Med Surg Practice A

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). A new bag is not available when the current infusion is nearly completed. Which of the following actions should the nurse take?

Administer dextrose 10% in water until the new bag arrives.

A nurse is caring for a client who has a new precription for TPN. The client is to receive 2,000 kcal per day. The TPN has 500 kcal/L. The IV pump should be set at how many mL/hr?

167 ml/hr

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

A. "I am dieting to lose weight." R. Excess weight creates increased abdominal pressure that can result in stress incontinence.

A nurse is providing teaching to a client who has chronic kidney disease and a new prescription for erythropoietin. Which of the following statements by the client indicates an understanding of the teaching?

A. "I am taking this medication to increase my energy level." R. The goal of erythropoietin therapy is to increase the level of hematocrit in clients who have anemia. When the medication is effective, the client should have a decrease in fatigue and an improvement in activity tolerance.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

A. "I should take this medication with a meal." R. The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.

A nurse is evaluating a client who has a new diagnosis of type 1 DM. Which of the following client statements indicates the client is successfully coping with the change?

A. "I used to never worry about my feet. Now, I inspect my feet every day with a mirror." R. This statement indicates that the client is successfully coping with the change because the client is performing preventive foot care to reduce the risk for complications.

A nurse is providing a teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which statements should the nurse identify as an indication that the client understands the teacing?

A. "I will use my hands rather than a washcloth toD clean the radiation area." R. The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is teaching a client who has venous insufficiency about self-care. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

A. "I will wear clean graduated compression stockings every day." R. When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly.

A nurse is caring for a client who has type 1 DM and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

A. "Take insulin even if you are unable to eat your regular diet." R. The client should continue the prescribed medication regimen when ill to prevent hyperglycemia.

A nurse is planning teaching for a client who has bladder cancer and is to undergo a cutaneous diversion procedure to establish a ureterostomy. Which of the following statements should the nurse include in the teaching?

A. "You should cut the opening of the skin barrier one-eighth inch wider than the stoma." R. The client should cut the opening of the skin barrier 0.3 cm (1/8-in) wider than the stoma to minimize irritation of the skin from exposure to urine.

A nurse in provider office is caring for a client who requests slidenail to treat erectile dysfunction. Which of the following statement should the nurse make?

A. "You will not be able to use sildenafil if you are taking nitroglycerin." R. The client should not use sildenafil when taking nitroglycerin because both medications can cause vasodilation and lead to significant hypotension.

A nurse is providing dietary teaching to a client who is postop following a thyroidectomy with removal of parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium?

A. 12 almonds R. The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

A nurse is teaching a class about client rights. Which of the following instructions should the nurse include?

A. A client should sign an informed consent before receiving a placebo during a research trial. R. A nurse should ensure a client has provided informed consent before administering a placebo. The nurse should not administer a placebo to a client who thinks it is an active medication, because this action is a violation of client rights

A nurse has recieved changed of shift report for a group of clients which of the following clients should the nurse assess first?

A. A client who had a MI 4 days ago and is asking for a PRN sublingual nitro tablet R. When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.

A nurse is assessing a group of clients for indications of role changes. The nurse should identify that which of the following clients is at risk for experiencing a role change?

A. A client who has multiple sclerosis and is experiencing progressive difficulty ambulating R. The nurse should identify that progression of a neurologic disease such as multiple sclerosis can lead to a role change as the client becomes less independent.

A nurse is caring for a group of clients. The nurse should plan to make a referral to physical therapy for which of the following clients?

A. A client who is receiving preoperative teaching for a right knee arthroplasty R. The nurse should make a referral to physical therapy for a client who is receiving preoperative teaching for a knee arthroplasty so the client can begin understanding postoperative exercises and physical restrictions.

A nurse is teaching a client who has a family history of colorectal cancer. To help mitigate this risk, which of the following dietary alterations should the nurse recommend?

A. Add cabbage to the diet. R. To help reduce the risk for colorectal cancer, the client should consume a diet that is high in fiber, low in fat, and low in refined carbohydrates. Brassica vegetables, such as cabbage, cauliflower, and broccoli, are high in fiber.

