arrhythmia

**this is a picture, couldnt attach it**

1. A nurse is assessing a client for a positive Chvostek's sign following a thyroidectomy. Which of the following areas on the client's head should the nurse tap to assess the client for tetany?

D. Muscle twitching

1. A nurse is assessing a client who had a total thyroidectomy 4 hr ago. Which of the following findings should the nurse report? A. Neck stiffness B. Hoarseness C. Moderate serosanguineous drainage D. Muscle twitching

B. Infection

1. A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions? A. Skin breakdown B. Infection C. Neurogenic bladder D. Phlebitis

A. Alopecia

1. A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition? A. Alopecia B. Diplopia C. Oily skin D. Increased salivation

A. Heart rate 48/min

1. A nurse is assessing a client who has heart failure and a new prescription for metoprolol. Which of the following findings should the nurse identify as an adverse effect of the medication? A. Heart rate 48/min B. Temperature 36.3° C (97.3° F) C. Respiratory rate 10/min D. Blood pressure 138/76 mm Hg

A. Altered level of consciousness

1. A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? A. Altered level of consciousness B. Pupillary dilation C. Decorticate posturing D. Cheyne-Stokes respirations

C. Altered level of consciousness

1. A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status? A. Cheyne-Stokes respirations B. Pupillary dilation C. Altered level of consciousness D. Decorticate posturing

C. "I have a hard time with brushing my hair."

1. A nurse is assessing a client who has myasthenia gravis. Which of the following client statements should indicate to the nurse that the client needs a referral for occupational therapy? A. "I've been having problems with bladder control." B. "I have difficulty swallowing food." C. "I have a hard time with brushing my hair." D. "I would rather be in a wheelchair than use a walker to get around."

A. Pain occurs about 1 hr after eating.

1. A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse expect? A. Pain occurs about 1 hr after eating. B. Pain in the right lower quadrant. C. Reports of constipation. D. Eating food relieves pain.

B. Increase the elevation of the affected extremity.

1. A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take? A. Tie knots in the ropes near the pulleys to shorten them. B. Increase the elevation of the affected extremity. C. Remove one of the weights. D. Pull the client up in bed.

B. Pallor in the affected extremity

1. A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately? A. Bruising around the incisional site B. Pallor in the affected extremity C. Urine output 150 mL over 4 hr D. Temperature of 37.9° C (100.2° F)

C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation.

1. A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take? A. Apply a cold compress to the suprapubic area. B. Secure the urinary catheter to the upper left quadrant of the client's abdomen. C. Use 0.9% sodium chloride to perform an intermittent bladder irrigation. D. Encourage the client to urinate every 2 hr.

D. Neurovascular assessment

1. A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessment should be the nurse's priority? A. Morse Fall Risk scale B. Braden scale C. Pain assessment D. Neurovascular assessment

A. Naloxone

1. A nurse is assessing a client who is receiving morphine for pain and has a respiratory rate of 8/min and a blood pressure of 80/40 mm Hg. Which of the following medications should the nurse administer? A. Naloxone B. Protamine sulfate C. Acetylcysteine D. Flumazenil

B. Decrease in blood pressure

1. A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective? A. Respiratory rate of 16/min B. Decrease in blood pressure C. Increase in urinary output D. Blood glucose of 110 mg/dL

B. "You will need to follow up with your provider."

1. A nurse is assessing a client who received a purified protein derivative (PPD) skin test 48 hr ago and notes erythema with induration of 12 mm at the injection site. Which of the following instructions should the nurse provide to the client? A. "You will need to have the skin test annually." B. "You will need to follow up with your provider." C. "You will need to return in 48 hours for re-evaluation." D. "Your test will need to be repeated at this time."

D. Edema at the site

1. A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hr ago. Which of the following findings should the nurse expect? A. Severe pain at the site B. Blistering at the site C. Epithelialization at the site D. Edema at the site

B. Weight loss of 2.8 kg (6.2 b)

1. A nurse is assessing a female client who has pneumonia. The nurse should identify which of the following findings increases the client's risk of skin breakdown? A. Receiving bronchodilator medication B. Weight loss of 2.8 kg (6.2 b) C. Hemoglobin 17 g/dl (12 to 16 g/dL) D. Wearing an oxygen device

D. A client who is paraplegic

1. A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown? A. A client who has occasional urinary incontinence B. A client who has inadequate nutrition C. A client who has moderate Alzheimer's disease D. A client who is paraplegic

A. A client who has pancreatitis reports pain in the left shoulder.

1. A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? A. A client who has pancreatitis reports pain in the left shoulder. B. A client who has peritonitis reports generalized abdominal pain. C. A client who is postoperative reports incisional pain. D. A client who has angina reports substernal chest pain.

B. A client who has pancreatitis reports pain in the left shoulder.

1. A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain? A. A client who has peritonitis reports generalized abdominal pain. B. A client who has pancreatitis reports pain in the left shoulder. C. A client who has angina reports substernal chest pain. D. A client who is postoperative reports incisional pain.

A. Use an elevated toilet seat.

1. A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take? A. Use an elevated toilet seat. B. Log roll the client onto the operative side. C. Keep client's affected heel on the bed. D. Perform internal and external rotation exercises of hip.

A. Diphenhydramine

1. A nurse is caring for a client following a cardiac catheterization who has hives and urticaria following administration of IV contrast dye. Which of the following medications should the nurse plan to administer? A. Diphenhydramine B. Spironolactone C. Desmopressin D. Metoclopramide

A. Gentle bubbling in the water seal chamber

1. A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate? A. Gentle bubbling in the water seal chamber B. Drainage and warmth at tube insertion site C. Crackling sensation felt around tube insertion site D. Drainage output less than 70 mL/hr

A. Instruct the client not to bend the affected leg.

1. A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take? A. Instruct the client not to bend the affected leg. B. Restrict the client's fluid intake. C. Elevate the head of the client's bed to a 45° angle. D. Monitor the client's vital signs once every hour.

D. Instruct the client not to bend the affected leg.

1. A nurse is caring for a client immediately following a cardiac catheterization through the right femoral artery. Which of the following actions should the nurse take? A. Monitor the client's vital signs once every hour. B. Elevate the head of the client's bed to a 45° angle. C. Restrict the client's fluid intake. D. Instruct the client not to bend the affected leg.

B. Instruct the client to lie flat.

1. A nurse is caring for a client immediately following a lumbar puncture. Which of the following actions should the nurse take? A. Measure blood glucose every 2 hr. B. Instruct the client to lie flat. C. Instruct the client to expect tingling in their extremities. D. Limit the client's fluid intake.

C. Atropine

1. A nurse is caring for a client in the ICU. The client's ECG monitor tracing reveals sinus bradycardia and S-T segment elevation. The client reports shortness of breath and feeling dizzy and faint. Which of the following medications should the nurse administer? A. Lidocaine B. Digoxin C. Atropine D. Sotalol

B. Standard

1. A nurse is caring for a client who has AIDS. Which of the following isolation precautions should the nurse implement? A. Droplet B. Standard C. Airborne D. Contact

B. Fowler's

1. A nurse is caring for a client who has COPD and reports dyspnea. In which of the following position should the nurse place the client? A. Lateral recumbent B. Fowler's C. Trendelenburg D. Prone

B. Clamp the tubing to check for air leaks.

1. A nurse is caring for a client who has a chest tube in the pleural space. The nurse notices continuous bubbling in the water seal chamber of the client's drainage system. Which of the following actions should the nurse take? A. Raise the drainage system to the client's chest level. B. Clamp the tubing to check for air leaks. C. Empty the collection chamber. D. Gently squeeze the tubing to remove excess drainage.

