Med Surg Final

The nurse is assessing a client's medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem? A. Cephalosporins B. NSAIDs C. Beta-adrenergic blockers D. Osmotic diuretics

B. NSAIDs

What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis? A. Diabetes B. Alcohol use C. High-protein diet D. Cigarette smoking

B. Alcohol use One of the leading risk factors in US

DRE & PSA screening

Digital rectal exam: -detects tumors, done after PSA Prostate specific antigen: -Screen for prostate cancer -Teach pt not to have sex 24 hours prior to

Phenazopyridine pt teaching

-Used for bacterial cystitis (UTI) -Likely to make urine orange/deep red -This urine may stain clothing -No dietary changes needed

Mirabegron pt teaching

-Used for urinary incontinence -Can caused increased BP, so monitor BP -Can increase effects of Warfarin, so monitor for bleeding/bruising/INR

Normal creatinine range

0.6-1.2 mg/dL (males) 0.5-1.1 mg/dL (females)

List the CD4+ T Cell count for each class of HIV

0: Normal CD4+ count, + HIV test I: 500+ II: 200-499 III: less than 200 (very low energy, low immune response)

Normal urine specific gravity

1.005-1.030 Higher indicates stronger concentration & dehydration

Normal BUN range

10-20 mg/dL

Normale hemoglobin range

13-16 (males) 11-15 (females)

A nurse reviews a client's laboratory results. Which results from the client's urinalysis would the nurse identify as normal? (Select all that apply.) A. pH:6 B. Specific gravity: 1.015 C. Protein: 1.2 mg/dL D. Glucose: negative E. Nitrate: small F. Leukocyte esterase: positive

A,B,D

Normal urine osmolality

300-900 Higher indicates stronger concentration & dehydration

Normal hematocrit range

38-48 % (males) 35-45 % (females) % of RBC in total blood volume

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy

A, C, D

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this clients condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

A, D, F

A nurse is learning about human immune deficiency virus (HIV) infection. Which statements about HIV infection are correct? (Select all that apply.) A. CD4+ cells begin to create new HIV virus particles. B. Antibodies produced are incomplete and do not function well. C. Macrophages stop functioning properly. D. Opportunistic infections and cancer are leading causes of death. E. People with HIV-I disease are not infectious to others. F. The CD4+ T-cell is only affected when the disease has progressed to HIV-III

A,B,C,D

The nurse is assessing a client who has undernutrition. What signs and symptom(s) would the nurse expect? (Select all that apply.) A. Alopecia B. Stomatitis C. Muscle wasting D. Peripheral edema E. Anemia F. Dry, scaly skin

A,B,C,D,E,F

The nurse is caring for a client who has late-stage (advanced) cirrhosis. What assessment findings would the nurse expect? (Select all that apply.) A. Jaundice B. Clay-colored stools C. Icterus D. Ascites E. Petechiae F. Dark urine

A,B,C,D,E,F

The nurse is caring for a client who is diagnosed with urinary tract infection (UTI). What common urinary signs and symptoms does the nurse expect? (Select all that apply.) a. Dysuria b. Frequency c. Burning d. Fever e. Chills f. Hematuria

A,B,C,F Fever and chills may occur if the UTI expands beyond the bladder into the kidneys, but it is not as common

A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? A. Corneal staining B. Fluorescein angiography C. Ophthalmoscopy D. Tonometry

A. Corneal staining

A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which question(s) would the nurse ask? (Select all that apply.) A. "How much water do you drink every day?" B. "Do you take estrogen replacement therapy?" C. "Does anyone in your family have a history of cystitis?" D. "Are you on steroids or other immune-suppressing drugs?" E. "Do you drink grapefruit juice or orange juice daily?"

A,B,D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis

The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) A. Decreased eye muscle tone B. Development of arcus senilis C. Increase in far point of near vision D. Decrease in general color perception E. Increase in point of near vision

A,B,D,E

The nurse is caring for a client with early encephalopathy due to cirrhosis of the liver. Which factors may contribute to increased encephalopathy for which the nurse would assess? (Select all that apply.) A. Infection B. GI bleeding C. Irritable bowel syndrome D. Constipation E. Anemia F. Hypovolemia

A,B,D,F

Which findings are AIDS-defining characteristics? (Select all that apply.) A. CD4+ cell count less than 200/mm3 (0.2 109/L) or less than 14% B. Infection with P. jiroveci C. Positive enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV) D. Presence of HIV wasting syndrome E. Taking antiretroviral medications F. Confusion, dementia, or memory loss

A,B,D,F

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?

A,B,E

A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

A,B,E You can do kegels laying down or sitting up, you will see improvement after several weeks (not days)

A nurse plans care for an older adult patient. Which interventions should the nurse include in this client's plan of care to promote kidney health? (Select all that apply.) A. Ensure adequate fluid intake. B. Leave the bathroom light on at night. C. Encourage use of the toilet every 6 hours. D. Delegate bladder training instructions to the assistive personnel (AP). E. Provide thorough perineal care after each voiding. F. Assess for urinary retention and urinary tract infection.

A,B,E,F

The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) A. Age greater than 65 years B. Increased breast density C. Osteoporosis D. Multiparity E. Genetic factors F. Early menarche

A,B,E,F

The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What possible risk factors would the nurse assess? (Select all that apply.) A. Smoking B. Multiple births C. Poor diet D. Nulliparity E. Younger than 18 at first intercourse F. Infections with HPV

A,B,F

The nurse is teaching assistive personnel (AP) about care of a client who has advanced cirrhosis. Which statements would the nurse include in the staff teaching? (Select all that apply.) A. "Apply lotion to the client's dry skin areas." B. "Use a basin with warm water to bathe the patient." C. "For the patient's oral care, use a soft toothbrush." D. "Provide clippers so the patient can trim the fingernails." E. "Bathe with antibacterial and water-based soaps."

A,C,D

A client asks the nurse why she has urinary incontinence. What risk factors would the nurse recall in preparing to respond to the client's question? (Select all that apply.) A. Diuretic therapy B. Anorexia nervosa C. Stroke D. Dementia E. Arthritis F. Parkinson disease

A,C,D,E,F

The nurse assesses a client who has chronic pancreatitis. What assessment findings would the nurse expect for this client? (Select all that apply.) A. Ascites B. Weight gain C. Steatorrhea D. Jaundice E. Polydipsia F. Polyuria

A,C,D,E,F Pt will likely lose weight, not gain it

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.) A. Peau d'orange B. Dense breast tissue C. Nipple retraction D. Mobile mass at 2 o'clock E. Nontender axillary nodes F. Skin ulceration

A,C,D,F

A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash your hands before and after self-catheterization. b. Use a large-lumen catheter for each catheterization. c. Use lubricant on the tip of the catheter before insertion. d. Self-catheterize at least twice a day or every 12 hours. e. Use sterile gloves and sterile technique for the procedure. f. Maintain a specific schedule for catheterization.

A,C,F

A nurse assesses a client recovering from a cystoscopy. Which assessment findings would alert the nurse to urgently contact the primary health care provider? (Select all that apply.) A. Decrease in urine output B. Tolerating oral fluids C. Prescription for metformin D. Blood clots present in the urine E. Burning sensation when urinating

A,D Burning sensation is expected

A client is interested in learning about the risk factors for prostate cancer. Which factors does the nurse include in the teaching? (Select all that apply.) A. First-degree relative with prostate cancer B. Smoking C. Obesity D. Advanced age E. Eating too much red meat F. Race

A,D,E,F

The nurse is teaching a group of adults about ways to prevent early cataract formation. What health teaching would the nurse include? (Select all that apply.) A. "Wear eye and head protection when playing sports." B. "Be sure to get 7 to 8 hours of sleep each night." C. "Drink less carbonated beverages, especially those with caffeine." D. "Wear sunglasses when going outdoors or in ultraviolet light." E. "Increase consumption of high-protein, low-carbohydrate foods." F. "Avoid smoking or participate in a smoking cessation program."