A nurse in an emergency department is reviewing the providers prescriptions for a client who sustained a rattlesnake bite to the lower leg. Which should the nurse expect?

A. Administer and opioid analgesic to the client R. The nurse should expect a prescription for an opioid analgesic to promote comfort following a rattlesnake bite.

A nurse in community clinic is caring for a client who reports an increase in frequency of migraine headaches. To reduce the risk for headaches, which food should he avoid?

A. Aged cheese R. Foods that contain tyramine, such as aged cheese and sausage, can trigger migraine headaches.

A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority?

A. Apply firm pressure to the insertion site. R. The greatest risk to the client is bleeding. Therefore, the priority intervention is for the nurse to apply firm pressure to the hematoma to stop the bleeding.

A nurse is planning care for a client who has burns and is immunocompromised. Which precautions should the nurse include in the plan of care to rpevent pseudomonas aeruginosa?

A. Avoid placing plants in the room R. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report?

A. BP 170/80 R. Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

A nurse is caring for a client who has DKA. Which of the following lab finding should be expected?

A. BUN 32 R. DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad?

A. Bradycadria R. A client who has increased intracranial pressure from a traumatic brain injury can develop bradycardia, which is one component of Cushing's triad. The other components of Cushing's triad are severe hypertension and a widened pulse pressure.

A nurse is caring for a client who has pancreatitis. Which of the labs should be expected?

A. Calcium R. A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is providing teaching to a client who has hypothyroidism and is receicing levothyroxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medications?

A. Calcium R. Calcium limits the development of osteoporosis in clients who are postmenopausal and works as an antacid. Calcium supplements can interfere with the metabolism of a number of medications, including levothyroxine. The nurse should instruct the client to avoid taking calcium within 4 hr of levothyroxine administration.

A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?

A. Calcium carbonate R. Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.

A nurse is performing a dressing change for a client who is recovering from a hemicolectomy. When removing the dressing, the nurse notes that a large part of the bowel is protruding through the abdomen. Which of the following actions should the nurse take first?

A. Call for help. R. Evidence-based practice indicates that the nurse should first stay with the client and call for assistance. The client will require emergency surgery and is at risk for shock; therefore, the nurse should obtain immediate assistance.

A nurse is assessing a client who has a had a plaster cast applied to their left leg 2 hr ago.Which of the following actions should the nurse take?

A. Check that one finger fits between the cast and the leg. R. To make sure the cast is not too tight, the nurse should be able to slide one finger under the cast. It is not uncommon for casts to loosen as swelling subsides, but that should not be an issue 2 hr after application.

A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings?

A. Current medications R. The nurse should review the client's medication record and identify medications, including ACE inhibitors, beta blockers, theophylline, nifedipine, and glucocorticoids, such as prednisone, that can alter the allergy skin test results. These medications can diminish the client's reaction to the allergens. The nurse should notify the provider and instruct the client to discontinue prednisone for 2 weeks before allergy skin testing.

A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIV treatment?

A. Decreased viral load R. Viral load testing measures the presence of HIV viral genetic material. Therefore, a decreased viral load indicates a positive response to the prescribed HIV treatment.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

A. Demonstrate ways to deep breathe and cough. R. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the prescribed meds should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

A. Digoxin R. Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.

A nurse is assessing a client who has had a suspected stroke. The nurse should place the priority on which of the following findings?

A. Dysphagia R. Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following lboratory values should the nurse expect?

A. Elevated bilirubin level R. Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

A nurse is in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

A. Ensure that the client has a patent IV. R. The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse in an emergency department is caring for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should indicate to the nurse that the client is experiencing fluid volume deficit?

A. HR of 110/min R. A client who has a 3-day history of vomiting and diarrhea is likely to have fluid volume deficit and an elevated heart rate.

A nurse is caring for a client who presents to a clinic for a 1-week follow up visit after hospitalization for HF. Based on the information in the client's chart, which of the following findings should the nurse report to the provider?

A. Heart rate 55/min R. The client's heart rate of 55/min is a decrease from the client's baseline of 74/min, and it can indicate the development of digoxin toxicity. The nurse should report this finding to the provider.

A nurse is caring for a client who is postop following a total hip arthroplaty. Which of the following lab values should the nurse report to the provider?