B. "Your breathing pattern causes this."

1. A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? A. "Suction pressure that is too high causes this." B. "Your breathing pattern causes this." C. "This indicates a possible air leak." D. "This means your lung is fully re-expanded."

A. "Your breathing pattern causes this."

1. A nurse is caring for a client who has a chest tube. The client asks why the fluid in the water-seal chamber rises and falls. Which of the following statements should the nurse make? A. "This means your lung is fully re-expanded." B. "Your breathing pattern causes this." C. "Suction pressure that is too high causes this." D. "This indicates a possible air leak."

D. Desmopressin

1. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications? A. Epinephrine B. Furosemide C. Nitroprusside D. Desmopressin

B. Desmopressin

1. A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hr. The nurse should anticipate a prescription for which of the following IV medications? A. Furosemide B. Desmopressin C. Epinephrine D. Nitroprusside

A. Provide humidified oxygen.

1. A nurse is caring for a client who has a flail chest. Which of the following actions should the nurse take? A. Provide humidified oxygen. B. Administer antibiotic medication. C. Implement fluid restriction D. Administer acetaminophen orally.

B. Monitor the client's calorie intake daily.

1. A nurse is caring for a client who has a full thickness burn injury covering 15% of their body. Which of the following actions should the nurse take? A. Place the client on a low-carbohydrate diet. B. Monitor the client's calorie intake daily. C. Place the client on strict bed rest. D. Weigh the client once per week.

B. "Let's discuss your concerns about this procedure."

1. A nurse is caring for a client who has a herniated disc and is scheduled for a peripheral nerve block. The client tells the nurse. "I am afraid to have this procedure." Which of the following responses should the nurse make? A. "After this procedure, you will feel much better." B. "Let's discuss your concerns about this procedure." C. "Are you afraid of needles that will be used during the procedure?" D. "Tell me why you are scared to have this procedure."

B. Ondansetron

1. A nurse is caring for a client who has a history of chemotherapy-induced nausea and vomiting. Which of the following medications should the nurse administer prior to chemotherapy? A. Diphenhydramine B. Ondansetron C. Sertraline D. Methylprednisolone

A. "I can assist you with making a list of foods you like for the dietitian."

1. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for a dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care? A. "I can assist you with making a list of foods you like for the dietitian." B. "I understand that the dietary choices can seem overwhelming." C. "Managing your diabetes will require you to make accommodations." D. "The dietitian will provide you with the best food choices to manage your diabetes."

B. "I can assist you with making a list of foods you like for the dietitian."

1. A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, "I will have to eat whatever the dietitian tells me." Which of the following statements by the nurse encourages the client's involvement in their plan of care? A. "I understand that the dietary choices can seem overwhelming." B. "I can assist you with making a list of foods you like for the dietitian." C. "The dietitian will provide you with the best food choices to manage your diabetes." D. "Managing your diabetes will require you to make accommodations."

A. Initiate IV fluid replacement.

1. A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority? A. Initiate IV fluid replacement. B. Measure the client's urinary output. C. Administer insulin. D. Teach the client about manifestations of HHS

B. Use sterile technique for the procedure.

1. A nurse is caring for a client who has a peripherally inserted central catheter (PICC) for the administration of total parenteral nutrition (TPN). The transparent dressing over the insertion site requires replacement. Which of the following actions should the nurse take? A. Aspirate the catheter to check for a brisk blood return. B. Use sterile technique for the procedure. C. Cleanse the insertion site with hydrogen peroxide. D. Flush the TPN port with 20 mL of 0.9% sodium chloride.

D. Flush the catheter with a 0.9% sodium chloride solution after each use.

1. A nurse is caring for a client who has a peripherally inserted central catheter (PICC) line in her left forearm. The client is receiving an antibiotic via intermittent IV bolus every 12 hr. Which of the following actions should the nurse take in managing the client's PICC line? A. Change the transparent membrane dressing daily. B. Access the catheter using a non-coring needle. C. Maintain a continuous IV infusion through the PICC line. D. Flush the catheter with a 0.9% sodium chloride solution after each use.

B. Limit family member visits to 30 min per day.

1. A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take? A. Give the dosimeter badge to the oncoming nurse at the end of the shift. B. Limit family member visits to 30 min per day. C. Remove soiled linens from the room after each change. D. Apply a second pair of gloves before touching the client's implant if it dislodges.

D, B, A, C

1. A nurse is caring for a client who has a spinal cord injury and has developed autonomic dysreflexia. Identify the sequence of steps the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

C. Administer nitroglycerin.

1. A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first? A. Administer aspirin. B. Measure blood pressure. C. Administer nitroglycerin. D. Initiate IV access.

A. Administer nitroglycerin

1. A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first? A. Administer nitroglycerin B. Administer aspirin C. Measure blood pressure D. Initiate IV access

C. Decreased anxiety

1. A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective? A. Emesis of 250 mL B. Increased respiratory rate to 26/min C. Decreased anxiety D. Decreased urinary output

D. Decreased anxiety

1. A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective? A. Increased respiratory rate to 26/min B. Emesis of 250 mL C. Decreased urinary output D. Decreased anxiety

C. Decreased anxiety

1. A nurse is caring for a client who has acute heart failure and received morphine intravenously 30 minutes ago. Which of the following findings should the nurse identify as an indication that the medication was effective? A. Decreased urinary output B. Emesis of 250 mL C. Decreased anxiety D. Increased respiratory rate to 26/min

A. Palpable thrill

1. A nurse is caring for a client who has an arteriovenous graft. Which of the following findings indicates adequate circulation of the graft? A. Palpable thrill B. Absence of a bruit C. Normotensive blood pressure D. Dilated appearance of the graft

D. "I will tell your provider that you do not want to take this medication."

1. A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

B. Instruct visitors to remain 6 feet from the client.

1. A nurse is caring for a client who has cervical cancer and is receiving brachytherapy. Which of the following actions should the nurse take? A. Limit time for visitors to 2 hr per day. B. Instruct visitors to remain 6 feet from the client. C. Discard the radioactive device in the client's trash can. D. Keep soiled bed linens in the client's room.

B. Diphenhydramine

1. A nurse is caring for a client who has developed hives and urticaria following the administration of IV contrast dye after a cardiac catheterization. Which of the following medications should the nurse plan to administer? A. Desmopressin B. Diphenhydramine C. Spironolactone D. Metoclopramide

B. Glycosylated hemoglobin level

1. A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long- term glycemic control? A. Postprandial blood glucose level B. Glycosylated hemoglobin level C. Fasting blood glucose level D. Oral glucose tolerance test results

A. Glycosylated hemoglobin level

1. A nurse is caring for a client who has diabetes mellitus and has been following a treatment plan for 3 months. Which of the following laboratory results should the nurse monitor to determine long-term glycemic control? A. Glycosylated hemoglobin level B. Postprandial blood glucose level C. Fasting blood glucose level D. Oral glucose tolerance test results

A. Administer oxygen at 2 L/min.

1. A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care? A. Administer oxygen at 2 L/min. B. Encourage use of incentive spirometry for 5 minutes every 2 hours. C. Teach the client a breathing exercise with a longer inhalation phase. D. Limit fluid intake to 1,000 mL per day.

