Med Surg Practice Qs (combined)

Following a transsphenoidal hypophysectomy, the nurse should assess the client for: 1. Cerebrospinal fluid (CSF) leak. 2. Fluctuating blood glucose levels. 3. Cushing's syndrome. 4. Cardiac arrhythmias

1 A major focus of nursing care after transsphenoidal hypophysectomy is the prevention of and monitoring for a CSF leak. CSF leakage can occur if the patch or incision is disrupted. The nurse should monitor for signs of infection, including elevated temperature, increased white blood cell count, rhinorrhea, nuchal rigidity, and persistent headache. Hypoglycemia and adrenocortical insufficiency may occur. Monitoring for fluctuating blood glucose levels is not related specifically to transsphenoidal hypophysectomy. The client will be given IV fluids postoperatively to supply carbohydrates. Cushing's disease results from adrenocortical excess, not insufficiency. Monitoring for cardiac arrhythmias is important, but arrhythmias are not anticipated following a transsphenoidal hypophysectomy.

After the administration of t-PA, the nurse should: 1. Observe the client for chest pain. 2. Monitor for fever. 3. Review the 12-lead electrocardiogram (ECG). 4. Auscultate breath sounds

1 Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary artery may recur. Clients who receive t- PA frequently receive heparin to prevent closure of the artery after administration of t- PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin time are essential to detect complications. Administration of t-PA should not cause fever.

The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia? 1. 59 mg/dL (3.3 mmol/L). 2. 75 mg/dL (4.2 mmol/L). 3. 108 mg/dL (6 mmol/L). 4. 119 mg/dL (6.6 mmol/L).

1 Although some individual variation exists, when the blood glucose level decreases to less than 70 mg/dL (3.9 mmol/L), the client experiences or is at risk for hypoglycemia. Hypoglycemia can occur in both type 1 and type 2 diabetes mellitus, although it is more common when the client is taking insulin. The nurse should instruct the client on the prevention, detection, and treatment of hypoglycemia.

The nurse is developing standards of care for a client with gastroesophageal reflux disease and wants to review current evidence for practice. Which one of the following resources will provide the most helpful information? 1. A review in the Cochrane Library. 2. A literature search in a database, such as the Cumulative Index to Nursing and Allied Health Literature (CINAHL). 3. An online nursing textbook. 4. The policy and procedure manual at the health care agency.

1 . The Cochrane Library provides systematic reviews of health care interventions and will provide the best resource for evidence for nursing care. CINAHL offers key word searches to published articles in nursing and allied health literature, but not reviews. A nursing textbook has information about nursing care, which may include evidence-based practices, but textbooks may not have the most up-to-date information. While the policy and procedure manual may be based on evidence-based practices, the most current practices will be found in evidence-based reviews of literature.

A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client. 1. Postoperative pain. 2. Peripheral pulses. 3. Urine output. 4. Incision site.

(2,4,3,1) Because assessment of the presence and quality of the pedal pulses in the affected extremity is essential after surgery to make sure that the bypass graft is functioning, this step should be done first. The nurse should next ensure that the dressing is intact, and then that the client has adequate urine output. Lastly, the nurse should determine the client's level of pain.

The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled "Penicillin 500,000 units/mL". How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.) __________

0.4

8. A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

0.6 ml

A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

0.6 ml

The healthcare provider prescribes epoetin alfa (Procrit) 8,200 units subcutaneously for a client with chronic kidney disease (CKD). The 2 ml multidose vial is labeled, "Each 1 ml of solution contains 10,000 units of epoetin alfa." How many ml should the nurse administer?

0.8

49. The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)

0.9 ml

The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.)

0.9 ml

A client with toxic shock has been receiving ceftriaxone sodium (Rocephin), 1 g every 12 hours. In addition to culture and sensitivity studies, which other laboratory findings should the nurse monitor? 1. Serum creatinine. 2. Spinal fluid analysis. 3. Arterial blood gases. 4. Serum osmolality.

1 The nurse monitors the blood levels of antibiotics, white blood cells, serum creatinine, and blood urea nitrogen because of the decreased perfusion to the kidneys, which are responsible for filtering out the Rocephin. It is possible that the clearance of the antibiotic has been decreased enough to cause toxicity. Increased levels of these laboratory values should be reported to the physician immediately. A spinal fluid analysis is done to examine cerebral spinal fluid, but there is no indication of central nervous system involvement in this case. Arterial blood gases are used to determine actual blood gas levels and assess acid-base balance. Serum osmolality is used to monitor fluid and electrolyte balance.

A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. The nurse should make sure that personnel involved with the procedure do which of the following when obtaining the lymph node biopsy specimen for histologic examination for this client? 1. Maintain sterile technique. 2. Use a mask, gloves, and a gown when assisting with the procedure. 3. Send the specimen to the laboratory when someone is available to take it. 4. Ensure that all instruments used are placed in a sealed and labeled container.

1 The nurse must ensure that sterile technique is used when a biopsy is obtained because the client is at high risk for infection. In most cases, a lymph node biopsy is sent immediately to the laboratory once it is placed in a specific solution in a closed container. It is not necessary to wear a gown and mask when obtaining the specimen. It is not necessary to use special handling procedures for the instruments used.

The best indicator that the client has learned how to give an insulin self injection correctly is when the client can: 1. Perform the procedure safely and correctly. 2. Critique the nurse's performance of the procedure. 3. Explain all steps of the procedure correctly. 4. Correctly answer a posttest about the procedure

1 The nurse should judge that learning has occurred from the evidence of a change in the client's behavior. A client who performs a procedure safely and correctly demonstrates that he has acquired a skill. Evaluation of this skill acquisition requires performance of that skill by the client with observation by the nurse. The client must also demonstrate cognitive understanding, as shown by the ability to critique the nurse's performance. Explaining the steps demonstrates acquisition of knowledge at the cognitive level only. A posttest does not indicate the degree to which the client has learned a psychomotor skill.

Which of the following individuals is most at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is: 1. 4 to 12 years. 2. 20 to 30 years. 3. 40 to 50 years. 4. 60 to 70 years.

1 The peak incidence of ALL is at 4 years of age. ALL is uncommon after 15 years of age. The median age at incidence of CML is 40 to 50 years. The peak incidence of AML occurs at 60 years of age. Two-thirds of cases of chronic lymphocytic leukemia occur in clients older than 60 years of age.

The client probably has not progressed to an advanced stage. 98. The nurse is developing a discharge plan about home care with a client who has lymphoma. The nurse should emphasize which of the following? 1. Use analgesics as needed. 2. Take a shower with perfumed shower gel. 3. Wear a mask when outside of the home. 4. Take an antipyretic every morning.

1 Analgesics are used as needed to relieve painful encroachment of enlarged lymph nodes. Perfumed shower gel will increase pruritus. Wearing a mask does not protect the client from infection if pathogens are not spread by airborne droplets. Antipyretics should be used to treat fever symptomatically after infection is ruled out.

When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the following? 1. Cardiac arrhythmias. 2. Hypertension. 3. Seizure. 4. Hypothermia.

1 Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administration of t-PA. Seizures and hypothermia are not generally associated with reperfusion of the cardiac tissue.

Which of the following is a risk factor for hypovolemic shock? 1. Hemorrhage. 2. Antigen-antibody reaction. 3. Gram-negative bacteria. 4. Vasodilation.

1 Causes of hypovolemic shock include external fluid loss, such as hemorrhage; internal fluid shifting, such as ascites and severe edema; and dehydration. Massive vasodilation is the initial phase of vasogenic or distributive shock, which can be further subdivided into three types of shock: septic, neurogenic, and anaphylactic. A severe antigen-antibody reaction occurs in anaphylactic shock. Gram-negative bacterial infection is the most common cause of septic shock. Loss of sympathetic tone (vasodilation) occurs in neurogenic shock.

The client with acute lymphocytic leukemia (ALL) is at risk for infection. The nurse should: 1. Place the client in a private room. 2. Have the client wear a mask. 3. Have staff wear gowns and gloves. 4. Restrict visitors

1 Clients with ALL are at risk for infection due to granulocytopenia. The nurse should place the client in a private room. Strict hand-washing procedures should be enforced and will be the most effective way to prevent infection. It is not necessary to have the client wear a mask. The client is not contagious and the staff does not need to wear gloves. The client can have visitors; however, they should be screened for infection and use hand-washing procedures.