A. Hgb 8 g/dL R. The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.

A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further assessment?

A. History of asthma R. A client who has a history of asthma has a greater risk of reacting to the contrast dye used during the procedure. Other conditions that can result in a reaction to contrast media include allergies to foods, such as shellfish, eggs, milk, and chocolate.

A nurse is caring for a client who has chronic glomerulonphritis with oliguria. Which of the findings should the nurse identify as a manifestation?

A. Hyperkalemia R. The nurse should identify that a client who has chronic glomerulonephritis can experience hyperkalemia as a result of kidney failure. Kidney failure results in decreased excretion of potassium.

A nurse is caring for a client who has potassium level of 3 meq/L. Which of the following assessment findings should the nurse expect?

A. Hypoactive bowel sounds R. Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

A nurse is caring for a client who has hepatic encephalopthy that is being treated with lactulose. The client is experiencing excessive stools. Which of the folllowing findings is an adverse effect of the medication?

A. Hypokalemia R. Lactulose works by stimulating the production of excess stools to rid the body of excess ammonia. These excessive stools can result in hypokalemia and dehydration

A nurse in an emergency department is caring for a client who has full-thickness burns over 20% of their total body surface area. After ensuring a patent airway and administering oxygen, which of the following items should the nurse prepare to administer first?

A. IV fluids R. After establishing that the client's airway is secure and administering oxygen, evidence-based practice indicates that the nurse should prepare to administer IV fluids to provide circulatory support.

A nurse is providing teaching to a client who has IBS. Which of the following instructions should the nurse include in the teaching?

A. Increase fiber intake to at least 30 g per day. R. DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse is providing discharge instructions to a client following an upper GI seris with barium contrast. Which information should the nurse provide?

A. Increase fluid intake R. Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority?

A. Increased respiratory secretions R. Using the airway, breathing, circulation approach to client care, the nurse should determine that the priority assessment finding is increased respiratory secretions. These secretions place the client at risk for aspiration pneumonia due to respiratory muscle weakness caused by the ALS and the pneumonia.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

A. Initiate airborne precautions R. This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions

A nurse is caring for a client who is on bed rest and has a new prescription for enoxaprin subQ. Which of the following actions should the nurse take?

A. Inject the medication into the anterolateral abdominal wall. R. The nurse should inject the medication into the anterolateral or posterolateral abdominal wall to enhance medication absorption and prevent hematoma formation.

A nurse is caring for a client who is receiving morphine for daily dressing changes. The client tells the nurse, "I don't want any more morphine because I don't want to get addicted." Which of the following actions should the nurse take?

A. Instruct the client on alternative therapies for pain reduction. R. The nurse should respect the client's concerns and offer nonpharmacologic alternatives to pain management, such as relaxing activities and distraction.

A nurse is caring for a client who has emphysema and is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first?

A. Instruct the client to allow the machine to breathe for them. R. When providing client care, the nurse should first use the least restrictive intervention. Therefore, the first action the nurse should take is to provide verbal instructions and emotional support to help the client relax and allow the ventilator to work. Clients can exhibit anxiety and restlessness when trying to "fight the ventilator."

A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report?

A. It's like a curtain closed over my eye R. A retinal detachment is the separation of the retina from the epithelium. It can occur because of trauma, cataract surgery, retinopathy, or uveitis. Clients who have retinal detachment typically report the sensation of a curtain being pulled over part of the visual field.

A nurse is assessing a client who has Graves' disease. Which of the following images should indicate to the nurse that the client has exophthalmos?

A. Lady with popped out eyes R. The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve.

A nurse is performing a cardiac assessment for a client who had a myocardial infarction 2 days ago. Which of the following actions should the nurse take first after hearing the following sound? (Click on the audio button to listen to the clip.)

A. Listen with the client on their left side R. When providing nursing care, the nurse should first use the least invasive intervention. Therefore, after auscultating a murmur, the first action the nurse should take is to place the client on their left side and listen to the heart again so that the murmur can be heard more clearly.

A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

A. Loosen restrictive clothing. R. The nurse should loosen tight, restrictive clothing to prevent injury and suffocation.