A. Administer oxygen at 2 L/min.

1. A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care? A. Administer oxygen at 2 L/min. B. Teach the client a breathing exercise with a longer inhalation phase. C. Encourage use of incentive spirometry for 5 min every 2 hr. D. Limit fluid intake to 1,000 ml. per day.

D. Administer oxygen at 2 L/min.

1. A nurse is caring for a client who has emphysema. Which of the following interventions should the nurse include in the client's plan of care? A. Teach the client a breathing exercise with a longer inhalation phase. B. Limit fluid intake to 1,000 mL per day. C. Encourage use of incentive spirometry for 5 min every 2 hr. D. Administer oxygen at 2 L/min.

C. "I am not very good about taking prescribed medication."

1. A nurse is caring for a client who has end-stage liver disease and is being placed on a transplant list. Which of the following statements by the client is the priority for the nurse to report to the provider? A. "My parent has type 2 diabetes mellitus." B. "I wish my family was more supportive of my decision." C. "I am not very good about taking prescribed medication." D. "I had symptoms of asthma when I was a child."

C. Decreased blood pressure

1. A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration? A. Distended jugular veins B. Pitting, dependent edema C. Decreased blood pressure D. Increased blood pressure

D. The client's capillary refill in the left toe is 6 seconds.

1. A nurse is caring for a client who has just returned from surgery with an external fixator to the left tibia. Which of the following assessment findings requires immediate intervention by the nurse? A. The client has 100 mL blood in the closed-suction drain. B. The client has an oral temperature of 38.3° C (100.9° F). C. The client reports a pain level of 7 on a scale from 0 to 10 at the operative site. D. The client's capillary refill in the left toe is 6 seconds.

C. Confusion

1. A nurse is caring for a client who has left-sided heart failure. Which of the following findings should indicate to the nurse that the client is experiencing a decrease in cardiac output? A. Weight gain B. Distended abdomen C. Confusion D. Dyspnea

C. Daytime oliguria

1. A nurse is caring for a client who has left-sided heart failure. Which of the following manifestations should the nurse expect? A. Pedal edema B. Neck vein distention C. Daytime oliguria D. Enlarged liver

D. Consider respite care services.

1. A nurse is caring for a client who has moderate Alzheimer's disease. During weekly home visits, the nurse notices that the client's caregiver is tired, irritable, and impatient with the client. Which of the following actions should the nurse recommend to the caregiver? A. Pursue local protective services. B. Take a nonprescription sleeping medication. C. Contact hospice services for end-of-life care. D. Consider respite care services.

B. "Do you feel life you have food stuck at the base of your throat?"

1. A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow? A. "Do you feel any burning sensations in your throat?" B. "Do you feel life you have food stuck at the base of your throat?" C. "Do you have any feelings of fullness in the neck?" D. "Do you have any problems with pain while swallowing?"

B. Provide the client with a trapeze bar.

1. A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take? A. Check pressure points every 12 hr. B. Provide the client with a trapeze bar. C. Remove the weights before changing the client's bedlinens. D. Instruct the client to use their elbows to reposition.

D. Provide the client with a trapeze bar.

1. A nurse is caring for a client who has skeletal traction applied to the left leg. Which of the following actions should the nurse take? A. Remove the weights before changing the client's bed linens. B. Instruct the client to use their elbows to reposition. C. Check pressure points every 12 hours. D. Provide the client with a trapeze bar.

A. Joint inflammation

1. A nurse is caring for a client who has systemic lupus erythematosus. During assessment, which of the following should the nurse expect to find? A. Joint inflammation B. Tophi C. Esophagitis D. "Bull's Eye" lesion

D. "The elastic bandage will prevent excessive edema."

1. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? A. "The elastic bandage will prevent a postoperative wound infection." B. "The elastic bandage will keep you from seeing the surgical site." C. "The elastic bandage will keep the sutures from loosening." D. "The elastic bandage will prevent excessive edema."

B. "The elastic bandage will prevent excessive edema."

1. A nurse is caring for a client who is 2 days postoperative following a below-the-knee amputation and asks about the purpose of maintaining an elastic bandage around the residual limb of the extremity. Which of the following is an appropriate response by the nurse? A. "The elastic bandage will prevent a postoperative wound infection." B. "The elastic bandage will prevent excessive edema." C. "The elastic bandage will keep you from seeing the surgical site." D. "The elastic bandage will keep the sutures from loosening."

C. Encourage the client to perform circumduction of the feet.

1. A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism? A. Keep the client's knees in a flexed position while they are in bed. B. Massage the client's legs every 4 hr while they are awake. C. Encourage the client to perform circumduction of the feet. D. Limit the client's fluid intake to 2,000 mL daily.

D. Tachycardia

1. A nurse is caring for a client who is 3 hr postoperative. Which of the following findings should the nurse understand is a manifestation of bleeding? A. Hypertension B. 2+ edema C. Crackles in lungs D. Tachycardia

B. Lower the client to the floor.

1. A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first? A. Clear items from the client's surrounding area. B. Lower the client to the floor. C. Obtain the client's vital signs. D. Loosen the client's restrictive clothing.

D. Inability to exhale retained carbon dioxide

1. A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations? A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Acute loss of alveolar elasticity D. Inability to exhale retained carbon dioxide

C. Inability to exhale retained carbon dioxide

1. A nurse is caring for a client who is experiencing an acute asthma attack. Which of the following should the nurse identify as a contributing factor to the client's manifestations? A. Decreased responsiveness of airways to allergens B. Suppressed bronchiolar inflammatory response C. Inability to exhale retained carbon dioxide D. Acute loss of alveolar elasticity

C. Restlessness

1. A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP? A. Projectile vomiting B. Papilledema C. Restlessness D. Decorticate posturing

D. Naloxone

1. A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe? A. Diphenhydramine B. Flumazenil C. Calcium gluconate D. Naloxone

C. Muscle twitching

1. A nurse is caring for a client who is postoperative following a complete thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider? A. Client report of nausea B. Serosanguineous drainage C. Muscle twitching D. Client report of incisional pain

D. Gag reflex

1. A nurse is caring for a client who is postoperative following an endoscopy with moderate (conscious) sedation. Which of the following assessment findings is the nurse's priority? A. Level of pain B. Temperature C. Warmth of extremities D. Gag reflex

B. Slow infusion rate and contact the provider.

1. A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take? A. Administer prescribed corticosteroids. B. Slow infusion rate and contact the provider. C. Change infusion to lactated Ringer's and maintain rate. D. Lower the head of the bed to semi-Fowler's.

A. Slow infusion rate and contact the provider.

1. A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take? A. Slow infusion rate and contact the provider. B. Lower the head of the bed to semi-Fowler's. C. Administer prescribed corticosteroids. D. Change infusion to Lactated Ringer's and maintain rate.

C. Evaluate the client for a cuff leak.

1. A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? A. Increase the client's ventilator flow rate. B. Empty water from the client's ventilator tubing. C. Evaluate the client for a cuff leak. D. Suction the client's airway.