A,D,F

After teaching a client who has chronic pancreatitis and will be discharged with enzyme replacement therapy, a nurse assesses the client's understanding. Which statement by the client indicates a need for FURTHER teaching? (Select all that apply.) A. "I will take the enzymes between meals." B. "The enteric-coated preparations cannot be crushed." C. "Swallowing the tables without chewing is best." D. "I will wipe my lips after taking the enzymes." E. "Enzymes should be taken with high-protein foods."

A,E Enzymes should be taken immediately before meals/snacks & they should be lower protein

A client has recurrent vulvovaginitis. Which statements by the client indicate a need for FURTHER teaching? (Select all that apply.) A. "I can take a long, hot bath to relieve itching." B. "I need to take all of my antibiotics as prescribed." C. "I should avoid having sex until my infection is gone." D. "I should not douche or use feminine hygiene sprays." E. "I should use antibacterial soap to clean the area." F. "I should switch to wearing only cotton underwear."

A,E Only warm not hot baths, use water to cleanse (not soap), avoid sex until infection is gone, do not douche, use cotton only underwear

A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate? A. "Always wear a bicycle helmet." B. "Avoid swimming in ponds or lakes." C. "Don't attend fireworks shows." D. "Use a cerumen spoon to clean ears."

A. "Always wear a bicycle helmet." Preventing head trauma most important

A client calls the clinic to report exposure to poison ivy and an itchy rash that is not helped with over-the-counter antihistamines. What response by the nurse is most appropriate? A. "Antihistamines do not help poison ivy." B. "There are different antihistamines to try." C. "You should be seen in the clinic right away." D. "You will need to take some IV steroids."

A. "Antihistamines do not help poison ivy."

A nurse assesses a client who presents with renal calculi. Which question would the nurse ask? A. "Do any of your family members have this problem?" B. "Do you drink any cranberry juice?" C. "Do you urinate after sexual intercourse?" D. "Do you experience burning with urination?"

A. "Do any of your family members have this problem?" Strong correlation between stone formation & recurrence, other options are related to UTI, not renal calculi

A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question would the nurse ask when determining this client's risk factors? A. "Do you smoke cigarettes?" B. "Do you use any alcohol?" C. "Do you use recreational drugs?" D. "Do you take any prescription drugs?"

A. "Do you smoke cigarettes?" Other options MAY increase risk, but smoking is one of the greatest risk factors for bladder cancer

The nurse is caring for a client with hepatitis C. The client's brother states, "I do not want to get this infection, so I'm not going into his hospital room." How would the nurse respond? A. "Hepatitis C is not spread through casual contact." B. "If you wear a gown and gloves, you will not get this virus." C. "This virus is only transmitted through a fecal specimen." D. "I can give you an update on your brother's status from here."

A. "Hepatitis C is not spread through casual contact." C is spread by blood to blood contact

A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates ADDITIONAL instruction is needed? A. "I don't need to go to the hospital after using it." B. "I must carry two autoinjectors with me at all times." C. "I will write the expiration date on my calendar." D. "This can be injected right through my clothes."

A. "I don't need to go to the hospital after using it." Need medical attention b/c it can wear off before rx is done

The nurse is teaching an uncircumcised 65-year-old client about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates the client needs MORE info? A. "I have to wash the outside of the catheter once a day with soap and water." B. "I should take extra time to clean the catheter site by pushing the foreskin back." C. "The drainage bag needs to be changed at least once a week and as needed." d. "I should pour a solution of vinegar and water through the tubing and bag."

A. "I have to wash the outside of the catheter once a day with soap and water." Only the first few inches of the catheter starting at the penis should be washed daily Other options are correct home management methods

After teaching a client with a history of renal calculi, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? A. "I should drink at least 3 L of fluid every day." B. "I will eliminate all dairy or sources of calcium from my diet." C. "Aspirin and aspirin-containing products can lead to stones." D. "The doctor can give me antibiotics at the first sign of a stone."

A. "I should drink at least 3 L of fluid every day." Dehydration contributes to stone development

After teaching a client who has stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I will limit my total intake of fluids." "B. I must avoid drinking alcoholic beverages." C. "I must avoid drinking caffeinated beverages." D. "I shall try to lose about 10% of my body weight."

A. "I will limit my total intake of fluids." Pt should stay hydrated - dehydration can lead to UTIs and even worsen incontinence

A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? A. "Immediately report headache or stiff neck." B. "Keep all follow-up appointments." C. "Take the antibiotics with a full glass of water." D. "Take the antibiotic on an empty stomach."

A. "Immediately report headache or stiff neck." Meningitis is a complication of mastoiditis (infection of mastoid bone)

A client with HIV-III is hospitalized and has weeping Kaposi sarcoma lesions. The nurse dresses them with sterile gauze. When changing these dressings, which action is most important for the nurse's safety? A. Adhering to Standard Precautions B. Assessing tolerance to dressing changes C. Performing hand hygiene before and after care D. Disposing of soiled dressings properly

A. Adhering to Standard Precautions

A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? A. Administering ordered antibiotics B. Assessing the patient's visual acuity C. Obtaining consent for enucleation D. Removing the object immediately

A. Administering ordered antibiotics Objects only removed by ophthalmologist

The nurse is presenting information to a community group on safer sex practices. The nurse would teach that which sexual practice is the riskiest? A. Anal intercourse B. Masturbation C. Oral sex D. Vaginal intercourse

A. Anal

A nurse is talking with a client about a negative enzyme-linked immunosorbent assay (ELISA) test for human immune deficiency virus (HIV). The test is negative and the client states "Whew! I was really worried about that result." What action by the nurse is most important? A. Assess the client's sexual activity and patterns. B. Express happiness over the test result. C. Remind the client about safer sex practices. D. Tell the client to be retested in 3 months.

A. Assess client's sexual activity (b/c ELISA tests can be false negatives if the HIV antibodies aren't present yet - there is a 21 day window period between infection & antibody production)

An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? A. Assess for cerumen buildup. B. Facilitate audiological testing. C. Perform tuning fork tests. D. Review the medication list.

A. Assess for cerumen buildup.

A client has just been informed of a positive HIV test. The client is distraught and does not know what to do. What intervention by the nurse is best? A. Assess the client for support systems. B. Determine if a clergy member would help. C. Explain legal requirements to tell sex partners. D. Offer to tell the family for the client.

A. Assess the client for support systems.

A patient has been admitted with acute liver failure. Which assessment data are most important for the nurse to communicate to the health care provider? A. Asterixis and lethargy B. Jaundiced sclera and skin C. Elevated total bilirubin level D. Liver 3 cm below costal margin

A. Asterixis and lethargy This may indicate hepatic encephalopathy

A client with HIV-II is hospitalized for an unrelated condition, and several medications are prescribed in addition to the regimen already being used. What action by the nurse is most important? Consult with the pharmacy about drug interactions. A. Consult with the pharmacy about drug interactions. B. Ensure that the client understands the new medications. C. Give the new drugs without considering the old ones. D. Schedule all medications at standard times.