A nurse is creating a plan of care for a client who has neutropenia as a result of chemotherapy. Which of the following interventions should the nurse include in the plan?

A. Monitor the client's temperature every 4 hr. R. The nurse should monitor the temperature of a client who has neutropenia every 4 hr because the client's reduced amount of leukocytes greatly increases the client's risk for infection.

A nurse is in a providers office is assesing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interacts with feverfew?

A. Naproxen R. Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

A. Nonrebrether mask R. The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first?

A. Obtain vital signs. R. The first action the nurse should take using the nursing process is to assess the client's vital signs. A client who has portal hypertension can develop esophageal varices, which are fragile and can rupture, resulting in large amounts of blood loss and shock. Obtaining vital signs provides information about the client's condition that can contribute to decision making.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as an adverse effect of the medication?

A. Orthostatic hypotension R. The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min, blood pressure 78/40 mm Hg, and respiratory rate 30/min. Which of the following actions should the nurse take?

A. Perform synchronized cardioversion. R. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

A. Place a pillow between the client's legs. R. The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?

A. Place the client in high-Fowler's position. R. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange.

A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take?

A. Remain with the client for the first 15 min of the infusion. R. The nurse should remain with the client for the first 15 to 30 min of the infusion because hemolytic reactions usually occur during the infusion of the first 50 mL of blood.

A nurse is planning to provide discharge teaching or the family of an older adult client who has hemianopsia and is at risk for falls. Which of the following instructions should the nurse include?

A. Remind the client to scan their complete range of vision during ambulation. R. The nurse should instruct the family to remind a client who has hemianopsia, or blindness in half of the visual field, to use visual scanning to look over their complete range of vision during ambulation. This practice can accommodate for the loss of vision and help to reduce the risk for falls.

A nurse in a provider office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

A. Report of night cough R. The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse is assessing a client following the administration of magnesium sulfate 1 g IV bolus. For which of the following adverse effects should the nurse monitor?

A. Respiratory paralysis R. The nurse should monitor a client who is receiving magnesium sulfate via IV bolus closely as the adverse effects can impact the CNS, the cardiovascular system, and the respiratory system. Respiratory paralysis is a life-threatening adverse effect of magnesium sulfate

A nurse is teaching a young adult client how to perform testicular self examination. Which of the following instructions should the nurse include?

A. Roll each testicle between the thumb and fingers. R. The nurse should instruct the client to roll each testicle horizontally between the thumbs and fingers to feel for any lumps deep in the center of the testicle.

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure (ICP)? (Select all that apply.)

A. Sleepiness exhibited Widening pulse pressure Decerebrate posturing R. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Both decerebrate and decorticate posturing indicate increased ICP.

A nurse is assessing a client who had ESWL 6 hr ago. Which of the following should the nurse expect?

A. Stone fragments in the urine R. ESWL is an effort to break the calculi so that the fragments pass down the ureter, into the bladder, and through the urethra during voiding. Following the procedure, the nurse should strain the client's urine to confirm the passage of stones.

A nurse is preparing to admit a client who has dysphagia. The nurse should plan to place which of the following items at the clients bedside?

A. Suction machine R. The nurse should ensure that a suction machine is at the bedside of a client who has dysphagia to clear the client's airway as needed and reduce the risk for aspiration.

A nurse is providing teaching to a client who has gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

A. Suppressing gastric acid production R. Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is assessing a client who has acute cholecystitis. Which of the following findings is the nurse's priority?

A. Tachycardia R. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is tachycardia. Tachycardia is a manifestation of biliary colic, which can lead to shock. The nurse should position the head of the client's bed flat and report this finding immediately to the provider.

A nurse is providing teaching to a female client who has a history of urinary tract infections (UTIs). Which of the following information should the nurse include in the teaching?

A. Take daily cranberry supplements. R. The client should take cranberry supplements or drink low-fructose cranberry juice because it contains compounds that adhere to the urinary tract wall, decreasing the risk for developing a UTI.

A nurse is planning care to decrease psychosocial health issues for a client who is starting dialysis treatments for chronic kidney disease. Which of the following interventions should the nurse include in the plan?

A. Tell the client that it is possible to return to similar previous levels of activity. R. The nurse should help the client develop realistic goals and activities to have a productive life.