D. Evaluate the client for a cuff leak.

1. A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds on the ventilator. Which of the following actions should the nurse take? A. Suction the client's airway. B. Empty water from the client's ventilator tubing. C. Increase the client's ventilator flow rate. D. Evaluate the client for a cuff leak.

C. Teach the client how to self-medicate using the PCA device.

1. A nurse is caring for a client who is receiving morphine through a PCA (Patient-Controlled Analgesia) device. Which of the following actions should the nurse take? A. Encourage family members to press the PCA button for the client. B. Monitor the client's respiratory status every 4 hours. C. Teach the client how to self-medicate using the PCA device. D. Administer an oral opioid for breakthrough pain.

D. Teach the client how to self-medicate using the PCA device.

1. A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take? A. Monitor the client's respiratory status every 4 hr. B. Encourage family members to press the PCA button for the client. C. Administer an oral opioid for breakthrough pain. D. Teach the client how to self-medicate using the PCA device.

B. Monitor serum blood glucose during infusion. C. Verify the solution with another RN prior to infusion. E. Obtain the client's weight daily.

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.) A. Increase the rate of infusion if administration is delayed. B. Monitor serum blood glucose during infusion. C. Verify the solution with another RN prior to infusion. D. Infuse 0.9% sodium chloride if the solution is not available. E. Obtain the client's weight daily.

B. Obtain the client's weight daily. C. Monitor serum blood glucose during infusion. D. Verify the solution with another RN prior to infusion.

1. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following nursing actions are appropriate? (Select all that apply.) A. Infuse 0.99% sodium chloride if the solution is not available. B. Obtain the client's weight daily. C. Monitor serum blood glucose during infusion. D. Verify the solution with another RN prior to infusion. E. Increase the rate of infusion if administration is delayed.

C. Turn the CPM machine off while the client is eating.

1. A nurse is caring for a client who is using a continuous passive motion (CPM) machine following a total knee arthroplasty. Which of the following actions should the nurse take? A. Increase the range of motion rapidly when the CPM machine is used intermittently. B. Store the CPM machine on the floor when not in use. C. Turn the CPM machine off while the client is eating. D. Check settings of the CPM machine every 12 hr.

B. Make sure the client's room has positive-pressure airflow.

1. A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection? A. Monitor the client's temperature once every 6 hr. B. Make sure the client's room has positive-pressure airflow. C. Wear an N95 respirator when providing direct client care. D. Make sure dietary plates and utensils are disposable.

B. Make sure the client's room has positive-pressure airflow.

1. A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection? A. Wear an N95 respirator when providing direct client care. B. Make sure the client's room has positive-pressure airflow. C. Make sure dietary plates and utensils are disposable. D. Monitor the client's temperature once every 6 hr.

D. Albumin 3.1 g/dL (3.5 to 5 g/dL)

1. A nurse is caring for a female client who had a stroke. Which of the following findings should indicate to the nurse that the client has an increased risk of developing skin breakdown? A. Hgb 18 g/dL (12 to 16 g/dl) B. WBC 12.000/mm3 (5,000 to 10,000/mm3) C. 25-Hydroxyvitamin D 92 ng/ml. (25 to 80 ng/mL) D. Albumin 3.1 g/dL (3.5 to 5 g/dL)

D. Generalized rash.

1. A nurse is caring for a female client who has toxic shock syndrome. Which of the following findings should the nurse expect? A. Elevated platelet count. B. Decreased total bilirubin. C. Hypertension. D. Generalized rash.

C. Internal fixation of a fractured hip

1. A nurse is caring for a group of clients who are 12 hr postoperative. The nurse should identify that the client who had which of the following procedures is at risk for developing fat embolism syndrome? A. Repair of a torn rotator cuff B. Tympanoplasty C. Internal fixation of a fractured hip D. Thyroidectomy

D. A client who has a right upper extremity arteriovenous fistula.

1. A nurse is caring for a group of clients. From which of the following clients should the nurse obtain a blood pressure reading using only the left extremity? A. A client who has a peripherally inserted central catheter (PICC) in the left arm. B. A client who has left-sided Bell's palsy. C. A client who has right-sided weakness due to Parkinson's disease. D. A client who has a right upper extremity arteriovenous fistula.

B. Place the client in the dorsal recumbent position.

1. A nurse is caring for a postoperative client who has an indwelling urinary catheter. Which of the following actions should the nurse take when removing the catheter? A. Rapidly deflate the balloon before removing the tubing. B. Place the client in the dorsal recumbent position. C. Reinsert the catheter if the client does not void within 1 hr. D. Obtain a sterile urine specimen after catheter removal.

C. "Your symptoms are likely due to decreasing estrogen levels."

1. A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make? A. "These discomforts should decrease with time." B. "Women your age experience thickening of the vaginal tissue." C. "Your symptoms are likely due to decreasing estrogen levels." D. "You should avoid intercourse to prevent injury to your vagina."

C. "I will be sure to wear gloves and wash my hands when I change my cat's litter box."

1. A nurse is completing discharge teaching with a client who has a new diagnosis of AIDS. Which of the following statements by the client indicates an understanding of the teaching? A. "I will increase the amount of fresh fruits and vegetables I consume." B. "I will need to take my clothes to the dry cleaners to sterilize them." C. "I will be sure to wear gloves and wash my hands when I change my cat's litter box." D. "I will wipe up areas soiled with body fluids with alcohol and immediately dispose of the trash."

B. "I guess feeling down is just part of aging."

1. A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up? A. "I do my best to protect my skin from bumps and cuts. It's more fragile now." B. "I guess feeling down is just part of aging." C. "My hair is thinning. I'm going to go to the wig shop soon." D. "I missed my eye appointment, but I rescheduled it."

B. The client maintains two points of support on the floor.

1. A nurse is instructing a client who has left-sided hemiparesis about the use of a quad cane. Which of the following actions by the client indicates an understanding of the teaching? A. The client advances their right foot to meet their left foot. B. The client maintains two points of support on the floor. C. The client holds the cane in their left hand. D. The client moves the cane forward 50.8 cm (20 in) when ambulating.

B. Institute bleeding precautions.

1. A nurse is monitoring an older adult client who has an exacerbation of chronic lymphocytic leukemia. The nurse notes petechiae on the client's skin. Which of the following actions should the nurse take? A. Determine the client's blood type. B. Institute bleeding precautions. C. Avoid administering IV pain medication. D. Implement airborne precautions.

C. Cleanse the connections with providone-iodine.

1. A nurse is obtaining a blood sample from a client's central venous access device. Which of the following actions should the nurse take? A. Flush the catheter with sterile water after specimen collection. B. Use a vacuum tube to obtain a specimen from the catheter hub. C. Cleanse the connections with providone-iodine. D. Flush the catheter with a 5 mL syringe.

C. Disequilibrium with movement

1. A nurse is performing a cranial nerve assessment on a client following a head injury. Which of the following findings should the nurse expect if the client has impaired function of the vestibulocochlear nerve (cranial nerve VIII)? A. Inability to smell B. Loss of peripheral vision C. Disequilibrium with movement D. Deviation of the tongue from midline

B. The client has a history of urinary incontinence.

1. A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk? A. The client asks for help before ambulating. B. The client has a history of urinary incontinence. C. The client lives with their caregiver. D. The client has bronchitis.