A. Consult with the pharmacy about drug interactions.

A client has been hospitalized with an opportunistic infection secondary to HIV-III. The client's partner is listed as the emergency contact, but the client's mother insists that she should be listed instead. What action by the nurse is best? A. Contact the social worker to assist the client with advance directives. B. Ignore the mother; the client does not want her to be involved. C. Let the client know, gently, that nurses cannot be involved in these disputes. D. Tell the client that, legally, the mother is the emergency contact.

A. Contact the social worker to assist the client with advance directives.

The nurse is caring for a client diagnosed with HIV-II. The client's CD4+ cell count is 399/mm3 (0.399 109/L). What action by the nurse is best? A. Counsel the client on safer sex practices/abstinence. B. Encourage the client to abstain from alcohol. C. Facilitate genetic testing for CD4+ CCR5/CXCR4 co-receptors. D. Help the client plan high-protein/iron meals.

A. Counsel the client on safer sex practices

An HIV-negative client who has an HIV-positive partner asks the nurse about receiving tenofovir/emtricitabine. What information is most important to teach the client about this drug? A. Does not reduce the need for safe sex practices. B. Has been taken off the market due to increases in cancer. C. Reduces the number of HIV tests you will need. D. Is only used for postexposure prophylaxis.

A. Does not reduce the need for safe sex practices.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to immediately contact the primary health care provider? A. Drainage from a fistula B. Diminished bowel sounds C. Pain at the incision site D. Nasogastric (NG) tube drainage

A. Drainage from a fistula

The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? A. Every 1 to 2 years B. Every 2 to 4 years C. Every 3 to 5 years D. When the primary health care provider recommends

A. Every 1 to 2 years

The nurse is teaching a client a client about taking elbasvir for hepatitis C. What information in the client's history would the nurse need prior to drug administration? A. History of hepatitis B B. History of kidney disease C. History of cardiac disease D. History of rectal bleeding

A. History of hepatitis B Elbasvir can cause liver toxicity

A nurse contacts the primary health care provider after reviewing a client's laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL (12.5 mmol/L) and a serum creatinine of 1.0 mg/dL (88.4 mcmol/L). What collaborative care measure would the nurse recommend? A. Intravenous fluids B.Hemodialysis C. Fluid restriction D. Urine culture and sensitivity

A. Intravenous fluids Normal BUN = 10-20, increased = dehydration

The nurse providing direct client care uses specific practices to reduce the chance of acquiring infection with human immune deficiency virus (HIV) from clients. Which practice is most effective? A. Consistent use of Standard Precautions B. Double-gloving before body fluid exposure C. Labeling charts and armbands "HIV+" D. Wearing a mask within 3 feet (1 m) of the client

A. Standard precautions

Which finding indicates to the nurse that lactulose is effective for an older adult who has advanced cirrhosis? A. The patient is alert and oriented. B. The patient denies nausea or anorexia. C. The patient's bilirubin level decreases. D. The patient has at least one stool daily.

A. The patient is alert and oriented. Lactulose helps remove ammonia from body, ammonia causes confusion so less confusion means it's working

The nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding would require immediate action by the nurse? A. Urine output via indwelling urinary catheter is 20 mL/hr B. Blood pressure increases from 110/58 to 120/62 mm Hg C. Respiratory rate decreases from 22 to 16 breaths/min D. A decrease in the client's weight by 3 lb (1.4 kg)

A. Urine output via indwelling urinary catheter is 20 mL/hr Hypovolemia from drainage of abdominal fluid too rapidly

A nurse receives hand-off report on four postoperative clients who each had total hysterectomies. Which client would the nurse assess first upon initial rounding? A. Vaginal hysterectomy: two saturated perineal pads in 2 hours B. Abdominal: temperature of 99° F (37.2° C), blood pressure of 116/74 mm Hg C. Vaginal: opened incisional edges and moderate bleeding D. Abdominal: urinary catheter output of 150 mL in the last 3 hours

A. Vaginal hysterectomy: two saturated perineal pads in 2 hours A normal amount of bleeding would be 1 saturated pad in 4 hours

Which medication taken by a patient with decreased renal function will be of most concern to the nurse? A. ibuprofen (Motrin) B. warfarin (Coumadin) C. folic acid (vitamin B9) D. penicillin (Bicillin C-R)

A. ibuprofen (Motrin) NSAIDs are nephrotoxic

International Prostate Symptom Score (I-PSS)

Assessment for Benign Prostatic Hyperplasia Based on 7 symptoms: Incomplete emptying Frequency Intermittency Urgency Weak store, Straining Nocturia Higher score = worse BPH

The nurse is assessing a client who has hepatitis C. What extrahepatic complications would the nurse anticipate? (Select all that apply.) A. Pancreatitis B. Polyarthritis C. Heart disease D. Myalgia E. Peptic ulcer disease F. Ulcerative colitis

B,C,D

A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in health teaching to reduce symptoms for this disorder? (Select all that apply.) A. "Apply heat to the ear for 20 minutes three times a day." B. "Move the head slowly to prevent worsening of the vertigo." C. "Avoid food additives such as monosodium glutamate (MSG)." D. "Quit smoking to increase blood flow to the inner ear." E. "Avoid caffeinated beverages." F. "Avoid standing on chairs, step stools, or ladders."

B,C,D,E,F

The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.) A. "Don't lift objects weighing more than 20 lb (9.1 kg)." B. "Avoid blowing your nose or sneezing." C. "Don't bend down from the waist." D. "Don't strain to have a bowel movement." E. "Avoid having sexual intercourse." F. "Don't wear tight shirt or blouse collars."

B,C,D,E,F A is not true b/c pts should not lift more than 10 lbs

A client with HIV-III has oral thrush and difficulty eating. What actions does the nurse delegate to the assistive personnel (AP)? (Select all that apply.) A. Apply oral anesthetic gels before meals. B. Assist the client with oral care every 2 hours. C. Offer the client frequent sips of cool drinks. D. Provide the client with alcohol-based mouthwash. E. Remind the client to use only a soft toothbrush. F. Offer the client soft foods like gelatin or pudding.

B,C,E,F

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

B,D Pt would experience pallor, not flushed skin & tachypnea, not shallow respirations

A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

B,E

A client has been newly diagnosed with systemic lupus erythematosus and is reviewing self-care measures with the nurse. Which statement by the client indicates a need to REVIEW the material? A. "I will avoid direct sunlight as much as possible." B. "Baby powder is good for the constant sweating." C. "Grouping errands will help prevent fatigue." D. "Rest time will have to become a priority."

B. "Baby powder is good for the constant sweating." Constant sweating isn't a symptom of SLE, other statements are correct

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the client's understanding. Which statement by the client indicates correct understanding of the teaching? A. "Some medications have been known to cause hepatitis A." B. "I may have been exposed when we ate shrimp last weekend." C. "I was infected with hepatitis A through a recent blood transfusion." D. "My infection with Epstein-Barr virus can co-infect me with hepatitis A."

B. "I may have been exposed when we ate shrimp last weekend." Hep B is transmitted via contaminated water or seafood

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic, and the family expresses distress that the patient is receiving little dietary protein. How would the nurse respond? A. "A low-protein diet will help the liver rest and will restore liver function." B. "Less protein in the diet will help prevent confusion associated with liver failure." C. "Increasing dietary protein will help the patient gain weight and muscle mass." D. "Low dietary protein is needed to prevent fluid from leaking into the abdomen."

B. "Less protein in the diet will help prevent confusion associated with liver failure." PSE has neurological symptoms, low protein diet helps reduce symptoms

A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, "I never have urinary tract infections. Why is this happening now?" How would the nurse respond? A. "Your immune system becomes less effective as you age." B. "Low estrogen levels can make the tissue more susceptible to infection." C. "You should be more careful with your personal hygiene in this area." D. "It is likely that you have an untreated sexually transmitted disease."