The client admitted with peripheral vascular disease (PVD) asks the nurse why her legs hurt when she walks. The nurse bases a response on the knowledge that the main characteristic of PVD is: 1. Decreased blood flow. 2. Increased blood flow. 3. Slow blood flow. 4. Thrombus formation.

1 Decreased blood flow is a common characteristic of all PVD. When the demand for oxygen to the working muscles becomes greater than the supply, pain is the outcome. Slow blood flow throughout the circulatory system may suggest pump failure. Thrombus formation can result from stasis or damage to the intima of the vessels.

When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following findings? 1. Herpes zoster infections. 2. Discolored teeth. 3. Hemorrhage. 4. Hypercellular immunity.

1 Herpes zoster infections are common in clients with Hodgkin's disease. Discoloring of the teeth is not related to Hodgkin's disease but rather to the ingestion of iron supplements or some antibiotics such as tetracycline. Mild anemia is common in Hodgkin's disease, but the platelet count is not affected until the tumor has invaded the bone marrow. A cellular immunity defect occurs in Hodgkin's disease in which there is little or no reaction to skin sensitivity tests. This is called anergy.

The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following? 1. Left ventricular atrophy. 2. Irregular heartbeats. 3. Peripheral vascular occlusion. 4. Pacemaker placement

1 In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the myocardial muscle. Decreased cardiac output, cardiac hypertrophy, and heart failure are examples of the chronic conditions that may develop in response to inactivity, rather than in response to the aging process. Irregular heartbeats are generally not associated with an older sedentary adult's lifestyle. Peripheral vascular occlusion or pacemaker placement should not affect response to stress.

The client asks the nurse to explain what it means that his Hodgkin's disease is diagnosed at stage 1A. Which of the following describes the involvement of the disease? 1. Involvement of a single lymph node. 2. Involvement of two or more lymph nodes on the same side of the diaphragm. 3. Involvement of lymph node regions on both sides of the diaphragm. 4. Diffuse disease of one or more extralymphatic organs

1 In the staging process, the designations A and B signify that symptoms were or were not present when Hodgkin's disease was found, respectively. The Roman numerals I through IV indicate the extent and location of involvement of the disease. Stage I indicates involvement of a single lymph node; stage II, two or more lymph nodes on the same side of the diaphragm; stage III, lymph node regions on both sides of the diaphragm; and stage IV, diffuse disease of one or more extralymphatic organs.

A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection.

1 Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts approximately 4 hours. A major advantage of Humalog is that the client can eat almost immediately after the insulin is administered. The client needs to be instructed regarding the onset, peak, and duration of all insulin, as meals need to be timed with these parameters. Waiting 1 hour to eat may precipitate hypoglycemia. Eating 2 hours before the insulin lispro could cause hyperglycemia if the client does not have circulating insulin to metabolize the carbohydrate.

The client has been managing angina episodes with nitroglycerin. Which of the following indicate the drug is effective? 1. Decreased chest pain. 2. Increased blood pressure. 3. Decreased blood pressure. 4. Decreased heart rate

1 Nitroglycerin acts to decrease myocardial oxygen consumption. Vasodilation makes it easier for the heart to eject blood, resulting in decreased oxygen needs. Decreased oxygen demand reduces pain caused by heart muscle not receiving sufficient oxygen. While blood pressure may decrease ever so slightly due to the vasodilation effects of nitroglycerine, it is only secondary and not related to the angina the patient is experiencing. Increased blood pressure would mean the heart would work harder, increasing oxygen demand and thus angina. Decreased heart rate is not an effect of nitroglycerine.

In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding. Which of the following is not a common site? 1. Biliary system. 2. Gastrointestinal tract. 3. Brain and meninges. 4. Pulmonary system.

1 The biliary system is not especially prone to hemorrhage. Thrombocytopenia (a low platelet count) leaves the client at risk for a potentially life-threatening spontaneous hemorrhage in the gastrointestinal, respiratory, and intracranial cavities.

A male client expresses concern about how a hypophysectomy will affect his sexual function. Which of the following statements provides the most accurate information about the physiologic effects of hypophysectomy? 1. Removing the source of excess hormone should restore the client's libido, erectile function, and fertility. 2. Potency will be restored, but the client will remain infertile. 3. Fertility will be restored, but impotence and decreased libido will persist. 4. Exogenous hormones will be needed to restore erectile function after the adenoma is removed.

1 The client's sexual problems are directly related to the excessive prolactin level. Removing the source of excessive hormone secretion should allow the client to return gradually to a normal physiologic pattern. Fertility will return, and erectile function and sexual desire will return to baseline as hormone levels return to normal.

The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia? 1. Nervousness. 2. Anorexia. 3. Kussmaul's respirations. 4. Bradycardia.

1 The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is.

Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following? 1. Sore throat. 2. Painful, excessive menstruation. 3. Constipation. 4. Increased urine output.

1 The most serious adverse effects of PTU are leukopenia and agranulocytosis, which usually occur within the first 3 months of treatment. The client should be taught to promptly report to the health care provider signs and symptoms of infection, such as a sore throat and fever. Clients having a sore throat and fever should have an immediate white blood cell count and differential performed, and the drug must be withheld until the results are obtained. Painful menstruation, constipation, and increased urine output are not associated with PTU therapy.

The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms: 1. To the client from sources outside the client's environment. 2. From the client to health care personnel, visitors, and other clients. 3. By using special techniques to dispose of contaminated materials. 4. By using special techniques to handle the client's linens and personal items.

1 The primary purpose of reverse isolation is to reduce transmission of organisms to the client from sources outside the client's environment.

Which of the following is a priority goal for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? 1. Obtaining adequate food intake. 2. Managing own health. 3. Relieving pain. 4. Increasing activity.

1 The priority goal for the client with diabetes mellitus who is experiencing vomiting with influenza is to obtain adequate nutrition. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 cal every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider should be called or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's health management skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is increasing activity during the illness.

Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate? 1. Urine output greater than 30 mL/h. 2. Systolic blood pressure greater than 110 mm Hg. 3. Diastolic blood pressure greater than 90 mm Hg. 4. Respiratory rate of 20 breaths/min.

1 Urine output provides the most sensitive indication of the client's response to therapy for hypovolemic shock. Urine output should be consistently greater than 35 mL/h. Blood pressure is a more accurate reflection of the adequacy of vasoconstriction than of tissue perfusion. Respiratory rate is not a sensitive indicator of fluid balance in the client recovering from hypovolemic shock.

The nurse is planning care for a client who is diagnosed with peripheral vascular disease (PVD) and has a history of heart failure. The nurse should develop a plan of care that is based on the fact that the client may have a low tolerance for exercise related to: 1. Decreased blood flow. 2. Increased blood flow. 3. Decreased pain. 4. Increased blood viscosity.

1 A client with PVD and heart failure will experience decreased blood flow. In this situation, low exercise tolerance (oxygen demand becomes greater than the oxygen supply) may be related to less blood being ejected from the left ventricle into the systemic circulation. Decreased blood supply to the tissues results in pain. Increased blood viscosity may be a component, but it is of much less importance than the disease processes.

A client is scheduled for an arteriogram. The nurse should explain to the client that the arteriogram will confirm the diagnosis of occlusive arterial disease by: 1. Showing the location of the obstruction and the collateral circulation. 2. Scanning the affected extremity and identifying the areas of volume changes. 3. Using ultrasound to estimate the velocity changes in the blood vessels. 4. Determining how long the client can walk.

1 An arteriogram involves injecting a radiopaque contrast agent directly into the vascular system to visualize the vessels. It usually involves computed tomographic scanning. The velocity of the blood flow can be estimated by duplex ultrasound. The client's ankle-brachial index is determined, and then the client is requested to walk. The normal response is little or no drop in ankle systolic pressure after exercise.

A client with heart failure has bilateral +4 edema of the right ankle that extends up to midcalf. The client is sitting in a chair with the legs in a dependent position. Which of the following goals is the priority? 1. Decrease venous congestion. 2. Maintain normal respirations. 3. Maintain body temperature. 4. Prevent injury to lower extremities.

1 Decreasing venous congestion in the extremities is a desired outcome for clients with heart failure. The nurse should elevate the client's legs above the level of the heart to achieve this goal. The client is not demonstrating difficulty breathing or being cold. The nurse should prevent injury to the swollen extremity; however, this is not the priority.