A nurse is providing discharge teaching to a client who has HF and a new prescription for a potassium sparing diuretic. Which of the following information should the nurse include in the teaching?

A. Try to walk at least three times per week for exercise. R. The development of a regular exercise routine can improve outcomes in clients who have heart failure.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?

A. Turn the client to the side. R. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

A nurse is caring for a client who has a stage III pressure injury. Which of the following findings contributes to delayed wound healing?

A. Urine output 25 ml/hr R. Urinary output reflects fluid status. Inadequate urine output can indicate dehydration, which can delay wound healing.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

A. Urine specific gravity 1.045 R. A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure injury. Which of the following actions should the nurse take?

A. Use a 30 ml syringe R. The nurse should use a 30-mL to 60-mL syringe with an 18- or 19-gauge catheter to deliver the ideal pressure of 8 pounds per square inch (psi) when irrigating a wound. To maintain healthy granulation tissue, the wound irrigation should be delivered at between 4 and 15 psi.

A nurse is providing teaching for a female client who has reccurrent urinary tract infections. Which of the following information should the nurse include in the teaching?

A. Void before and after intercourse. R. The nurse should instruct the client to empty her bladder before and after intercourse, which flushes bacteria out of the urinary tract and prevents the occurrence of infection.

A nurse is planning care fora client who is undergoing brachytherapy via a sealed vaginal implant to treat endometrial cancer. Which cations should be included in plan of care?

A. Wear a lead apron while providing care to the client. R. The nurse should wear a lead apron when providing direct care to provide protection from the radiation source and not turn their back toward the client, because the apron only shields the front of the body. The nurse should also wear a dosimeter film badge to measure radiation exposure.

A nurse is providing discharge instructions to a client who has partial thickness burn on the hand. Which of the following should the nurse include?

A. Wrap fingers with individual dressing R. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.

A nurse is providing teaching to an older adult client who has cancer and a new prescription for an opioid analegesic for pain management. Which of the following information should the nurse include in the teaching?

A. You should void every 4 hours to decrease the risk of urinary retention R. The nurse should instruct the client to void at least every 4 hr to decrease the risk of urinary retention, which is an adverse effect of opioid analgesics.

A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? (Select all that apply.)

Fever is correct. The nurse should expect the client to have a fever because of the excessive thyroid hormone release. Hypertension is correct. The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release. Tachycardia is correct. The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release. Nonpitting edema is incorrect. Nonpitting edema is a manifestation of myxedema coma, a complication of hypothyroidism. Hypoglycemia is incorrect. Hypoglycemia is a manifestation of myxedema coma, a complication of hypothyroidism.

A nurse is providing teaching to a client who is receiving chemo and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

I will monitor my BP while taking this medication

A nurse is caring for a client who has a leg cast and is returning demonstration on the proper use of crutches while climbing stairs. Identify the sequence the client should follow when demonstrating crutch use. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

The client should first place their body weight on the crutches. Next, they should advance the unaffected leg onto the stair. Third, they should shift their weight from the crutches to the unaffected leg. Last, they should bring the crutches and the affected leg up to the stair.

A home health nurse is assigned to a client who has recently discharged from a rehabiltion center after experiencing a right hemispheric stroke. Which of the following neurologic deficts should the nurse expect to find when assessing the client?

Visual spatial deficits Left hemianopsia One-sided neglect

A home health nurse is assigned to a client who was recently discharged from rehabilitation center after experiencing a RIGHT-hemispheric cerebrovascular accident (CVA). Which of the following neurological deficits should the nurse expect to find when assess?

Visual spatial deficits (loss of depth perception occur secondary) Left hemianopsia (blindness in the left half of the visual field, occurs secondary) One-sided neglect (unawareness of the affected side, occurs secondary) Expressive aphasia is incorrect. Expressive aphasia, or an inability to express what one wants to convey, occurs secondary to a left-hemispheric stroke. Right hemiplegia is incorrect. Right hemiplegia occurs secondary to a left-hemispheric stroke.

A nurse and an AP are caring for a client who has bacterial meningitis. The nurse should give the AP which instructions?

Wear a mask.