B. "Low estrogen levels can make the tissue more susceptible to infection." Low estrogen leads to decreased moisture/secretions which help deter bacteria

A client with metastatic prostate cancer has been prescribed leuprolide, a bisphosphonate, and flutamide. Which statement by the client warrants further investigation by the nurse? A. "I go for a short walk each day, even when I am very tired." B. "My wife has noticed my eyes looking a little yellow." "C. I ordered some looser shirts to hide my enlarging breasts." D. "Now I understand my wife's hot flashes with menopause."

B. "My wife has noticed my eyes looking a little yellow." Flutamid ecan cause liver toxicity Leuprolide can cause osteoporosis, hot flashes, and gynecomastia.

A client had a retinal detachment and has undergone surgical correction. What discharge health teaching is MOST important for the nurse to include? A. "Avoid reading, writing, or close work such as sewing." B. "Report immediate loss of vision of pain in the affected eye." C. "Keep the follow-up appointment with the ophthalmologist." D. "Remove your eye patch every hour for eyedrops."

B. "Report immediate loss of vision of pain in the affected eye." A & C are also correct, but not the most important

The nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question would the nurse ask first? A. "Are you drinking plenty of water?" B. "What medications are you taking?" C. "Have you tried laxatives or enemas?" D. "Has this type of thing ever happened before?"

B. "What medications are you taking?" Anticholinergic drugs can cause dry mouth, constipation, inability to void

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, "I'm having right belly pain and have a temperature of 101° F (38.3° C)." How would the nurse respond? A. "The anti-rejection drugs you are taking make you susceptible to infection." B. "You should go to the hospital immediately to get checked out." C. "You should take an additional dose of cyclosporine today." D. "Take acetaminophen every 4 hours until you feel better soon."

B. "You should go to the hospital immediately to get checked out." Possible transplant rejection

A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse requires communication with the primary health care provider? A. Allergy to eggs B. Allergy to sulfonamides C. Use of contact lenses D. Use of beta blockers

B. Allergy to sulfonamides Brinzolamine is not a sulfonamide, but it is very similar & can cause a similar allergic rx

What is most important for the nurse to monitor to detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices? A. Bilirubin levels B. Ammonia levels C. Potassium levels D. Prothrombin time

B. Ammonia levels

Which action should the nurse take to evaluate treatment effectiveness for a patient who has hepatic encephalopathy? A. Request that the patient stand on one foot. B. Ask the patient to extend both arms forward. C. Request that the patient walk with eyes closed. D. Ask the patient to perform the Valsalva maneuver.

B. Ask the patient to extend both arms forward. To check for ASTERIXIS (loss of control of body part, usually flapping hand)

A client with HIV-II has had a sudden decline in status with a large increase in viral load. What action would the nurse take first? A. Ask the client about travel to any foreign countries. B. Assess the client for adherence to the drug regimen. C. Determine if the client has any new sexual partners. D. Request information about new living quarters or pets.

B. Assess for adherence to drug regimen (Drugs must be taken 90% of the time to slow progression)

A client with HIV-III has been hospitalized with suspected cryptosporidiosis. What physical assessment would be most important with this condition? A. Auscultating the lungs B. Assessing mucous membranes C. Listening to bowel sounds D. Performing a neurologic examination

B. Assessing mucous membranes (crytosporidiosis causes diarrhea w/ wasting & extreme loss of fluids & electrolytes)

Nursing staff on a hospital unit are reviewing rates of health care-associated infections (HAI) of the urinary tract. Which nursing action will be most helpful in decreasing the risk for urinary HAI in patients admitted to the hospital? A. Testing urine with a dipstick daily for nitrites B. Avoiding unnecessary urinary catheterization C. Encouraging adequate oral fluid and nutritional intake D. Providing perineal hygiene to patients daily and as needed

B. Avoiding unnecessary urinary catheterization

A client is awaiting bariatric surgery in the morning. What action by the nurse is most important? A. Answering questions the client has about surgery B. Beginning venous thromboembolism prophylaxis c. Informing the client that he or she will be out of bed tomorrow d. Teaching the client about needed dietary changes

B. Beginning venous thromboembolism prophylaxis Obese pts at greater risk for DVTs, specially after surgery

A nurse is caring for a client with HIV-III who was admitted with HAND. What sign or symptom would be most important for the nurse to report to the primary health care provider? A.Nausea B. Change in pupil size C. Weeping open lesions D. Cough

B. Change in pupil size HAND = HIV associated neurocognitive disorder

A nurse is reviewing laboratory values for several clients. Which value indicates a need for a nutritional assessment? A. Client with an albumin of 3.5 g/dL B. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) C. Client with a hemoglobin of 9.8 mg/dL (98 mmol/L) D. Client with a prealbumin of 28 mg/dL

B. Client with a cholesterol of 142 mg/dL (3.7 mmol/L) Cholesterol under 160 may indicate undernutrition

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? A. Administering steroids for a positive TB test B. Correctly identifying the client prior to a blood transfusion C. Keeping the client free of the offending agent D. Providing a latex-free environment for the client

B. Correctly identifying the client prior to a blood transfusion

The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take? A. Obtain a urine specimen to check for hematuria. B. Document the information on the assessment form. C. Ask the patient about any history of recent sore throat. D. Ask the health care provider about scheduling a renal ultrasound.

B. Document the information on the assessment form. Kidneys are not always palpable, protected by other GI organs

A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? A. Administer a tetanus booster shot. B. Ensure that the client has a patent airway. C. Prepare to irrigate the client's eye. D. Turn the client on the unaffected side.

B. Ensure that the client has a patent airway.

A nurse reviews the health history of a client with an oversecretion of renin. Which disorder would the nurse correlate with this assessment finding? A. Alzheimer disease B. Hypertension C. Diabetes mellitus D. Viral hepatitis

B. Hypertension

A 78-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care? A. Limit fluid intake to no more than 1000 mL/day. B. Leave a light on in the bathroom during the night. C. Ask the patient to use a urinal so that urine can be measured. D. Pad the patient's bed to accommodate overflow incontinence.

B. Leave a light on in the bathroom during the night. Nocturia is common w/ BPH, fall prevention is important especially b/c of his age

The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome? A. Having fluid and electrolyte balance B. Maintaining normal respiratory function C. Expressing satisfaction with pain control D. Developing no ongoing pancreatic disease

B. Maintaining normal respiratory function

A nurse reviews the laboratory findings of a client with a urinary tract infection (bacterial cystitis). The laboratory report notes a "shift to the left" in the client's white blood cell count. What action would the nurse take? A. Request that the laboratory perform a differential analysis on the white blood cells. B. Notify the primary health care provider and start an intravenous line for parenteral antibiotics c. Ask assistive personnel (AP) to strain the client's urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

B. Notify the primary health care provider and start an intravenous line for parenteral antibiotics Usually occurs w/ urosepsis & must be treated, not usually seen w/ average/uncomplicated UTIs

The nurse is caring for a client who is recovering from an open traditional Whipple surgical procedure. What action would the nurse take? A. Clamp the nasogastric tube. B. Place the patient in semi-fowler C. Assess vital signs once every shift. D. Provide oral rehydration.

B. Place the patient in semi-fowler To reduce tension on suture line & promote thoracic expansion

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is appropriate to help control ascites? A. Monitor intake and output. B. Provide a low-sodium diet. C. Increase oral fluid intake. D. Weigh the patient daily.