A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to: 1. Increase the frequency of self-monitoring (blood glucose testing). 2. Reduce food intake to diminish nausea. 3. Discontinue that dose of insulin if unable to eat. 4. Take half of the normal dose of insulin

1 Colds and influenza present special challenges to the client with diabetes mellitus because the body's need for insulin increases during illness. Therefore, the client must take the prescribed insulin dose, increase the frequency of blood glucose testing, and maintain an adequate fluid intake to counteract the dehydrating effect of hyperglycemia. Clear fluids, juices, and Gatorade are encouraged. Not taking insulin when sick, or taking half the normal dose, may cause the client to develop ketoacidosis.

A 68-year-old client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to: 1. Inquire about the onset, duration, severity, and precipitating factors of the heaviness. 2. Administer oxygen via nasal cannula. 3. Offer pain medication for the chest heaviness. 4. Inform the physician of the chest heaviness.

1 Further assessment is needed in this situation. It is premature to initiate other actions until further data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of the chest heaviness will provide pertinent information to convey to the physician.

An overweight client taking warfarin (Coumadin) has dry skin due to decreased arterial blood flow. What should the nurse instruct the client to do? Select all that apply. 1. Apply lanolin or petroleum jelly to intact skin. 2. Follow a reduced-calorie, reduced-fat diet. 3. Inspect the involved areas daily for new ulcerations. 4. Instruct the client to limit activities of daily living (ADLs). 5.Use an electric razor to shave

1,2,3,5 Maintaining skin integrity is important in preventing chronic ulcers and infections. The client should be taught to inspect the skin on a daily basis. The client should reduce weight to promote circulation; a diet lower in calories and fat is appropriate. Because the client is receiving Coumadin, the client is at risk for bleeding from cuts. To decrease the risk of cuts, the nurse should suggest that the client use an electric razor. The client with decreased arterial blood flow should be encouraged to participate in ADLs. In fact, the client should be encouraged to consult an exercise physiologist for an exercise program that enhances the aerobic capacity of the body.

The nurse is caring for a client who recently experienced a myocardial infarction and has been started on clopidogrel (Plavix). The nurse should develop a teaching plan that includes which of the following points? Select all that apply. 1. The client should report unexpected bleeding or bleeding that lasts a long time. 2. The client should take Plavix with food. 3. The client may bruise more easily and may experience bleeding gums. 4. Plavix works by preventing platelets from sticking together and forming a clot. 5. The client should drink a glass of water after taking Plavix.

1,3,4 Plavix is generally well absorbed and may be taken with or without food; it should be taken at the same time every day and, while food may help prevent potential GI upset, food has no effect on absorption of the drug. Bleeding is the most common adverse effect of Plavix; the client must understand the importance of reporting any unexpected, prolonged, or excessive bleeding including blood in urine or stool. Increased bruising and bleeding gums are possible side effects of Plavix; the client should be aware of this possibility. Plavix is an antiplatelet agent used to prevent clot formation in clients that have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome. It is not necessary to drink a glass of water after taking Plavix.

A client receives a prescription for 1 liter of lactated Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.) ____________

167

Which of the following is an indication of a complication of septic shock? 1. Anaphylaxis. 2. Acute respiratory distress syndrome (ARDS). 3. Chronic obstructive pulmonary disease (COPD). 4. Mitral valve prolapse.

2

The client who does not respond adequately to fluid replacement has a prescription for an IV infusion of dopamine hydrochloride at 5 mcg/kg/min. To determine that the drug is having the desired effect, the nurse should assess the client for: 1. Increased renal and mesenteric blood flow. 2. Increased cardiac output. 3. Vasoconstriction. 4. Reduced preload and afterload.

2 At medium doses (4 to 8 mcg/kg/min), dopamine hydrochloride slightly increases the heart rate and improves contractility to increase cardiac output and improve tissue perfusion. When given at low doses (0.5 to 3.0 mcg/kg/min), dopamine increases renal and mesenteric blood flow. At high doses (8 to 10 mcg/kg/min), dopamine produces vasoconstriction, which is an undesirable effect. Dopamine is not given to affect preload and afterload.

A client is receiving dopamine hydrochloride for treatment of shock. The nurse should: 1. Administer pain medication concurrently. 2. Monitor blood pressure continuously. 3. Evaluate arterial blood gases at least every 2 hours. 4. Monitor for signs of infection.

2 The client who is receiving dopamine hydrochloride requires continuous blood pressure monitoring with an invasive or noninvasive device. The nurse may titrate the IV infusion to maintain a systolic blood pressure of 90 mm Hg. Administration of a pain medication concurrently with dopamine hydrochloride, which is a potent sympathomimetic with dose-related alpha-adrenergic agonist, beta 1-selective adrenergic agonist, and dopaminergic blocking effects, is not an essential nursing action for a client who is in shock with already low hemodynamic values. Arterial blood gas concentrations should be monitored according to the client's respiratory status and acidbase balance status and are not directly related to the dopamine hydrochloride dosage. Monitoring for signs of infection is not related to the nursing action for the client receiving dopamine hydrochloride.

A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to: 1. Administer epinephrine. 2. Inform the physician. 3. Administer oxygen. 4. Inform the client that the procedure is almost over.

2 .Clients may have an immediate or a delayed reaction to the radiopaque dye. The physician should be notified immediately because the symptoms suggest an allergic reaction. Treatment may involve administering oxygen and epinephrine. Explaining that the procedure is over does not address the current symptoms

A client with thyrotoxicosis says to the nurse, "I am so irritable. I am having problems at work because I lose my temper very easily." Which of the following responses by the nurse would give the client the most accurate explanation of her behavior? 1. "Your behavior is caused by temporary confusion brought on by your illness." 2. "Your behavior is caused by the excess thyroid hormone in your system." 3. "Your behavior is caused by your worrying about the seriousness of your illness."

2 A typical sign of thyrotoxicosis is irritability caused by the high levels of circulating thyroid hormones in the body. This symptom decreases as the client responds to therapy. Thyrotoxicosis does not cause confusion. The client may be worried about her illness, and stress may influence her mood; however, irritability is a common symptom of thyrotoxicosis and the client should be informed of that fact rather than blamed.

A client has driven himself to the emergency department. He is 50 years old, has a history of hypertension, and informs the nurse that his father died from a heart attack at age 60. The client has indigestion. The nurse connects him to an electrocardiogram monitor and begins administering oxygen at 2 L/min per nasal cannula. The nurse's next action should be to: 1. Call for the physician. 2. Start an IV infusion. 3. Obtain a portable chest radiograph. 4. Draw blood for laboratory studies

2 Advanced cardiac life support recommends that at least one or two IV lines be inserted in one or both of the antecubital spaces. Calling the physician, obtaining a portable chest radiograph, and drawing blood for the laboratory are important but secondary to starting the IV line.

The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements by the client about reasons for using combination chemotherapy indicates the need for further explanation? 1. "Combination chemotherapy is used to interrupt cell growth cycle at different points." 2. "Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously." 3. "Combination chemotherapy is used to decrease resistance." 4. "Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent."

2 Combination chemotherapy does not mean two groups of drugs, one to kill the cancer cells and one to treat the adverse effects of the chemotherapy. Combination chemotherapy means that multiple drugs are given to interrupt the cell growth cycle at different points, decrease resistance to a chemotherapy agent, and minimize the toxicity associated with use of a high dose of a single agent (ie, by using multiple agents with different toxicities).

Which of the following is an expected outcome when a client is receiving an IV administration of furosemide? 1. Increased blood pressure. 2. Increased urine output. 3. Decreased pain. 4. Decreased premature ventricular contractions.

2 Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood pressure, decrease pain, or decrease arrhythmias.

The nurse is completing a health assessment of a 42-year-old female with suspected Graves' disease. The nurse should assess this client for: 1. Anorexia. 2. Tachycardia. 3. Weight gain. 4. Cold skin.

2 Graves' disease, the most common type of thyrotoxicosis, is a state of hypermetabolism. The increased metabolic rate generates heat and produces tachycardia and fine muscle tremors. Anorexia is associated with hypothyroidism. Loss of weight, despite a good appetite and adequate caloric intake, is a common feature of hyperthyroidism. Cold skin is associated with hypothyroidism.