D. Rebound tenderness with palpation

1. A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority? A. Gurgling bowel sounds every 10 seconds. B. Centrally located umbilical protrusion. C. Abdominal distention during breathing. D. Rebound tenderness with palpation

C. Obtain a stool specimen with gloves.

1. A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action? A. Wash hands with alcohol-based hand rub. B. Clean surfaces with chlorhexidine. C. Obtain a stool specimen with gloves. D. Place the client in a protective environment.

B. Barium swallow

1. A nurse is planning care for a client who has GERD and reports regurgitation after eating. Which of the following tests should the nurse anticipate the provider to prescribe for the client? A. Flexible sigmoidoscopy B. Barium swallow C. Paracentesis D. Chest x-ray

B. Ensure that there is space for one finger to fit between the vest and the client's skin.

1. A nurse is planning care for a client who has a cervical spine injury and has a halo traction device in place. Which of the following actions should the nurse plan to take? A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

D. Maintain the client on NPO status.

1. A nurse is planning care for a client who has a new diagnosis of acute pancreatitis. Which of the following interventions should the nurse include in the plan of care? A. Place the client in a supine position. B. Administer antihypertensive medications. C. Monitor the client for hypercalcemia. D. Maintain the client on NPO status.

B. The client reports numbness of the fingers of the left hand.

1. A nurse is planning care for a client who has a radial fracture and a newly placed short arm cast on the left arm. Which of the following findings is the nurse's priority? A. The client requires assistance with getting dressed. B. The client reports numbness of the fingers of the left hand. C. The client reports itching of the left arm. D. The client has a pillow under their left arm.

D. Oral airway

1. A nurse is planning care for a client who has a seizure disorder. Which of the following equipment should the nurse place in the client's room? A. Wrist restraints B. NG tube C. Tongue blade D. Oral airway

C. Ensure lights are dimmed in the client's room.

1. A nurse is planning care for a client who has bacterial meningitis. Which of the following interventions should the nurse implement? A. Ensure the client's bed is positioned to greater than 45°. B. Initiate airborne precautions. C. Ensure lights are dimmed in the client's room. D. Encourage frequent ambulation.

C. Place the client's bed at the lowest height.

1. A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include? A. Turn off all lights in the client's room at night. B. Assist the client with toileting at least once every 4 hr. C. Place the client's bed at the lowest height. D. Request a prescription for a nightly sedative.

A. Decrease protein intake

1. A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include? A. Decrease protein intake B. Decrease carbohydrate intake C. Increase potassium intake D. Increase phosphorus intake

D. Place pillows between the client's knees when in a side-lying position.

1. A nurse is planning care for a client who has hemiplegia. Which of the following interventions should the nurse include? A. Instruct the client to sit on a rubber ring when seated in a chair. B. Raise the head of the client's bed to a 90° angle. C. Use moisturizing lotion while massaging the client's bony prominences. D. Place pillows between the client's knees when in a side-lying position.

C. Assess urine output hourly.

1. A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care? A. Administer opioids orally. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Check the client's blood pressure every 8 hr.

A. Check the pulse distal to the graft.

1. A nurse is planning care for a client who is postoperative following insertion of an arteriovenous graft in their left forearm. Which of the following actions should the nurse include in the plan of care? A. Check the pulse distal to the graft. B. Splint the left forearm to prevent damage to the graft. C. Collect blood specimens from the graft. D. Keep the left forearm below the level of the heart.

C. Mouth ulcers

1. A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy? A. Constipation B. Decreased tear production C. Mouth ulcers D. Peripheral neuropathy

B. Flush the PICC line with 0.9% sodium chloride after medication administration.

1. A nurse is planning care for a client who requires insertion of a peripherally inserted central catheter (PICC) line. Which of the following actions should the nurse plan to take? A. Use a 3 ml syringe when flushing the PICC line. B. Flush the PICC line with 0.9% sodium chloride after medication administration. C. Expect the PICC line to be inserted into a lower extremity vein. D. Monitor for a pneumothorax following insertion of the PICC line.

C. Antithrombotic

1. A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? A. Anticonvulsant B. Diuretic C. Antithrombotic D. Opioid analgesic

D. Antithrombotic

1. A nurse is planning the discharge of a client who had an ischemic stroke. The nurse should ensure that the client is discharged with which of the following types of pharmacologic therapy? A. Opioid analgesic B. Anticonvulsant C. Diuretic D. Antithrombotic

D. "The client should be referred to a dietitian."

1. A nurse is planning to meet with the interprofessional team about the care of a client who has a new diagnosis of ulcerative colitis. Which of the following recommendations should the nurse plan to make during the meeting? A. "The client should be referred to pain management." B. "The client should be referred to hospice services." C. "The client should be referred to a wound, ostomy, and continence nurse." D. "The client should be referred to a dietitian."

A. Dispose of the top of the ampule in a sharps container.

1. A nurse is planning to withdraw medication from an ampule to prepare for an injection. Which of the following actions should the nurse plan to take? A. Dispose of the top of the ampule in a sharps container. B. Place a paper towel around the ampule's neck to break off the top with both hands. C. Expel air into the ampule to aspirate air bubbles. D. Withdraw the medication from the ampule using a needleless system.

A. Administer prednisone before the test.

1. A nurse is preparing a client for a magnetic resonance angiography (MRA). The client is allergic to iodinated contrast dye. Which of the following actions should the nurse plan to take? A. Administer prednisone before the test. B. Consult with the provider to change to a CT scan. C. Assess the alkaline phosphatase level. D. Obtain the client's allergy history to seafood.

B. "Brush your teeth for 60 seconds twice daily."

1. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include? A. "Rinse your mouth with hydrogen peroxide." B. "Brush your teeth for 60 seconds twice daily." C. "Wear your dentures only during meals." D. "Floss your teeth gently following each meal."

C. Review the medical record for type and crossmatch information.

1. A nurse is preparing to administer a unit of packed RBCs to a female client who has a hemoglobin of 7.2 g/dL (12 to 16 g/dL). Which of the following actions should the nurse take? A. Obtain the blood from the blood bank prior to inserting the peripheral catheter. B. Prime the tubing with lactated Ringer's. C. Review the medical record for type and crossmatch information. D. Identify the client using their full name and room number.

B. Administer the plasma immediately after thawing.

1. A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take? A. Administer the transfusion through a 25-gauge saline lock. B. Administer the plasma immediately after thawing. C. Transfuse the plasma over 4 hr. D. Hold the transfusion if the client is actively bleeding.

C. Use a 25-gauge needle to inject the medication.

1. A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse? A. Inject the medication into the abdomen above the level of the iliac crest. B. Use a 1-inch needle to inject the medication. C. Use a 25-gauge needle to inject the medication. D. Massage the injection site after administration of the medication.

B. Vastus lateralis

1. A nurse is preparing to administer intramuscular epinephrine to a client who is experiencing anaphylaxis. Which of the following sites should the nurse use? A. Ventrogluteal B. Vastus lateralis C. Dorsolateral D. Deltoid

C. Place a strip of pH paper under the upper lid of the affected eye.

1. A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take? A. Irrigate the affected eye from the inner corner toward the outer corner. B. Sit the client up with their head turned toward the right side. C. Place a strip of pH paper under the upper lid of the affected eye. D. Irrigate the affected eye using sterile water.