B. Provide a low-sodium diet. Controls abdominal fluid collection (ascites)

Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B? A. Advise limiting alcohol intake to 1 drink daily. B. Schedule for liver cancer screening every 6 months. C. Initiate administration of the hepatitis C vaccine series. D. Monitor anti-hepatitis B surface antigen (anti-HBs) levels.

B. Schedule for liver cancer screening every 6 months. Higher risk for liver cancer NO alcohol intake at all

A client is admitted with acute pancreatitis. What priority problem would the nurse expect the client to report? A. Nausea and vomiting B. Severe boring abdominal pain C. Jaundice and itching D. Elevated temperature

B. Severe boring abdominal pain Usually rated a 10/10

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis? A. Palpate along both sides of the lumbar vertebral column. B. Strike a flat hand covering the costovertebral angle (CVA). C. Push fingers upward into the two lowest intercostal spaces. D. Percuss between the iliac crest and ribs at the midaxillary line.

B. Strike a flat hand covering the costovertebral angle (CVA). This is how you assess flank pain

The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk? A. Excess cerumen B. Swimming C. Sinus congestion D. Meniere disease

B. Swimming External otitis often called "swimmer's ear"

A female patient with a suspected urinary tract infection is to provide a clean-catch urine specimen for culture and sensitivity testing. What should the nurse do to obtain the specimen? A. Have the patient empty the bladder completely; then obtain the next urine specimen that the patient is able to void. B. Tell the patient to clean the urethral area, void a small amount into the toilet, then void directly into a sterile container. C. Insert a short sterile "mini" catheter attached to a collecting container into the urethra and bladder to obtain the specimen. D. Clean the area around the patient's meatus with a povidone iodine (Betadine) swab and then have the patient void into a sterile specimen cup.

B. Tell the patient to clean the urethral area, void a small amount into the toilet, then void directly into a sterile container.

When caring for a patient after cystoscopy, what should the nurse include in the plan of care? A. The patient learns to request narcotics for pain. B. The patient understands to expect blood-tinged urine. C. The patient restricts activity to bed rest for 4 to 6 hours. D. The patient remains NPO for 8 hours to prevent vomiting.

B. The patient understands to expect blood-tinged urine.

Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis? A. The patient's urine is bright yellow. B. The patient's stools are tan colored. C. The patient reports chronic heartburn. D. The patient has increased pain after eating.

B. The patient's stools are tan colored. Tan or grey stool indicate biliary obstruction

How is HIV transmitted?

Blood, semen, vaginal secretions, breast milk, amniotic fluid, CSF, pleural fluid NOT by: saliva, sweat, urine, vomit, tears, sputum

A client had a myringotomy. What would the nurse include as part of discharge teaching? A. Buy dry shampoo to use for a week. B. Drink liquids through a straw. C. Flying is not allowed for 1 month. D. Hot water showers will help the pain.

Buy dry shampoo to use for a week. Pt cannot shower for 1 week post-op, straws & flying are not allowed for 2-3 weeks post-op

A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, "Is my anemia related to my kidney problem?" How would the nurse respond? A. "Red blood cells produce erythropoietin, which increases blood flow to the kidneys." B. "Your anemia and kidney problem are related to inadequate vitamin D and a loss of bone density." C. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow." D. "Kidney insufficiency inhibits active transportation of red blood cells throughout the blood."

C. "Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow."

The client's electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? A. "Do you feel like something is in your ear?" B. "Do you have frequent ear infections?" C. "Have you been exposed to loud noises?" D. "Have you been told your ear bones don't move?"

C. "Have you been exposed to loud noises?" Other options related to conductive hearing loss

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? A. "I cannot drink any alcohol at all anymore." B. "I should not take over-the-counter medications." C. "I need to avoid protein in my diet." D. "I should eat small, frequent, balanced meals."

C. "I need to avoid protein in my diet." It should be decreased, but not entirely avoided b/c it is necessary for albumin production & normal healing

The nurse is caring for a client who has cirrhosis from substance abuse. The client states, "All of my family hates me." How would the nurse respond? A. "You should make peace with your family." B. "This is not unusual. My family hates me too." C. "I will help you identify a support system." D. "You must attend Alcoholics Anonymous."

C. "I will help you identify a support system."

A nurse has presented an educational program to a community group on Lyme disease. What statement by a participant indicates the need to REVIEW the material? A. "I should take precautions against ticks, especially in the summer." B. "A red rash that looks like a bull's-eye may be one of the symptoms." C. "If Lyme disease is not treated successfully, it is usually fatal." D. "For Stage I disease, antibiotics are usually needed for 14 to 21 days."

C. "If Lyme disease is not treated successfully, it is usually fatal." Can cause chronic complications or stage III lyme, but usually not fatal

A client with pneumonia and dementia is admitted with an indwelling urinary catheter in place. During interprofessional rounds the following day, which question would the nurse ask the primary health care provider? A. "Do you want daily weights on this client?" B. "Will the client be able to return home?" C. "May we discontinue the indwelling catheter?" D. "Should we get another chest x-ray today?"

C. "May we discontinue the indwelling catheter?" Poses increased risk for UTIs - indwelling catheter should only be in if needed

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the client's understanding. Which statement by the client indicates a need for FURTHER teaching? A. "The capsules can be opened & sprinkled on applesauce if needed." B. "I will wipe my lips carefully after I drink the enzyme preparation." C. "The best time to take the enzymes is immediately after I have a meal or a snack." D. "I will not mix the enzyme powder with food or liquids that contain protein."

C. "The best time to take the enzymes is immediately after I have a meal or a snack." Enzymes should be taken immediately BEFORE meals or snacks

A client with HIV-III asks the nurse why gabapentin is part of the drug regimen when the client does not have a history of seizures. What response by the nurse is best? A. "Gabapentin can be used as an antidepressant too." B. "I have no idea why you would be taking this drug." C. "This drug helps treat the pain from nerve irritation." D. "You are at risk for seizures due to fungal infections."

C. "This drug helps treat the pain from nerve irritation."

A nurse teaches a client who is starting urinary bladder training. Which statement would the nurse include in this client's teaching? A. "Use the toilet when you first feel the urge, rather than at specific intervals." B. "Initially try to use the toilet at least every half hour for the first 24 hours." C. "Try to consciously hold your urine until the scheduled toileting time." D. "The toileting interval can be increased once you have been continent for a week."

C. "Try to consciously hold your urine until the scheduled toileting time." This is to train bladder & reduce incontinence

A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What statement by the nurse is appropriate? A. "You should check with your primary health care provider about eye examination." B. "You should have genetic testing to determine your risk for glaucoma." C. "You should have your intraocular pressure measured once or twice a year." "D. You should check with your primary health care provider about preventive drug therapy."

C. "You should have your intraocular pressure measured once or twice a year." Glaucoma occurs more often in pts w/ a family history of it

The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation? A. "You will receive general anesthesia for the surgical procedure." B. "You will be in the hospital for only 1 to 2 days if everything goes as expected." C. "You will need to put several types of eyedrops in your eyes before and after surgery." D. "You will be on bedrest for about a week after the surgical procedure."

C. "You will need to put several types of eyedrops in your eyes before and after surgery." This surgery is done at an ambulatory center & does not require bedrest post-op

A patient passing bloody urine has scheduled a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate? A. "Your doctor will place a catheter into an artery in your groin and inject a dye to visualize the blood supply to the kidneys." B. "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into your kidneys." C. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye to outline your bladder on x-ray." D."Your doctor will inject a radioactive solution into a vein in your arm, then the isotope in your kidneys and bladder will be visible on a scanner."

C. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye to outline your bladder on x-ray."

Which nursing action is essential for a patient immediately after a renal biopsy? A. Insert a urinary catheter and test urine for microscopic hematuria. B. Check blood glucose to assess for hyperglycemia or hypoglycemia. C. Apply a pressure dressing and position the patient on the affected side. D. Monitor blood urea nitrogen (BUN) and creatinine to assess renal function.

C. Apply a pressure dressing and position the patient on the affected side. The pressure prevents bleeding from the biopsy

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take? A. Notify the patient's health care provider. B. Teach correct midstream urine collection. C. Ask the patient about current medications. D. Question the patient about urinary tract infection risk factors.

C. Ask the patient about current medications. Some drugs can alter the color of urine

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, "My pain has suddenly increased from a 3 to a 10 on a scale of 0-10." Which action would the nurse take first? A.Reposition the client on the operative side. B. Administer the prescribed opioid analgesic. C. Assess the client's pulse rate and blood pressure. D. Examine the color of the client's urine.

C. Assess the client's pulse rate and blood pressure. Sudden pain increase may indicate hemorrhage

A 68-yr-old patient admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action should be included in the plan of care? A. Restrict fluids between meals and after the evening meal. B. Insert an indwelling catheter until the symptoms have resolved. C. Assist the patient to the bathroom every 2 hours during the day. D. Apply absorbent adult incontinence diapers and pads over the bed linens.

C. Assist the patient to the bathroom every 2 hours during the day.

A 68-yr-old male patient who has bladder cancer had a cystectomy with creation of an Indiana pouch. Which topic will be included in patient teaching? A. Application of ostomy appliances B. Barrier products for skin protection C. Catheterization technique and schedule D. Analgesic use before emptying the pouch

C. Catheterization technique and schedule Indiana pouch allows for pt to self-catheterize every 4-6 hours without need of an ostomy device The pouch resembles a bladder (for those w/ severe bladder issues) & holds urine, rather than it being excreted via the urethra

Which action should the nurse in the emergency department take first for a new patient who is vomiting blood? A. Insert a large-gauge IV catheter. B. Draw blood for coagulation studies. C. Check blood pressure and heart rate. D. Place the patient in the supine position.

C. Check blood pressure and heart rate.

The nurse is examining an adult patient. For what purpose would the nurse use palpation? A. Determining kidney function B. Identifying renal artery bruits C. Checking for bladder distention D. Assessing for ureteral peristalsis

C. Checking for bladder distention Other forms of assessment would be used for other choices

A nurse assesses a client who has cholecystitis. Which sign or symptom indicates that this condition is chronic rather than acute? A. Temperature of 100.1° F (37.8° C) B. Positive Murphy sign C. Clay-colored stools D. Upper abdominal pain after eating

C. Clay-colored stools Clay stool & jaundice are more chronic symptoms

A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? A. It blocks the release of luteinizing hormone. B. It interferes with cancer cell division. C. It selectively blocks estrogen in the breast. D. It inhibits DNA synthesis in rapidly dividing cells.

C. It selectively blocks estrogen in the breast. Reduced breast estrogen stops or slows growth of tumors

The nurse is caring for a client who has a risk gene for developing cirrhosis. Which racial/ethnic group has this gene most often? A. Blacks B. Asian/Pacific Islanders C. Latinos D. French

C. Latinos PNPLA3 gene in Latinos increases risk

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis? A. Nausea and vomiting B. Hypotonic bowel sounds C. Muscle twitching and finger numbness D. Upper abdominal tenderness and guarding

C. Muscle twitching and finger numbness Indicates hypocalcemia & possibly tetany

Which finding in a female client by the nurse would receive the highest priority for further diagnostics? A. Tender moveable masses throughout the breast tissue B. Nipple discharge without a palpable mass C. Nontender fixed mass in the upper outer quadrant of the breast D. Small, painful mass under warm reddened skin and nipple discharge

C. Nontender fixed mass in the upper outer quadrant of the breast Malignant lesions are fixed, hard and irregularly shaped and this lesion would be the priority for further diagnostic study The others have benign characteristics

A client who is nearly blind is admitted to the hospital. What action by the nurse is most important? A. Allow the client to feel his or her way around. B. Let the client arrange objects on the bedside table. C. Orient the client to the room using a focal point. D. Speak loudly and slowing when talking to the client.

C. Orient the client to the room using a focal point.

The nurse assesses a client who has possible bladder cancer. What common assessment finding associated with this type of cancer would the nurse expect? A. Urinary retention B. Urinary incontinence C. Painless hematuria D. Difficulty urinating

C. Painless hematuria

A patient admitted to the hospital with pneumonia has a history of functional urinary incontinence. Which nursing action will be included in the plan of care? A. Demonstrate the use of the Credé maneuver. B. Teach exercises to strengthen the pelvic floor. C. Place a bedside commode close to the patient's bed. D. Use an ultrasound scanner to check postvoiding residuals.

C. Place a bedside commode close to the patient's bed.

A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? A. Assess vital signs every 15 minutes. B. Dim or turn off lights in the client's room. C. Place the client in bed with the upper side rails up. D. Provide a cool, wet cloth for the client's face.

C. Place the client in bed with the upper side rails up. Meniere disease results in severe vertigo (fall risk), it's a chronic ear disorder that also results in hearing changes/tinnitus

A client who had minimally invasive bypass gastric surgery 2 days ago reports new-onset of severe abdominal pain. What is the nurse's best action as this time? A. Listen to the client's bowel sounds. B. Call the Rapid Response Team. C. Take the client's vital signs. D. Contact the primary health care provider.

C. Take the client's vital signs. May have tachycardia & hypotension

A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? A. Educate the client on corneal transplantation. B. Facilitate scheduling the eye surgery. C. Teach about drugs for glaucoma. D. Refer the patient to local Braille classes.

C. Teach about drugs for glaucoma. Normal IOP = 10-20

A client has external otitis. About what comfort measure would the nurse instruct the client? A. Applying ice four times a day B. Instilling vinegar-and-water drops C. Use of a heating pad to the ear D. Using a home humidifier

C. Use of a heating pad to the ear

Which information from a patient's urinalysis requires that the nurse notify the health care provider? A. pH 6.2 B. Trace protein C. WBC 20 to 26/hpf D. Specific gravity 1.021

C. WBC 20 to 26/hpf Indicates UTI

A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to: A. perform leg exercises hourly while awake. B. ambulate the evening of the operative day. C. turn, cough, and deep breathe every 2 hours. D. choose preferred low-fat foods from the menu.

C. turn, cough, and deep breathe every 2 hours. Prevention of respiratory complications

Overflow incontinence

Constant dribbling of urine

Which statement by a patient who had a cystoscopy the previous day should the nurse report immediately to the health care provider? A. "My urine looks pink." B. "My IV site is bruised." C. "My sleep was restless." D. "My temperature is 101."

D. "My temperature is 101."

The nurse is preparing to teach a client with chronic hepatitis B about lamivudine therapy. What health teaching would the nurse include? A."Follow up on all appointments to monitor your lab values." B. "Do not take amiodorone at any time while on this drug." C. "Monitor for jaundice, rash, and itchy skin while on this drug." D. "Report any changes in urinary elimination while on this drug."

D. "Report any changes in urinary elimination while on this drug." It can cause kidney impairment

A nurse teaches a client with functional urinary incontinence. Which statement would the nurse include in this client's teaching? A. "You must clean around your catheter daily with soap and water." B. "You will need to be on your drug therapy for life." C. "Operations to repair your bladder are available, and you can consider these." D. "You might want to get pants with elastic waistbands."