The client is a survivor of non-Hodgkin's lymphoma. Which of the following statements indicates the client needs additional information? 1. "Regular screening is very important for me." 2. "The survivor rate is directly proportional to the incidence of second malignancy." 3. "The survivor rate is indirectly proportional to the incidence of second malignancy." 4. "It is important for survivors to know the stage of the disease and their current treatment plan."

2 It is incorrect that the survivor rate is directly proportional to the incidence of second malignancy. The survivor rate is indirectly proportional to the incidence of second malignancy, and regular screening is very important to detect a second malignancy, especially acute myeloid leukemia or myelodysplastic syndrome. Survivors should know the stage of the disease and their current treatment plan so that they can remain active participants in their health care.

Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease? 1. Difficulty swallowing. 2. Painless, enlarged cervical lymph nodes. 3. Difficulty breathing. 4. A feeling of fullness over the liver.

2 Painless and enlarged cervical lymph nodes, tachycardia, weight loss, weakness and fatigue, and night sweats are signs of Hodgkin's disease. Difficulty swallowing and breathing may occur, but only with mediastinal node involvement. Hepatomegaly is a late-stage manifestation.

Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction? 1. Liquids as desired. 2. Small, easily digested meals. 3. Three regular meals per day. 4. Nothing by mouth

2 Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to nothing by mouth unless their condition is very unstable.

A client has peripheral vascular disease (PVD) of the lower extremities. The client tells the nurse, "I've really tried to manage my condition well." Which of the following routines should the nurse evaluate as having been appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity. 4. Wearing antiembolism stockings at all times when out of bed

2 Slow, steady walking is a recommended activity for clients with peripheral vascular disease because it stimulates the development of collateral circulation. The client with PVD should not remain inactive. Elevating the legs above the heart or wearing antiembolism stockings is a strategy for alleviating venous congestion and may worsen peripheral arterial disease

The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? 1. Aspirin. 2. Steroids. 3. Sulfonylureas. 4. Angiotensin-converting enzyme (ACE) inhibitors

2 Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism, making diabetic control more difficult. Aspirin is not known to affect glucose metabolism. Sulfonylureas are oral hypoglycemic agents used in the treatment of diabetes mellitus. ACE inhibitors are not known to affect glucose metabolism.

Which is a priority assessment for the client in shock who is receiving an IV infusion of packed red blood cells and normal saline solution? 1. Fluid balance. 2. Anaphylactic reaction. 3. Pain. 4. Altered level of consciousness.

2 The client who is receiving a blood product requires astute assessment for signs and symptoms of allergic reaction and anaphylaxis, including pruritus (itching), urticaria (hives), facial or glottal edema, and shortness of breath. If such a reaction occurs, the nurse should stop the transfusion immediately, but leave the IV line intact, and notify the physician. Usually, an antihistamine such as diphenhydramine hydrochloride (Benadryl) is administered. Epinephrine and corticosteroids may be administered in severe reactions. Fluid balance is not an immediate concern during the blood administration. The administration should not cause pain unless it is extravasating out of the vein, in which case the IV administration should be stopped. Administration of a unit of blood should not affect the level of consciousness.

When assessing a client for early septic shock, the nurse should assess the client for which of the following? 1. Cool, clammy skin. 2. Warm, flushed skin. 3. Increased blood pressure. 4. Hemorrhage.

2 Warm, flushed skin from a high cardiac output with vasodilation occurs in warm shock or the hyperdynamic phase (first phase) of septic shock. Other signs and symptoms of early septic shock include fever with restlessness and confusion; normal or decreased blood pressure with tachypnea and tachycardia; increased or normal urine output; and nausea and vomiting or diarrhea. Cool, clammy skin occurs in the hypodynamic or cold phase (later phase). Hemorrhage is not a factor in septic shock.

Which of the following indicates a potential complication of diabetes mellitus? 1. Inflamed, painful joints. 2. Blood pressure of 160/100 mm Hg. 3. Stooped appearance. 4. Hemoglobin of 9 g/dL (90 g/L).

2 The client with diabetes mellitus is especially prone to hypertension due to atherosclerotic changes, which leads to problems of the microvascular and macrovascular systems. This can result in complications in the heart, brain, and kidneys. Heart disease and stroke are twice as common among people with diabetes mellitus as among people without the disease. Painful, inflamed joints accompany rheumatoid arthritis. A stooped appearance accompanies osteoporosis with narrowing of the vertebral column. A low hemoglobin concentration accompanies anemia, especially iron deficiency anemia and anemia of chronic disease.

A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first? 1. IV fluid solution. 2. Pedal pulses. 3. Nasal cannula flow rate. 4. Capillary refill

2 With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess; however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.

The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements? 1. "I will pace my activities with rest periods." 2. "I can't wait to get home to my cat!" 3. "I will use warm saline gargle instead of brushing my teeth." 4. "I must report a temperature of 100°F (37.7°C)."

2 The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's white blood cells (WBCs). The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods. Platelet production will be decreased, and the client will be at risk for bleeding tendencies; oral hygiene will have to be provided by using a warm saline gargle instead of brushing the teeth and gums. The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of 100°F (37.8°C) or higher.

The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify? 1. Diabetes. 2. Age. 3. Exercise level. 4. Dietary preferences

2 Age is a nonmodifiable risk factor for atherosclerosis. The nurse instructs the client to manage modifiable risk factors such as comorbid diseases (eg, diabetes), activity level, and diet. Controlling serum blood glucose levels, engaging in regular aerobic activity, and choosing a diet low in saturated fats can reduce the risk of developing atherosclerosis.

A 34-year-old female is diagnosed with hypothyroidism. The nurse should assess the client for which of the following? Select all that apply. 1. Rapid pulse. 2. Decreased energy and fatigue. 3. Weight gain of 10 lb (4.5 kg). 4. Fine, thin hair with hair loss. 5. Constipation. 6. Menorrhagia.

2, 3, 5, 6. Clients with hypothyroidism exhibit symptoms indicating a lack of thyroid hormone. Bradycardia, decreased energy and lethargy, memory problems, weight gain, coarse hair, constipation, and menorrhagia are common signs and symptoms of hypothyroidism.

A client reports vomiting every hour for the past 8 to 10 hours. The nurse should assess the client for risk of which of the following? Select all that apply. 1. Metabolic acidosis. 2. Metabolic alkalosis. 3. Hypokalemia. 4. Hyperkalemia. 5. Hyponatremia.

2,3 Gastric acid contains a substantial amount of potassium, hydrogen ions, and chloride ions. Frequent vomiting can induce an excessive loss of these acids leading to alkalosis. Excessive loss of potassium produces hypokalemia. Frequent vomiting does not lead to the condition of too much potassium (hyperkalemia) or too little sodium

The nurse is assessing the lower extremities of the client with peripheral vascular disease (PVD). During the assessment, the nurse should expect to find which of the following clinical manifestations of PVD? Select all that apply. 1. Hairy legs. 2. Mottled skin. 3. Pink skin. 4. Coolness. 5. Moist skin.

2,4 Reduction of blood flow to a specific area results in decreased oxygen and nutrients. As a result, the skin may appear mottled. The skin will also be cool to the touch. Loss of hair and dry skin are other signs that the nurse may observe in a client with PVD of the lower extremities.

The nurse is evaluating a client with hyperthyroidism who is taking Propylthiouracil (PTU) 100 mg/day in three divided doses for maintenance therapy. Which of the following statements from the client indicates the desired outcome of the drug? 1. "I have excess energy throughout the day." 2. "I am able to sleep and rest at night." 3. "I have lost weight since taking this medication." 4. "I do perspire throughout the entire day."

2. PTU is a prototype of thioamide antithyroid drugs. It inhibits production of thyroid hormones and peripheral conversion of T4 to the more active T3. A client taking this antithyroid drug should be able to sleep and rest well at night since the level of thyroid hormones is reduced in the blood. Excess energy throughout the day, loss of weight and perspiring through the day are symptoms of hyperthyroidism indicating the drug has not produced its outcome.

A client with advanced Hodgkin's disease is admitted to hospice because death is imminent. The goal of nursing care at this time is to: 1. Reduce the client's fear of pain. 2. Support the client's wish to discontinue further therapy. 3. Prevent feelings of isolation. 4. Help the client overcome feelings of social inadequacy.

3 Terminally ill clients most often describe feelings of isolation because they tend to be ignored, they are often left out of conversations (especially those dealing with the future), and they sense the attitudes of discomfort that many people feel in their presence. Helpful nursing measures include taking the time to be with the client, offering opportunities to talk about feelings, and answering questions honestly.