C. Discard samples that contain urine.

1. A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take? A. Collect three samples from a single bowel movement. B. Wear sterile gloves when collecting the sample. C. Discard samples that contain urine. D. Take the sample from the outer edge of formed stool.

B. B

1. A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) A. A B. B C. C D. None

A. "I will use canola oil when making salad dressing."

1. A nurse is providing dietary instructions to a client who has cardiovascular disease. The nurse should identify that which of following statements by the client indicates an understanding of the teaching? A. "I will use canola oil when making salad dressing." B. "I will increase my intake of canned vegetables." C. "I will limit my portions of meat to 8 ounces." D. "I will drink whole milk with my cereal."

B. "I will notify my provider if I experience muscle weakness."

1. A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching? A. "I will take this medication with fiber to prevent constipation." B. "I will notify my provider if I experience muscle weakness." C. "I will increase my dose if my vision becomes blurred." D. "I will take my digoxin if my pulse is less than 50 beats per minute."

A. "I should expect to take my medication for 3 weeks."

1. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching? A. "I should expect to take my medication for 3 weeks." B. "I should use natural skin condoms during sexual intercourse." C. "I should expect my lesions to resolve in 6 weeks." D. "I should apply antibiotic ointment to the lesions."

D. "I should expect to take my medication for 3 weeks."

1. A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates the effectiveness of the teaching? A. "I should apply antibiotic ointment to the lesions." B. "I should use natural skin condoms during sexual intercourse." C. "I should expect my lesions to resolve in 6 weeks." D. "I should expect to take my medication for 3 weeks."

C. Hot flashes

1. A nurse is providing discharge teaching to a client who had a bilateral orchiectomy. The nurse should instruct the client to expect which of the following symptoms? A. Increased libido B. Hypoglycemia C. Hot flashes D. Increased muscle mass

B. "I should take this medication as soon as the pain begins."

1. A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching? A. "I can take another dose after 2 minutes." B. "I should take this medication as soon as the pain begins." C. "I should chew the tablet before I swallow it." D. "I can put the tablet against my cheek and gum."

B. Negative sputum cultures for acid-fast bacillus

1. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication that the client is no longer infectious? A. Mantoux skin test revealing an induration of less than 1 mm B. Negative sputum cultures for acid-fast bacillus C. The client is no longer coughing up blood-tinged sputum D. Positive QuantiFERON-TB Gold test (negative)

A. Negative sputum cultures for acid-fast bacteria

1. A nurse is providing discharge teaching to a client who has pulmonary tuberculosis. Which of the following findings should the nurse include as an indication the client is no longer infectious? A. Negative sputum cultures for acid-fast bacteria B. Positive QuantiFERON-TB Gold test (negative) C. Mantoux skin test revealing an induration of less than 1 mm D. Client no longer coughing up blood-tinged sputum

C. "Use a raised toilet seat to maintain your hips above your knees."

1. A nurse is providing discharge teaching to a client who is postoperative following a total hip arthroplasty. Which of the following statements should the nurse make? A. "Twist at the waist when standing from a seated position." B. "Move your stronger leg first when using a walker." C. "Use a raised toilet seat to maintain your hips above your knees." D. "Apply a heating pad to the operative hip to decrease pain."

D. Avoid extremely hot or cold temperatures.

1. A nurse is providing discharge teaching to a client who is recovering from a sickle cell crisis. Which of the following instructions should the include? A. Avoid getting a flu vaccination. B. Limit fluids to 1.5 L per day. C. Limit alcohol intake to one drink per day. D. Avoid extremely hot or cold temperatures.

C. "You will need three follow-up blood tests within a 24-month period."

1. A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan? A. "You will need to take an antiviral medication for 6 months." B. "You will need cryotherapy for 1 to 2 weeks." C. "You will need three follow-up blood tests within a 24-month period." D. "You will need to be monitored for 15 minutes after receiving each medication dose."

D. "You will need three follow-up blood tests within a 24-month period."

1. A nurse is providing instructions to a client who has primary syphilis. Which of the following instructions should the nurse include in the discharge plan? A. "You will need to take an antiviral medication for 6 months." B. "You will need cryotherapy for 1 to 2 weeks." C. "You will need to be monitored for 15 minutes after receiving each medication dose." D. "You will need three follow-up blood tests within a 24-month period."

A. "I could refuse the treatment even after it has started."

1. A nurse is providing teaching about client rights to a client who has a brain tumor. Which of the following client statements indicates an understanding of the teaching? A. "I could refuse the treatment even after it has started." B. "I signed the surgical consent form because there are no other options." C. "If I choose not to accept my provider's plan of treatment, I will not be able to do any other treatment." D. "I am going to have radiation treatment because it has no adverse effects."

D. "I will draw up the regular insulin into the syringe first."

1. A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. The client has prescriptions for regular and NPH insulins. Which of the following statements by the client indicates an understanding of the teaching? A. "I will insert the needle at a 15-degree angle." B. "I will store prefilled syringes in the refrigerator with the needle pointed downward." C. "I will shake the NPH vial vigorously before drawing up the insulin." D. "I will draw up the regular insulin into the syringe first."

D. "I will have my liver function tested while I am taking this medication."

1. A nurse is providing teaching for a client who is taking isoniazid (INH) for tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? A. "This medication may cause my blood pressure to increase." B. "I should take an antacid with each dose of this medication." C. "I plan to take this medication for 1 week." D. "I will have my liver function tested while I am taking this medication."

D. "Provide the client with structured activities to fill their time."

1. A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include? A. "Provide plenty of stimulation in the client's room." B. "Display a monthly calendar in the client's room." C. "Keep the client's room dark at night to promote sleep." D. "Provide the client with structured activities to fill their time."

A. "Provide the client with structured activities to fill their time."

1. A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include? A. "Provide the client with structured activities to fill their time." B. "Keep the client's room dark at night to promote sleep." C. "Display a monthly calendar in the client's room." D. "Provide plenty of stimulation in the client's room."

C. Cloudy effluent

1. A nurse is providing teaching to a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication? A. Generalized abdominal pain B. Increased heart rate C. Cloudy effluent D. Fever

B. "I will try to limit foods that contain salt."

1. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? A. "I'll check my blood pressure, so it doesn't get too high." B. "I will try to limit foods that contain salt." C. "I will check my pulse before I take the medication." D. "I'm going to include more cantaloupe in my diet."

C. "I will try to limit foods that contain salt."

1. A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication? A. "I'm going to include more cantaloupe in my diet." B. "I will check my pulse before I take the medication." C. "I will try to limit foods that contain salt." D. "I'll check my blood pressure, so it doesn't get too high."

D. Flush the toilet with the lid closed three times after use.

1. A nurse is providing teaching to a group of clients who are receiving radioactive isotope therapy. Which of the following information should the nurse include? A. Remain at least 1 foot away from young children during treatment. B. Use cloth handkerchiefs instead of disposable tissues. C. Use absorbent briefs for incontinence as needed. D. Flush the toilet with the lid closed three times after use.