D. "You might want to get pants with elastic waistbands." Allows for easier access when urgency occurs, functional UI is related to the usually slow ambulation to the toilet, not the bladder itself

A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? A. Withhold both drugs. B. Administer both drugs. C. Administer the furosemide. D. Administer the spironolactone.

D. Administer the spironolactone. Spironolactone is a potassium sparing diuretic, administering it will help increase pt's potassium level (3.5-5)

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? A. Heart disease B. Glaucoma C. Diabetes mellitus D. Advanced age

D. Advanced age Lens lose water & lens fibers are more compact as we age

Which focused data should the nurse assess after identifying 4+ pitting edema on a patient who has cirrhosis? A. Hemoglobin B. Temperature C. Activity level D. Albumin level

D. Albumin level

The nurse is caring for a client who is scheduled for a paracentesis. Which action is appropriate for the nurse to take? A. Have the client sign the informed consent form. B. Get the patient into a chair before the procedure. C. Help the client lie flat in bed on the right side. D. Assist the client to void before the procedure.

D. Assist the client to void before the procedure. Reduce risk of puncturing bladder b/c it is empty/smaller

A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an annual physical examination. Which area of increased risk should the nurse plan to teach the patient? A. Renal failure B. Kidney stones C. Pyelonephritis D. Bladder cancer

D. Bladder cancer

The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? A. Diplopia B. Cloudy pupil C. Loss of peripheral vision D. Blurred vision

D. Blurred vision 1st sign blurred vision & photosensitivity, cloudy pupil is a LATE sign

The nurse is caring for a client scheduled to have a transjugular intrahepatic portal-systemic shunt (TIPS) procedure. What client assessment would the nurse perform prior to this procedure? A. Musculoskeletal assessment B. Neurologic assessment C. Mental health assessment D. Cardiovascular assessment

D. Cardiovascular assessment Complication of TIPS is right-sided HF

A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first? A. Client with intraocular pressure reading of 24 mm Hg B. Client with a tearing, reddened eye with exudate C. Client whose red reflex is absent on ophthalmologic examination D. Client who has had cataract surgery and has worsening vision

D. Client who has had cataract surgery and has worsening vision

A client had an open traditional Whipple procedure this morning. For what priority complication would the nurse assess? A. Urinary tract infection B. Chronic kidney disease C. Heart failure D. Fluid and electrolyte imbalances

D. Fluid and electrolyte imbalances Whipple procedure removes cancerous tumors from head of pancreas Long procedure can cause fluid/electrolyte imbalances

A client with HIV-III and wasting syndrome has inadequate nutrition. What assessment finding by the nurse best indicates that goals have been met for this client problem? A. Chooses high-protein food. B. Has decreased oral discomfort. C. Eats 90% of meals and snacks. D. Has a weight gain of 2 lb (1 kg)/1 mo.

D. Has a weight gain of 2 lb (1 kg)/1 mo.

The nurse is caring for a client who has cirrhosis of the liver. Which risk factor is the leading cause of cirrhosis? A. Metabolic syndrome B. Liver cancer C. Nonalcoholic fatty liver disease D. Hepatitis C

D. Hepatitis C

A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? A. Ask the client about excessive salivation. B. Take the client's blood pressure and temperature. C. Give the drops using punctal occlusion. D. Hold the eyedrops and notify the primary health care provider.

D. Hold the eyedrops and notify the primary health care provider. Timolol is a beta blocker & can slow HR

The nurse teaches a client who has stress incontinence methods to regain more urinary continence. Which health teaching is the most important for the nurse to include for this client? A. What type of incontinence pads to use? B. What types of liquids to drink and when? C. Need to perform intermittent catheterizations. D. How to do Kegel exercises to strengthen muscles?

D. How to do Kegel exercises to strengthen muscles? Strengthens the pelvic floor to reduce incontinence

A nurse cares for a client with a urine specific gravity of 1.040. What action would the nurse take? A. Obtain a urine culture and sensitivity. B. Place the client on restricted fluids. C. Assess the client's creatinine level. D. Increase the client's fluid intake.

D. Increase the client's fluid intake. Normal USG = 1.005 - 1.030, higher indicates dehydration

A client with HIV-III is admitted to the hospital with Toxoplasma gondii infection. Which action by the nurse is most appropriate? A. Initiate Contact Precautions. B. Conduct frequent neurologic assessments. C. Conduct frequent respiratory assessments. D. Initiate Protective Precautions.

D. Initiate Protective Precautions. (Toxoplasma gondii is extremely opportunistic & other immunosuppressed pts should be protected)

A nurse is teaching the client with systemic lupus erythematosus about prednisone. What information is the priority? A. Might make the client feel jittery or nervous. B. Can cause sodium and fluid retention. C. Long-term effects include fat redistribution. D. Never stop prednisone abruptly.

D. Never stop prednisone abruptly. Can lead to adrenal crisis, short term side effects include jitteriness & water retention

A client is hospitalized with Pneumocystis jiroveci pneumonia. The client reports shortness of breath with activity and extreme fatigue. What intervention is best to promote comfort? A. Administer sleeping medication. B. Perform most activities for the client. C. Increase the client's oxygen during activity. D. Pace activities, allowing for adequate rest.

D. Pace activities, allowing for adequate rest.

A nurse is considering which patient to admit to the same room as a patient who is hospitalized with acute rejection 3 weeks after a liver transplant. Which patient would be the best choice? A. Patient who is receiving chemotherapy for liver cancer B. Patient who is receiving treatment for acute hepatitis C C. Patient who has a wound infection after cholecystectomy D. Patient who requires pain management for chronic pancreatitis

D. Patient who requires pain management for chronic pancreatitis Other options are currently infected or at risk for it

A nurse reviews the urinalysis of a client and notes the presence of glucose. What action would the nurse take? A. Document findings and continue to monitor the client. B. Contact the primary health care provider and recommend a 24-hour urine test. C. Review the client's recent dietary selections over 3 days. D. Perform a finger stick blood glucose assessment.

D. Perform a finger stick blood glucose assessment. Glucose is not normally found in urine, may be hyperglycemic

A patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care? A. Restrict daily dietary protein intake. B. Reposition the patient every 4 hours. C. Perform passive range of motion twice daily. D. Place the patient on a pressure-relief mattress.

D. Place the patient on a pressure-relief mattress. Pt should be repositioning more frequently than q4hrs

A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? A. High fever B. Nausea and vomiting C.Elevated blood pressure D. Purulent ear drainage

D. Purulent ear drainage Likely otitis media or serous otitis which can cause tympanic eardrum perforation, leading to drainage

The outpatient clinic nurse has assessed a woman who reports a month-long history of feeling full, urinary frequency, and bloating. What action by the nurse is best? A. Obtain a clean catch urine specimen. B. Instruct the client on a 3-day diet history. C. Facilitate having a pelvic ultrasound. D. Teach the woman about CA-125 test.

D. Teach the woman about CA-125 test. This is a cancer antigen test, early signs of ovarian cancer include abdominal bloating, urinary frequency or urgency, feeling full or difficulty eating, and pelvic pain.

Cullen's sign

Ecchymosis/blue in umbilical area, seen with pancreatitis

Turner sign

Ecchymosis/blue on the flank area, seen with pancreatitis

Cirrhosis of liver lab findings

Elevated INR Elevated serum ammonia Elevated PT

Functions of the liver

Filtration, bile production, digestion, metabolizing, detoxifying, vitamin/mineral storage

What is ascites?