If a client displays risk factors for coronary artery disease, such as smoking cigarettes, eating a diet high in saturated fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the client change the behavior. The nurse can best reinforce new adaptive behaviors by: 1. Explaining how the risk factor behavior leads to poor health. 2. Withholding praise until the new behavior is well established. 3. Rewarding the client whenever the acceptable behavior is performed. 4. Instilling mild fear into the client to extinguish the behavior.

3 A basic principle of behavior modification is that behavior that is learned and continued is behavior that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

The client with Hodgkin's disease develops B symptoms. These manifestations indicate which of the following? 1. The client has a low-grade fever (temperature lower than 100°F [37.8°C]). 2. The client has a weight loss of 5% or less of body weight. 3. The client has night sweats. 4. The client probably has not progressed to an advanced stage.

3 A temperature higher than 100.4°F (38°C), profuse night sweats, and an unintentional weight loss of 10% of body weight represent the cluster of clinical manifestations known as the B symptoms. Forty percent of clients with Hodgkin's disease have B symptoms, and B symptoms are more common in advanced stages of the disease.

Which of the following lipid abnormalities is a risk factor for the development of atherosclerosis and peripheral vascular disease? 1. Low concentration of triglycerides. 2. High levels of high-density lipid (HDL) cholesterol. 3. High levels of low-density lipid (LDL) cholesterol. 4. Low levels of LDL cholesterol.

3 An increased LDL cholesterol concentration has been documented as a risk factor for the development of atherosclerosis. LDL cholesterol is not broken down in the liver but is deposited into the intima of the blood vessels. Low triglyceride levels are desirable. High HDL and low LDL levels are beneficial and are known to be protective for the cardiovascular system.

The client with Hodgkin's disease undergoes an excisional cervical lymph node biopsy under local anesthesia. After the procedure, which does the nurse assess first? 1. Vital signs. 2. The incision. 3. The airway. 4. Neurologic signs.

3 Assessing for an open airway is always first. The procedure involves the neck; the anesthesia may have affected the swallowing reflex, or the inflammation may have closed in on the airway, leading to ineffective air exchange. Once a patent airway is confirmed and an effective breathing pattern established, the circulation is checked. Vital signs and the incision are assessed as soon as possible, but only after it is established that the airway is patent and the client is breathing normally. A neurologic assessment is completed as soon as possible after other important assessments.

The nurse explains to the client with Hodgkin's disease that a bone marrow biopsy will be taken after the aspiration. What should the nurse explain about the biopsy? 1. "Your biopsy will be performed before the aspiration because enough tissue may be obtained so that you won't have to go through the aspiration." 2. "You will feel a pressure sensation when the biopsy is taken but should not feel actual pain; if you do, tell the doctor so that you can be given extra numbing medicine." 3. "You may hear a crunch as the needle passes through the bone, but when the biopsy is taken, you will feel a suction-type pain that will last for just a moment." 4. "You will be shaved and cleaned with an antiseptic agent, after which the doctor will inject a needle without making an incision to aspirate out the bone marrow."

2 A biopsy needle is inserted through a separate incision in the anesthetized area. The client will feel a pressure sensation when the biopsy is taken but should not feel actual pain. The client should be instructed to inform the physician if pain is felt so that more anesthetic agent can be administered to keep the client comfortable. The biopsy is performed after the aspiration and from a slightly different site so that the tissue is not disturbed by either test. The client will feel a suction-type pain for a moment when the aspiration is being performed, not the biopsy. A small incision is made for the biopsy to accommodate the larger-bore needle. This may require a stitch

Prior to administering tissue plasminogen activator (t-PA), the nurse should assess the client for which of the following contradictions to administering the drug? 1. Age greater than 60 years. 2. History of cerebral hemorrhage. 3. History of heart failure. 4. Cigarette smoking.

2 A history of cerebral hemorrhage is a contraindication to administration of t- PA because the risk of hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette smoking are not contraindications.

The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for clients who cannot perform this task for themselves. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care? 1. Assess the oral cavity each time mouth care is given and record observations. 2. Use a soft toothbrush to brush the client's teeth after each meal. 3. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours. 4. Rinse the client's mouth with mouthwash several times a day.

2 A soft toothbrush should be used to brush the client's teeth after every meal and more often as needed. Mechanical cleaning is necessary to maintain oral health, stimulate gingiva, and remove plaque. Assessing the oral cavity and recording observations is the responsibility of the nurse, not the nursing assistant. Swabbing with a safe foam applicator does not provide enough friction to clean the mouth. Mouthwash can be a drying irritant and is not recommended for frequent use.

When assessing the lower extremities of a client with peripheral vascular disease (PVD), the nurse notes bilateral ankle edema. The edema is related to: 1. Competent venous valves. 2. Decreased blood volume. 3. Increase in muscular activity. 4. Increased venous pressure.

4 In PVD, decreased blood flow can result in increased venous pressure. The increase in venous pressure results in an increase in capillary hydrostatic pressure, which causes a net filtration of fluid out of the capillaries into the interstitial space, resulting in edema. Valves often become incompetent with PVD. Blood volume is not decreased in this condition. Decreased muscular action would contribute to the formation of edema in the lower extremities.

A client with diabetes begins to cry and says, "I just cannot stand the thought of having to give myself a shot every day." Which of the following would be the best response by the nurse? 1. "If you do not give yourself your insulin shots, you will die." 2. "We can teach your daughter to give the shots so you will not have to do it." 3. "I can arrange to have a home care nurse give you the shots every day." 4. "What is it about giving yourself the insulin shots that bothers you?"

4 The best response is to allow the client to verbalize her fears about giving herself a shot each day. Tactics that increase fear are not effective in changing behavior. If possible, the client needs to be responsible for her own care, including giving selfinjections. It is unlikely that the client's insurance company will pay for home-care visits if the client is capable of self-administration.

The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 PM each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? 1. 11 AM, shortly before lunch. 2. 1 PM, shortly after lunch. 3. 6 PM, shortly after dinner. 4.1 AM, while sleeping

4 The client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.

. A client with acute myeloid leukemia (AML) reports overhearing one of the other clients say that AML had a very poor prognosis. The client has understood that the client's physician informed the client that his physician told him that he has a good prognosis. Which is the nurse's best response? 1. "You must have misunderstood. Who did you hear that from?" 2. "AML does have a very poor prognosis for poorly differentiated cells." 3. "AML is the most common nonlymphocytic leukemia." 4. "Your doctor stated your prognosis based on the differentiation of your cells."

4 The statement "Your doctor stated your prognosis based on the differentiation of your cells" addresses the client's situation on an individual basis. The nurse is clarifying that clients have different prognoses—even though they may have the same type of leukemia—because of the cell differentiation. Stating that the client misunderstood is inappropriate for an advocate of the client and serves no useful purpose. The other statements are true but do not address this client's individual concern.

Alteplase recombinant, or tissue plasminogen activator (t-PA), a thrombolytic enzyme, is administered during the first 6 hours after onset of myocardial infarction (MI) to: 1. Control chest pain. 2. Reduce coronary artery vasospasm. 3. Control the arrhythmias associated with MI. 4. Revascularize the blocked coronary artery.

4 The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery. The drug is most effective when administered within the first 6 hours after onset of MI. The drug does not reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhythmias are managed by antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and re-establish a blood supply to the area.

Which client is at greatest risk for coronary artery disease? 1. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago. 2. A 43-year-old male with a family history of CAD and cholesterol level of 158 (8.8 mmol/L). 3. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin. 4. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).

4 The woman who is 65 years old, overweight, and has an elevated LDL is at greatest risk. Total cholesterol greater than 200 (11.1 mmol/L), LDL greater than 100 (5.5 mmol/L), HDL less than 40 (2.2 mmol/L) in men, HDL less than 50 (2.8 mmol/L) in women, men 45 years and older, women 55 years and older, smoking and obesity increase the risk of CAD. Atorvastatin reduces LDL and decreases risk of CAD. The combination of postmenopausal, obesity, and high LDL places this client at greatest risk.

A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the: 1. Back of the mouth. 2. Nose. 3. Sinus channel below the right eye. 4.Upper gingival mucosa in the space between the upper gums and lip.

4 With transsphenoidal hypophysectomy, the sella turcica is entered from below, through the sphenoid sinus. There is no external incision; the incision is made between the upper lip and gums.