B. Empty the ostomy pouch when it is 2/3 full.

1. A nurse is reinforcing discharge teaching with a client on how to care for a newly created ileal conduit. Which of the following instructions should the nurse include in the teaching? A. Change the ostomy pouch daily. B. Empty the ostomy pouch when it is 2/3 full. C. Trim the opening of the ostomy seal to be 1/2 inch wider than the stoma. D. Apply lotion to the peristomal skin when changing the ostomy pouch.

B. "I take my alendronate on the same day every week with an 8-ounce glass of milk."

1. A nurse is reinforcing teaching with a client who has osteoporosis and is prescribed (Fosamax) alendronate 70 mg PO weekly. Which of the following statements by the client indicates a need for further instruction? A. "I take my other pills at least 30 minutes after my alendronate." B. "I take my alendronate on the same day every week with an 8-ounce glass of milk." C. "I sit up and read the morning paper after taking my alendronate." D. "I will need to have a bone density test occasionally while taking this medication."

D. Respiratory acidosis

1. A nurse is reviewing a client's ABG results and notes pH 7.3 (7.35 to 7.45), PaO2 81 mm Hg (80 to 100 mm Hg), PaCO2 50 mm Hg (35 to 45 mm Hg), and HCO, 26 mEq/L (21 to 28 mEq/L). Which of the following acid-base imbalances is the client experiencing? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

B. Epinephrine (Adrenaline)

1. A nurse is reviewing orders for a patient in anaphylactic shock. Which medication should the nurse plan to administer first? A. Glucose Dextrose Oral (GDO) B. Epinephrine (Adrenaline) C. Dexamethasone (Decadron) D. 0.9% Normal Saline

B. Apply a vest restraint daily at bedtime to prevent nighttime wandering.

1. A nurse is reviewing providers' prescriptions for four clients. Which of the following prescriptions should the nurse verify with the provider? A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

A. pH 7.28 (7.35 to 7.45)

1. A nurse is reviewing the arterial blood gas report of a client who is in metabolic acidosis. Which of the following findings should the nurse expect? A. pH 7.28 (7.35 to 7.45) B. PaCO2, 31 mm Hg (35 to 45 mm Hg) C. HCO2 18 mEq/L (21 to 28 mEq/L) D. Pa02, 85 mm Hg (72 to 100 mm Hg)

A. Strawberries

1. A nurse is reviewing the health history of a client who is scheduled for exploratory surgery. Which of the following food allergies indicates a risk for an allergic reaction to latex? A. Strawberries B. Eggs C. Peanuts D. Shellfish

B. Triiodothyronine 3

1. A nurse is reviewing the laboratory findings of a client who has a new diagnosis of Graves' disease. The nurse should anticipate which of the following laboratory values to be elevated? A. Phosphorus B. Triiodothyronine 3 C. Thyroid-stimulating hormone D. Calcium

C. Uric acid

1. A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results? A. Chloride level B. Creatinine kinase C. Uric acid D. Intrinsic factor

C. Uric acid

1. A nurse is reviewing the medical record of a client who has acute gout. The nurse should expect an increase in which of the following laboratory results? A. Intrinsic factor B. Creatinine kinase C. Uric acid D. Chloride level

B. Proteinuria

1. A nurse is reviewing the medical record of a client who has nephrotic syndrome. Which of the following findings should the nurse expect? A. Decreased coagulation B. Proteinuria C. Decreased serum lipid levels D. Hyperalbuminemia

C. Using a nicotine transdermal patch

1. A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's? A. A history of herpes zoster B. Taking amlodipine for hypertension C. Using a nicotine transdermal patch D. Eating a strict vegetarian diet

C. Initiate a referral for the client to a home health agency.

1. A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone. Which of the following actions by the nurse demonstrates client advocacy? A. Remind the client of the importance of medication adherence. B. Tell the client to avoid places where there are large crowds of people. C. Initiate a referral for the client to a home health agency. D. Instruct the client to avoid eating raw vegetables.

A. Increased temperature

1. A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching? A. Increased temperature B. Lethargy C. Decreased heart rate D. Hypotension

A. Soiled cat litter

1. A nurse is teaching a client who has HIV about infection prevention. The nurse should instruct the client to avoid contact with which of the following items? A. Soiled cat litter B. Scrambled eggs C. Pasteurized milk D. Electric razor

C. "Take a hot shower to reduce pain in the morning."

1. A nurse is teaching a client who has a new diagnosis of rheumatoid arthritis. Which of the following statements should the nurse include in the teaching? A. "Avoid napping during the day." B. "Avoid using ice packs when joints are inflamed." C. "Take a hot shower to reduce pain in the morning." D. "Decrease the amount of iron in your diet."

C. Kale

1. A nurse is teaching a client who has a new prescription for warfarin about foods that affect the INR. The nurse should include in the teaching that which of the following foods interacts with this medication? A. Beef stew B. Orange juice C. Kale D. Yogurt

D. "Hold your breath for 10 seconds once you inhale."

1. A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following information should the nurse include in the teaching? A. "Wait 30 seconds between puffs." B. "The spacer should make a whistling sound as you inhale." C. "Clean the spacer daily with cold water." D. "Hold your breath for 10 seconds once you inhale."

1. A nurse is teaching a client who has diabetes mellitus about home management of mild hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "Eat a large snack of carbohydrates and protein after treating hypoglycemia." B. "Treat the symptoms of hypoglycemia by consuming 45 grams of carbohydrates." C. "Drink 12 ounces of milk to treat the symptoms of hypoglycemia." D. "Retest your blood glucose 15 minutes after treatment of a hypoglycemic episode."

1. A nurse is teaching a client who has diabetes mellitus about home management of mild hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "Eat a large snack of carbohydrates and protein after treating hypoglycemia." B. "Treat the symptoms of hypoglycemia by consuming 45 grams of carbohydrates." C. "Drink 12 ounces of milk to treat the symptoms of hypoglycemia." D. "Retest your blood glucose 15 minutes after treatment of a hypoglycemic episode."

A. The client advances the weaker leg forward to the cane.

1. A nurse is teaching a client who has left-sided weakness how to use a quad cane. Which of the following client actions indicates an understanding of the teaching? A. The client advances the weaker leg forward to the cane. B. The client holds the cane with their left hand. C. The client takes a step with their right foot first. D. The client moves the cane 2 feet ahead.

B. Chronic infections of the middle ear C. Perforation of the eardrum E. Use of a loop diuretic

1. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Frequent exposure to low-volume noise B. Chronic infections of the middle ear C. Perforation of the eardrum D. Born with a high birth weight E. Use of a loop diuretic

A. Perforation of the eardrum D. Chronic infections of the middle ear E. Use of a loop diuretic

1. A nurse is teaching a group of young adult clients about risk factors for hearing loss. Which of the following factors should the nurse include in the teaching? (Select all that apply.) A. Perforation of the eardrum B. Born with a high birth weight C. Frequent exposure to low-volume noise D. Chronic infections of the middle ear E. Use of a loop diuretic

A. 1 cup white rice

1. A nurse is teaching about food choices to a client who has chronic kidney disease and must limit potassium intake. Which of the following choices should the nurse recommend as containing the least potassium? A. 1 cup white rice B. 1 medium baked potato with skin C. ½ cup nonfat yogurt D. 2 tbsp peanut butter

B. "I will support their feet with a rolled pillow when they are lying on their back."

1. A nurse is teaching about safe positioning with the caregiver of a client who has right-sided hemiplegia following a stroke. Which of the following statements by the caregiver indicates an understanding of the teaching? A. "I will ensure their neck is flexed backwards when they're lying on their stomach." B. "I will support their feet with a rolled pillow when they are lying on their back." C. "I will rest their heels on the mattress when they are sitting up in bed." D. "I will use a thick pillow under their head to support the neck."