Fluid in the peritoneal cavity, causing abdominal swelling, 3rd spacing occurs Complication of cirrhosis and/or portal hypertension

What is portal hypertension?

Increased pressure in the portal venous system from increased resistance or block of blood through portal vein Complication of cirrhosis Blood back flow can cause splenomegaly (enlarged spleen) PVS connects spleen, GI tract, liver via veins/capillaries

What does creatinine clearance measure?

It approximates the GFR Expected GFR = 125 mL/min & 180 L/day But only 1-3 L are excreted via urine/day - if more it can cause dehydration

Erectile Dysfunction types

Organic ED: gradual deterioration of erections, can be linked w/ other issues such as DM or obesity Psychogenic: episodic, usually comes w/ periods of high stress, will likely still have typical noctural/morning erections though

Age related ear changes

Pinna elongates, coarser/longer hair in ear, wax is drier & impacts easily, tympanic membranes loses elasticity/looks dull, decreased hearing acuity especially w/ high freq. & f, s, sh, pa sounds

What is PEP and cART?

Post-exposure prophylaxis for individuals that know they were or may have been exposed (accidental needle prick at work, sex w/ sex worker) cART is combo antiretroviral therapy - should be started ASAP after possible exposure

What is PrEP and what are the recommended drugs for it?

Pre-exposure prophylaxis for individuals w/ increased risk for getting HIV (gay men, IV drug users, etc.) -Truvada (tenofovir/emtricitabine) -Discovy (emtricitabine/tenofovir) -does not reduce need for safe sex practices

What is cirrhosis?

Scaring of liver, usually firm/enlarged & as it worsens the kidney shrinks Decreased liver function -Post-necrotic from Hep C -Laennec's from alcoholism -Biliary from chronic biliary obstruction or autoimmune disease (AKA cholestatic)

Prostate cancer

Slowest growing, most predictable pattern cancer Advanced age is greatest risk, also effects African Americans more freq. Eating more plants compared to animal fat proven to slow progression Men at 55-69 should decide w/ HCP if they should screen If 1st degree relative had it, screening should start at 45 S/S: problems w/ urination, hematuria, nocturne, pain while ejaculating, or hip/leg pain, changes in libido/function, or unintended weight loss

Cephalexin & Amoxil pt teaching

Teach pt to use second form of birth control (condom, abstinence) b/c it can reduce the effectiveness

What is hepatic encephalopathy?

The loss of brain function when a damaged liver doesn't remove toxins from the blood Result of cirrhosis & liver failure 4 stages s/s: personality changes, slurred speech, poor sleep pattern, disoriented & losing independence as it worsens Reversible in early stage w/ low protein diet...

Urge incontinence

Urination upon sudden urge to void Common w/ BPH, bladder cancer

Stress incontinence

Urine loss with unrelated physical exertion such as coughing, laughing, etc. Common w/ childbirth, obesity, post-menopausal women

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

a. A 20-year-old college student who has had several sexual partners Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route

A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

a. A 78-year-old female who is confused Forming a habit/schedule helps pt remember to urinate more frequently, decreasing urgency

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. Ambulating in the hallway twice a day will help. b. I will apply a cold compress to the painful area on your back. c. Drinking a warm beverage can relieve this referred pain. d. You should cough and deep breathe every hour.

a. Ambulating in the hallway twice a day will help. There is likely retention of CO2 in body, ambulating will help w/ better oxygen exchange

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond? a. Bile salts accumulate in the skin and cause the itching. b. Toxins released from an inflamed gallbladder lead to itching. c. Itching is caused by the release of calcium into the skin. d. Itching is caused by a hypersensitivity reaction.

a. Bile salts accumulate in the skin and cause the itching.

A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation c. A 64-year-old female with Alzheimers-type senile dementia Bladder training d. A 77-year-old female who has difficulty ambulating Exercise therapy

b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation

A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the clients capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

a. Contact the provider and recommend discontinuing the metformin.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

b. Assess the client by gently palpating the abdomen for tenderness. The liver is often injured from a MVA/the steering wheel

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home?b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?

a. Do you have a one- or two-story home? Strength will be limited and activity should be increased slowly

A 76-yr-old with benign prostatic hyperplasia (BPH) is agitated and confused, with a markedly distended bladder. Which intervention prescribed by the health care provider should the nurse implement first? a. Insert an indwelling urinary catheter. b. Draw blood for a serum creatinine level. c. Schedule an intravenous pyelogram (IVP). d. Administer lorazepam (Ativan) 0.5 mg PO.

a. Insert an indwelling urinary catheter. Will relieve retention caused by BPH

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.

a. Instruct the client to sit in as upright a position as possible. Thoracic expansion will improve gas exchange

Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis? a. Lipase b. Calcium c. Bilirubin d. Potassium

a. Lipase

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/kg (1200 mmol/kg). Which action would the nurse take? a. Contact the primary health care provider to recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Encourage the client to drink more fluids. d. Obtain a suction device and implement seizure precautions.

c. Encourage the client to drink more fluids. Normal urine osmolality is 300-900, higher = dehydration

Which goal has the highest priority in the plan of care for a 26-yr-old patient who was admitted with viral hepatitis, has severe anorexia and fatigue, and is homeless? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify source of hepatitis exposure.

b. Maintain adequate nutrition. Needed for regeneration of liver

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.

b. Maintain nothing by mouth (NPO) and administer intravenous fluids. NPO to reduce GI activity, pain should be addressed more frequently/around the clock, fetal position w/ legs drawn into chest will provide comfort

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.

c. Have you passed any flatus or moved your bowels? Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved

A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

b. Overflow incontinence

The home health nurse teaches a patient with a neurogenic bladder how to use intermittent catheterization for bladder emptying. Which patient statement indicates that the teaching has been effective? a. "I will buy seven new catheters weekly and use a new one every day." b. "I will use a sterile catheter and gloves for each time I self-catheterize." c. "I will clean the catheter carefully before and after each catheterization." d. "I will take prophylactic antibiotics to prevent any urinary tract infections."

c. "I will clean the catheter carefully before and after each catheterization." Pts can use clean technique at home, change catheter every 7 days, no need for prophylactic antibiotics

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity

c. A 50-year-old who has the BRCA2 gene mutation

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

c. A 58-year-old female who is not taking estrogen replacement Lower estrogen results in less vaginal mucous to protect from bacteria entering body

The nurse is caring for a patient with pancreatic cancer. Which nursing action is the highest priority? a. Offer psychologic support for depression. b. Offer high-calorie, high-protein dietary choices. c. Administer prescribed opioids to relieve pain as needed. d. Teach about the need to avoid scratching any pruritic areas.

c. Administer prescribed opioids to relieve pain as needed. Pain must be managed in order for pt to comfortably eat/maintain nutrition

A patient born in 1955 had hepatitis A infection 1 year ago. According to CDC guidelines, which should the nurse include in this pt's plan of care during a routine physical? a. Start the hepatitis B immunization series. b. Teach the patient about hepatitis A immune globulin. c. Ask whether the patient has been screened for hepatitis C. d. Test for anti-hepatitis-A virus immune globulin M (anti-HAV-IgM).

c. Ask whether the patient has been screened for hepatitis C "baby boomers" between year 1945-1965 have a higher risk for developing hep c

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

d. Mid-sternal chest pain It is indicative of angina or MI

Transurethral resection of the prostate (TURP)

the surgical cure for BPH instrument inserted through the penile urethra is used to partially cut away the prostate to relieve obstruction of the urinary tract pt will have indwelling catheter in after, can expect blood-tinged urine, report headache & dizziness to HCP