The nurse is assessing a 48-year-old client with a history of smoking during a routine clinic visit. The client, who exercises regularly, reports having pain in the calf during exercise that disappears at rest. Which of the following findings requires further evaluation? 1. Heart rate 57 bpm. 2. SpO2 of 94% on room air. 3. Blood pressure 134/82. 4. Ankle-brachial index of 0.65.

4 An Ankle-Brachial Index of 0.65 suggests moderate arterial vascular disease in a client who is experiencing intermittent claudication. A Doppler ultrasound is indicated for further evaluation. The bradycardic heart rate is acceptable in an athletic client with a normal blood pressure. The SpO2 is acceptable; the client has a smoking history.

When assessing an individual with peripheral vascular disease, which clinical manifestation would indicate complete arterial obstruction in the lower left leg? 1. Aching pain in the left calf. 2. Burning pain in the left calf. 3. Numbness and tingling in the left leg. 4. Coldness of the left foot and ankle

4 Coldness in the left foot and ankle is consistent with complete arterial obstruction. Other expected findings would include paralysis and pallor. Aching pain, a burning sensation, or numbness and tingling are earlier signs of tissue hypoxia and ischemia and are commonly associated with incomplete obstruction.

The nurse is obtaining the pulse of a client who has had a femoral-popliteal bypass surgery 6 hours ago. (See below) Which assessment provides the most accurate information about the client's postoperative status? 1. radial pulse 2. femoral pulse 3. apical pulse 4. dorsalis pedis pulse

4 The presence of a strong dorsalis pedis pulse indicates that there is circulation to the extremity distal to the surgery indicating that the graft between the femoral and popliteal artery is allowing blood to circulate effectively. Answer 1 shows the nurse obtaining the radial pulse; answer 2 shows the femoral pulse, which is proximal to the surgery site and will not indicate circulation distal to the surgery site. Answer 3 shows the nurse obtaining an apical pulse.

A client who has been taking warfarin has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL (110 g/L); and hematocrit, 33% (0.33). In which order should the nurse implement the following physician prescriptions? 1. Give 1 unit fresh frozen plasma (FFP). 2. Administer vitamin K 2.5 mg by mouth. 3. Schedule client for sigmoidoscopy. 4. Administer IV dextrose 5% in 0.45% normal saline solution.

4,1,2,3 Analysis of the client's laboratory results indicate that an INR of 8 is increased beyond therapeutic ranges. The client is also experiencing severe acute rectal bleeding and has a hemoglobin level in the low range of normal and a hematocrit reflecting fluid volume loss. The nurse should first establish an IV line and administer the dextrose in saline. Next the nurse should administer the FFP. FFP contains concentrated clotting factors and provides an immediate reversal of the prolonged INR. Vitamin K 2.5 mg PO should be given next because it reverses the warfarin by returning the PT to normal values. However, the reversal process occurs over 1 to 2 hours. Last, the nurse can schedule the client for the sigmoidoscopy.

. A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and Creactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse? 1. "The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet." 2. "The triglycerides are elevated and will not return to normal without these medications." 3. "The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed." 4. "These medications will reduce the risk of type 2 diabetes."

3 CRP is a marker of inflammation and is elevated in the presence of cardiovascular disease. The high sensitivity CRP (hs-CRP) is the blood test for greater accuracy in measuring the CRP to evaluate cardiovascular risk. The family history, postmenopausal age, LDL above optimum levels, and elevated CRP place the client at risk of CAD. Statin medications can decrease LDL, whereas statins and aspirin can reduce CRP and decrease the risk of MI and stroke. The blood sugar is within normal limits.

A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following? 1. "I am having fewer aches and pains." 2. "I do not have headaches anymore." 3. "I am able to walk further without leg pain." 4. "My toes are turning grayish black in color."

3 Cilostazol is indicated for management of intermittent claudication. Symptoms usually improve within 2 to 4 weeks of therapy. Intermittent claudication prevents clients from walking for long periods of time. Cilostazol inhibits platelet aggregation induced by various stimuli and improving blood flow to the muscles and allowing the client to walk long distances without pain. Peripheral arterial disease causes pain mainly of the leg muscles. "Aches and pains" does not specify exactly where the pain is occurring. Headaches may occur as a side effect of this drug, and the client should report this information to the health care provider. Peripheral arterial disease causes decreased blood supply to the peripheral tissues and may cause gangrene of the toes; the drug is effective when the toes are warm to the touch and the color of the toes is similar to the color of the body.

To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to: 1. Use incentive spirometry. 2. Turn in bed. 3. Take deep breaths. 4. Cough.

3 Deep breathing is the best choice for helping prevent atelectasis. The client should be placed in the semi-Fowler's position (or as prescribed) and taught deep breathing, sighing, mouth breathing, and how to avoid coughing. Blow bottles are not effective in preventing atelectasis because they do not promote sustained alveolar inflation to maximal lung capacity. Frequent position changes help loosen lung secretions, but deep breathing is most important in preventing atelectasis. Coughing is contraindicated because it increases intracranial pressure and can cause cerebrospinal fluid to leak from the point at which the sella turcica was entered.

A client with deep vain thrombosis (DVT) is receiving a continues infusion of heparin sodium 25,000 unit in 5% dextrose injection 250ml. The prescription indicates the dosage should be increase 900 units/hr. The nurse should program the infusion pump to deliver how many ml/hr?

9 mL/hour

After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. The expected outcome of this exercise is to: 1. Prepare the client for ambulation. 2. Promote urinary and intestinal elimination. 3. Prevent thrombophlebitis and blood clot formation. 4. Decrease the likelihood of pressure ulcer formation.

3 Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and prevents venous stasis in the lower extremities. These exercises are not intended to prepare the client for ambulation. These exercises are not associated with promoting urinary and intestinal elimination. These exercises are not performed to decrease the risk of pressure ulcer formation

A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client and two upset family members handle anxiety during the procedure? 1. Allow the client's family to stay as long as possible. 2. Stay with the client without speaking. 3. Encourage the client to take slow, deep breaths to relax. 4. Allow the client time to express feelings.

3 Encouraging the client to take slow, deep breaths during uncomfortable parts of procedures is the best method of decreasing the stress response of tightening and tensing the muscles. Slow, deep breathing affects the level of carbon dioxide in the brain to increase the client's sense of well-being. Allowing the client's family to stay may be appropriate if the family has a calming effect on the client, but this family is upset and may contribute to the client's stress. Silence can be therapeutic, but when the client is faced with a potentially life-threatening diagnosis and a new, invasive procedure, taking deep breaths will be more effective in reducing the stress response. Expressing feelings is important, but deep breathing will promote relaxation; the nurse can encourage the client to express feelings when the procedure is completed.

A nurse is teaching a client with type 1 diabetes mellitus who jogs daily about the preferred sites for insulin absorption. What is the most appropriate site for a client who jogs? 1. Arms. 2. Legs. 3. Abdomen. 4. Iliac crest.

3 If the client engages in an activity or exercise that focuses on one area of the body, that area may cause inconsistent absorption of insulin. A good regimen for a jogger is to inject the abdomen for 1 week and then rotate to the buttock. A jogger may have inconsistent absorption in the legs or arms with strenuous running. The iliac crest is not an appropriate site due to a lack of loose skin and subcutaneous tissue in that area.

. Following diagnosis of angina pectoris, a client reports being unable to walk up two flights of stairs without pain. Which of the following measures would most likely help the client prevent this problem? 1. Climb the steps early in the day. 2. Rest for at least an hour before climbing the stairs. 3. Take a nitroglycerin tablet before climbing the stairs. 4. Lie down after climbing the stairs.

3 Nitroglycerin may be used prophylactically before stressful physical activities such as stair climbing to help the client remain pain free. Climbing the stairs early in the day would have no impact on decreasing pain episodes. Resting before or after an activity is not as likely to help prevent an activity-related pain episode.