C. Hang a monthly calendar in the client's bedroom.

1. A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? A. Cover electrical outlets in the client's home with tape. B. Keep the client's bedroom dark at night. C. Hang a monthly calendar in the client's bedroom. D. Place a large-face clock in the client's bedroom.

D. Hang a monthly calendar in the client's bedroom.

1. A nurse is teaching the family of a client who has Alzheimer's disease about caring for the client at home. Which of the following instructions should the nurse include? A. Keep the client's bedroom dark at night. B. Place a large-face clock in the client's bedroom. C. Cover electrical outlets in the client's home with tape. D. Hang a monthly calendar in the client's bedroom.

C. A client who has a metal bar protruding from the upper abdomen and is hyperventilating.

1. A nurse is triaging clients following a mass casualty accident. Which of the following clients should be the nurse's priority? A. A client who has an open fractured femur and reports severe pain. B. A client who has vomited twice and has contusions to both arms and shoulders. C. A client who has a metal bar protruding from the upper abdomen and is hyperventilating. D. A client who has several large lacerations to the upper extremities and can explain what occurred.

D. "I should wear goggles when irrigating a wound."

1. A nurse manager is providing an in-service to a group of newly licensed nurses about the use of personal protective equipment. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? A. "I should wear a gown to remove linens from a client's bed." B. "Sterile gloves are required when administering an IM injection." C. "I should use both hands to recap a needle." D. "I should wear goggles when irrigating a wound."

C. Use a bed alarm.

1. A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement? A. Move client to a double room. B. Use chemical restraints at bedtime. C. Use a bed alarm. D. Encourage participation in activities that provide excessive stimulation.

A. Record the client's refusal in the electronic health record.

1. A nurse on a medical-surgical unit is preparing to administer amoxicillin PO when the client refuses the medication. Which of the following actions should the nurse take? A. Record the client's refusal in the electronic health record. B. Leave the medication at the client's bedside for them to take later. C. Schedule the client's medication for a later time. D. Prepare the client's medication intravenously instead of PO.

C. Mannitol

1. A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer? A. Chlorpromazine B. Dobutamine C. Mannitol D. Propranolol

A. Pad the upper two side rails of the client's bed.

1. A nurse on the medical-surgical unit is caring for a client who has a seizure disorder. Which of the following interventions should the nurse include in the plan of care? A. Pad the upper two side rails of the client's bed. B. Maintain peripheral IV access. C. Teach assistive personnel how to apply restraints. D. Keep a padded tongue blade at the client's bedside.

C. Cool, clammy skin

1. A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia. Which of the following assessment findings supports this suspicion? A. Kussmaul respirations B. Increased urine output C. Cool, clammy skin D. Acetone breath

D. Painless vaginal bleeding

1. A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer? A. Frequent diarrhea B. Urinary hesitancy C. Unexplained weight gain D. Painless vaginal bleeding

A. Wear a surgical mask when providing care to the client.

1. A nurse working in the emergency department is admitting a client who has pertussis. Which of the following actions should the nurse take? A. Wear a surgical mask when providing care to the client. B. Perform a Mantoux skin test on the client. C. Assign the client to a negative pressure airflow room. D. Recommend that the client's family members receive antiviral therapy.

D. Start an IV with a large-bore needle.

1. A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first? A. Increase the room temperature. B. Cleanse the client's wounds. C. Administer analgesic medication. D. Start an IV with a large-bore needle.

B. Pinch the trapezius muscle.

1. A patient is exhibiting an altered level of consciousness and is unresponsive to verbal stimuli. To elicit a response from a painful stimulus, the nurse would: A. Press down on the orbital area of the eye. B. Pinch the trapezius muscle. C. Use a 25-gauge needle. D. Elicit a reflex with a reflex hammer.

A. Hypotension D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

1. Client came to the emergency department this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite. Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn.The nurse is caring for the client in the ED. The nurse understands that the client is at risk of developing which of the following complications? (Select all that apply.) A. Hypotension B. Respiratory alkalosis C. Septic shock D. Cardiac arrhythmias E. Renal failure F. Cerebral edema

D. Regular insulin continuous intravenous infusion, titrate per diabetic ketoacidosis (DKA) protocol once potassium is greater than 3.3 mEq/L. E. 0.9% sodium chloride at 15 ml/kg/hr for 1 hr and then reduce to 10 ml/kg/hr. H. Monitor urine outputs.

1. Client came to the emergency department this morning and reports not feeling well for the last 12 hr and increasing blood glucose. Client has a history of type 1 diabetes mellitus and hypertension. Client weight is 88 kg (194 lb). The client was recently treated for bronchitis and pneumonia. Client reports nausea and decreased appetite. Client is alert and orientated x 4, heart and lung sounds are clear. Client states that they have been frequently urinating and are extremely thirsty. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 1+. Slight tenting of skin. Peripheral IV established and labs drawn.the client is at risk of developing which of the following complications? (Select all that apply.) A. Potassium chloride 20 mEq/L intravenous PRN potassium less than 5.0 mEq/L. B. Initiate cardiac monitoring. C. Regular insulin 20 units subcutaneously. D. Regular insulin continuous intravenous i

C. Blood pressure D. Pain level E. Electrocardiogram findings G. Troponin T level

1. Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds. The nurse is reviewing the client's medical record. Select the four findings that require immediate follow-up. A. Blood glucose level B. Bowel sounds C. Blood pressure D. Pain level E. Electrocardiogram findings F. Lung sounds G. Troponin T level

A. A client with type 1 diabetes mellitus who has taken a high dose of insulin.

1. The nurse is caring for several clients on a hospital unit. Which of the following clients is most at risk for hypoglycemia? A. A client with type 1 diabetes mellitus who has taken a high dose of insulin. B. A client who has type 2 diabetes and has not taken any medication. C. An older adult client taking an antibiotic for an infection. D. A client who has metabolic syndrome and is taking a statin drug to lower cholesterol levels.

D. One tablet SL (sublingual) every 5 minutes, up to 3 times.

1. The nurse is instructing the client on the correct way to take nitroglycerin as needed for chest pain: A. Two tablets PO (by mouth) every 15 minutes. B. One tablet SL (sublingual) every 15 minutes, up to 5 times. C. One tablet PO (by mouth) every one hour, up to 5 times. D. One tablet SL (sublingual) every 5 minutes, up to 3 times.

C. Purulent drainage around pins.

1. The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator? A. Areas around pins are dry. B. Crusts around pins. C. Purulent drainage around pins. D. Absence of pain at the site.

A. "I can arrange for a social worker to talk with you before you leave."

1. nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make? A. "I can arrange for a social worker to talk with you before you leave." B. "Contact your pharmacy to inquire about a different medication." C. "I can contact the occupational therapist to schedule a home visit." D. "You should ask your provider to prescribe a cheaper medication."