Which of the following is the most important goal of nursing care for a client who is in shock? 1. Manage fluid overload. 2. Manage increased cardiac output. 3. Manage inadequate tissue perfusion. 4. Manage vasoconstriction of vascular beds

3 Nursing interventions and collaborative management are focused on correcting and maintaining adequate tissue perfusion. Inadequate tissue perfusion may be caused by hemorrhage, as in hypovolemic shock; by decreased cardiac output, as in cardiogenic shock; or by massive vasodilation of the vascular bed, as in neurogenic, anaphylactic, and septic shock. Fluid deficit, not fluid overload, occurs in shock

The client who experiences angina has been told to follow a low-cholesterol diet. Which of the following meals would be best? 1. Hamburger, salad, and milkshake. 2. Baked liver, green beans, and coffee. 3. Spaghetti with tomato sauce, salad, and coffee. 4. Fried chicken, green beans, and skim milk

3 Pasta, tomato sauce, salad, and coffee would be the best selection for the client following a low-cholesterol diet. Hamburgers, milkshakes, liver, and fried foods tend to be high in cholesterol.

Angiotensin-converting enzyme (ACE) inhibitors may be prescribed for the client with diabetes mellitus to reduce vascular changes and possibly prevent or delay development of: 1. Chronic obstructive pulmonary disease (COPD). 2. Pancreatic cancer. 3. Renal failure. 4. Cerebrovascular accident.

3 Renal failure frequently results from the vascular changes associated with diabetes mellitus. ACE inhibitors increase renal blood flow and are effective in decreasing diabetic nephropathy. Chronic obstructive pulmonary disease is not a complication of diabetes, nor is it prevented by ACE inhibitors. Pancreatic cancer is neither prevented by ACE inhibitors nor considered a complication of diabetes. Cerebrovascular accident is not directly prevented by ACE inhibitors, although management of hypertension will decrease vascular disease.

The nurse is planning care with a client with acute leukemia who has mucositis. The nurse should advise the client that after every meal and every 4 hours while awake the client should use: 1. Lemon-glycerin swabs. 2. A commercial mouthwash. 3. A saline solution. 4. A commercial toothpaste and brush

3 Simple rinses with saline or a baking soda and water solution are effective and moisten the oral mucosa. Commercial mouthwashes and lemon-glycerin swabs contain glycerin and alcohol, which are drying to the mucosa and should be avoided. Brushing after each meal is recommended, but every 4 hours may be too traumatic. During acute leukemia, the neutrophil and platelet counts are often low and a soft-bristle toothbrush, instead of the client's usual brush, should be used to prevent bleeding gums.

The client with acute leukemia and the health care team establish mutual client outcomes of improved tidal volume and activity tolerance. Which measure would be least likely to promote outcome achievement? 1. Ambulating in the hallway. 2. Sitting up in a chair. 3. Lying in bed and taking deep breaths. 4. Using a stationary bicycle in the room.

3 The client with acute leukemia experiences fatigue and deconditioning. Lying in bed and taking deep breaths will not help achieve the goals. The client must get out of bed to increase activity tolerance and improve tidal volume. Ambulating in the hall (using a HEPA filter mask if neutropenic) is a sensible activity and helps improve conditioning. Sitting up in a chair facilitates lung expansion. Using a stationary bicycle in the room allows the client to increase activity as tolerated.

Which of the following conditions is the most significant risk factor for the development of type 2 diabetes mellitus? 1. Cigarette smoking. 2. High-cholesterol diet. 3. Obesity. 4. Hypertension.

3 The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-cholesterol diet does not necessarily predispose to diabetes mellitus, but it may contribute to obesity and hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus.

The nurse in the intensive care unit is giving a report to the nurse in the post surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to: 1. Give the report face to face with both nurses in a quiet room. 2. Audiotape the report for future reference and documentation. 3. Use a printed checklist with information individualized for the client. 4. Document essential transfer information in the client's electronic health record

3 Using an individualized printed checklist assures that all key information is reported; the checklist can then serve as a record to which nurses can refer later. Giving a verbal report leaves room for error in memory; using an audiotape or an electronic health record requires nurses to spend unnecessary time retrieving information.

The nurse is caring for a client with peripheral artery disease who has recently been prescribed clopidogrel (Plavix). The nurse understands that more teaching is necessary when the client states which of the following: 1. "I should not be surprised if I bruise easier or if my gums bleed a little when brushing my teeth." 2. "It doesn't really matter if I take this medicine with or without food, whatever works best for my stomach." 3. "I should stop taking Plavix if it makes me feel weak and dizzy." 4. "The doctor prescribed this medicine to make my platelets less likely to stick together and help prevent clots from forming."

3 Weakness, dizziness, and headache are common adverse effects of Plavix and the client should report these to the physician if they are problematic; in order to decrease risk of clot formation, Plavix must be taken regularly and should not be stopped or taken intermittently. The main adverse effect of Plavix is bleeding, which often occurs as increased bruising or bleeding when brushing teeth. Plavix is well absorbed, and while food may help decrease potential gastrointestinal upset, Plavix may be taken with or without food. Plavix is an antiplatelet agent used to prevent clot formation in clients who have experienced or are at risk for myocardial infarction, ischemic stroke, peripheral artery disease, or acute coronary syndrome.

The nurse is unable to palpate the client's left pedal pulses. Which of the following actions should the nurse take next? 1. Auscultate the pulses with a stethoscope. 2. Call the physician. 3. Use a Doppler ultrasound device. 4. Inspect the lower left extremity

3 When pedal pulses are not palpable, the nurse should obtain a Doppler ultrasound device. Auscultation is not likely to be helpful if the pulse isn't palpable. Inspection of the lower extremity can be done simultaneously when palpating, but the nurse should first try to locate a pulse by Doppler. Calling the physician may be necessary if there is a change in the client's condition.

A client has had a pulmonary artery catheter inserted. In performing hemodynamic monitoring with the catheter, the nurse will wedge the catheter to gain information about which of the following? 1. Cardiac output. 2. Right atrial blood flow. 3. Left end-diastolic pressure. 4. Cardiac index

3 When wedged, the catheter is "pointing" indirectly at the left end-diastolic pressure. The pulmonary artery wedge pressure is measured when the tip of the catheter is slowing inflated and allowed to wedge into a branch of the pulmonary artery. Once the balloon is wedged, the catheter reads the pressure in front of the balloon. During diastole, the mitral valve is open, reflecting left ventricular end diastolic pressure. Cardiac output is the amount of blood ejected by the heart in 1 minute and is determined through thermodilution and not wedge pressure. Cardiac index is calculated by dividing the client's cardiac output by the client's body surface area, and is considered a more accurate reflection of the individual client's cardiac output. Right atrial blood pressure is not measured with the pulmonary artery catheter.

The nurse is assessing an older Caucasian male who has a history of peripheral vascular disease. The nurse observes that the man's left great toe is black. The discoloration is probably a result of: 1. Atrophy. 2. Contraction. 3. Gangrene. 4. Rubor.

3 The term gangrene refers to blackened, decomposing tissue that is devoid of circulation. Chronic ischemia and death of the tissue can lead to gangrene in the affected extremity. Injury, edema, and decreased circulation lead to infection, gangrene, and tissue death. Atrophy is the shrinking of tissue, and contraction is joint stiffening secondary to disuse. The term rubor denotes a reddish color of the skin

When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle? 1. Dysmenorrhea. 2. Metrorrhagia. 3. Oligomenorrhea. 4. Menorrhagia.

3. A change in the menstrual interval, diminished menstrual flow (oligomenorrhea), or even the absence of menstruation (amenorrhea) may result from the hormonal imbalances of thyrotoxicosis. Oligomenorrhea in women and decreased libido and impotence in men are common features of thyrotoxicosis. Dysmenorrhea is painful menstruation. Metrorrhagia, blood loss between menstrual periods, is a symptom of hypothyroidism. Menorrhagia, excessive bleeding during menstrual periods, is a symptom of hypothyroidism.

The healthcare provider prescribes an IV solution of regular insulin (Hummulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour?

30

The nurse is instructing the client on insulin administration. The client is performing a return demonstration for preparing the insulin. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units?

32 units

A nurse has two middle-aged clients who have a prescription to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their IV lines and vital signs, what should the nurse do next? 1. Call for both clients' blood transfusions at the same time. 2. Ask another nurse to verify the compatibility of both units at the same time. 3. Call for and hang the first client's blood transfusion. 4. Ask another nurse to call for and hang the blood for the second client.

4

Which nursing intervention is most important in preventing septic shock? 1. Administering IV fluid replacement therapy as prescribed. 2. Obtaining vital signs every 4 hours for all clients. 3. Monitoring red blood cell counts for elevation. 4. Maintaining asepsis of indwelling urinary catheters.

4

Which of the following indicates hypovolemic shock in a client who has had a 15% blood loss? 1. Pulse rate less than 60 bpm. 2. Respiratory rate of 4 breaths/min. 3. Pupils unequally dilated. 4. Systolic blood pressure less than 90 mm Hg.

4 Typical signs and symptoms of hypovolemic shock include systolic blood pressure less than 90 mm Hg, narrowing pulse pressure, tachycardia, tachypnea, cool and clammy skin, decreased urine output, and mental status changes, such as irritability or anxiety. Unequal dilation of the pupils is related to central nervous system injury or possibly to a previous history of eye injury.

The nurse should caution the client with diabetes mellitus who is taking a sulfonylurea that alcoholic beverages should be avoided while taking these drugs because they can cause which of the following? 1. Hypokalemia. 2. Hyperkalemia. 3. Hypocalcemia. 4.Disulfiram (Antabuse)-like symptoms

4 A client with diabetes who takes any first- or second-generation sulfonylurea should be advised to avoid alcohol intake. Sulfonylureas in combination with alcohol can cause serious disulfiram (Antabuse)-like reactions, including flushing, angina, palpitations, and vertigo. Serious reactions, such as seizures and possibly death, may also occur. Hypokalemia, hyperkalemia, and hypocalcemia do not result from taking sulfonylureas in combination with alcohol.

The nurse is assessing a client with chronic myeloid leukemia (CML). The nurse should assess the client for: 1. Lymphadenopathy. 2. Hyperplasia of the gum. 3. Bone pain from expansion of marrow. 4. Shortness of breath

4 Although the clinical manifestations of CML vary, clients usually have confusion and shortness of breath related to decreased capillary perfusion to the brain and lungs. Lymphadenopathy is rare in CML. Hyperplasia of the gum and bone pain are clinical manifestations of AML.

The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent: 1. Cardiac arrhythmias. 2. Liver failure. 3. Renal failure. 4. Hemorrhage.

4 Bleeding and infection are the major complications and causes of death for clients with AML. Bleeding is related to the degree of thrombocytopenia, and infection is related to the degree of neutropenia. Cardiac arrhythmias rarely occur as a result of AML. Liver or renal failure may occur, but neither is a major cause of death in AML.

In assessing a client in the early stage of chronic lymphocytic leukemia (CLL), the nurse should determine if the client has: 1. Enlarged, painless lymph nodes. 2. Headache. 3. Hyperplasia of the gums. 4. Unintentional weight loss.

4 Clients with CLL develop unintentional weight loss; fever and drenching night sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy); and susceptibility to viral infections. Enlarged, painless lymph nodes are a clinical manifestation of Hodgkin's lymphoma. A headache would not be one of the early signs and symptoms expected in CLL because CLL does not cross the blood-brain barrier and would not irritate the meninges. Hyperplasia of the gums is a clinical manifestation of AML.

Crackles heard on lung auscultation indicate which of the following? 1. Cyanosis. 2. Bronchospasm. 3. Airway narrowing. 4.Fluid-filled alveoli.

4 Crackles are auscultated over fluid-filled alveoli. Crackles heard on lung auscultation do not have to be associated with cyanosis. Bronchospasm and airway narrowing generally are associated with wheezing sounds.

Assessment of the diabetic client for common complications should include examination of the: 1. Abdomen. 2. Lymph glands. 3. Pharynx. 4. Eyes.

4 Diabetic retinopathy, cataracts, and glaucoma are common complications in diabetics, necessitating eye assessment and examination. The feet should also be examined at each client encounter, monitoring for thickening, fissures, or breaks in the skin; ulcers; and thickened nails. Although assessments of the abdomen, pharynx, and lymph glands are included in a thorough examination, they are not pertinent to common diabetic complications.

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement?

Administer opioid and non-opioid medication simultaneously

A client tells the nurse that her biopsy results indicate that the cancer cells are well-differentiated. How should the nurse respond?

Ask the client if the healthcare provider has given her any information about the classification of her cancer

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) a. Monitor dryness of mucous membranes b. Check for changes in mentation c. Observe color of skin and nailbeds d. Note appearance of jugular veins e. Assess breathing patterns

B, C, E

25. Which client has the highest risk for developing skin cancer? A. A 16-year old dark-skinned female who tans in tanning beds once a week B. A 65 year-old fair-skinned male who is a construction worker C. A 25 year-old dark-skinned male whose mother had skin cancer D. A 70 year-old fair-skinned female who works as a secretary

B. A 65 year-old fair-skinned male who is a construction worker

Which client has the highest risk for developing skin cancer? A. A 16-year old dark-skinned female who tans in tanning beds once a week B. A 65 year-old fair-skinned male who is a construction worker C. A 25 year-old dark-skinned male whose mother had skin cancer D. A 70 year-old fair-skinned female who works as a secretary

B. A 65 year-old fair-skinned male who is a construction worker

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? A. Elasticity of the skin B. Appearance of any moles C. Muscle aches and pains D. Pigmentation of the skin

B. Appearance of any moles

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? A. Cheese pasta and a lettuce and tomato salad B. Beef steak with steamed broccoli and orange slices C. Broiled white fish with a baked sweet potato D. Grilled shrimp and season rice with asparagus salad

B. Beef steak with steamed broccoli and orange slices

48. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity B. Carotid bruit C. Jugular vein distention D. Palpable cervical lymph node

B. Carotid bruit

The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? A. Nuchal rigidity B. Carotid bruit C. Jugular vein distention D. Palpable cervical lymph node

B. Carotid bruit

An older male client with long-standing lung disease is admitted to the medical unit for treatment of pulmonary infection. In assessing for signs of increasing hypoxia, which action should the nurse include? (select all that apply) A. Monitor dryness of mucous membranes B. Check for changes in mentation C. Observe color of skin and nailbeds D. Note appearance of jugular veins E. Assess breathing patterns

B. Check for changes in mentation. C. Observe color of skin and mucous. E. Assess breathing patterns

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? A. Re-orient the client to his present location and circumstances B. Confirm that this is an effective technique to help with ambulation C. Assist the client to a carpeted area where he can walk more easily. D. Plan to assess the client's cognition after returning to his room.

B. Confirm that this is an effective technique to help with ambulation

29. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity

B. Decreased peripheral vision

When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity

B. Decreased peripheral vision

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. A. Strong foul-smelling flatus B. Gastroccult positive emesis C. Complaint of poor night vision D. Loose bowel movements

B. Gastroccult positive emesis

39. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? A. Osmolarity B. Glucose C. Albumin D. Platlets

B. Glucose

A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? A. Osmolarity B. Glucose C. Albumin D. Platelets

B. Glucose

4. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his last medications? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night?

B. Has his weight changed in the last several days?

A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? A. What time did he take his last medications? B. Has his weight changed in the last several days? C. Is he still able to tighten his belt buckle? D. How many hours did he sleep last night?

B. Has his weight changed in the last several days?

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? A. Black ulcers and dependent rubor B. Irregular ulcer shapes and sever edema C. Absent pedal pulses and shiny skin D. Hairless lower extremities and cool feet

B. Irregular ulcer shapes and severe edema

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? A. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi's sarcoma B. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month C. IV pentamidine will be given until oral pentamidine can be tolerated D. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.

B. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids D. Send the specimen to the lab for analysis

B. Observe the color, consistency, and amount of sputum

A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? A. Administer the first dose of antibiotic therapy B. Observe the color, consistency, and amount of sputum C. Encourage the client to consume plenty of warm liquids D. Send the specimen to the lab for analysis

B. Observe the color, consistency, and amount of sputum

38. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema and excoriation D. Identify all sexual partners in the last four days

B. Obtain a specimen of urethral drainage for culture

A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? A. Observe the perineal area for a chancroid-like lesion B. Obtain a specimen of urethral drainage for culture C. Assess for perineal itching, erythema and excoriation D. Identify all sexual partners in the last four days

B. Obtain a specimen of urethral drainage for culture

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? A. Glucose B. Platelet count C. White blood cell count D. Amylase

B. Platelet count

30. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase home air quality humidity between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation

B. Practice inhaling through the nose and exhaling slowly

A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? A. Allow additional time to complete physical activities to reduce oxygen demand B. Practice inhaling through the nose and exhaling slowly through pursed lips C. Use a humidifier to increase home air quality humidity between 30-50% D. Strengthen abdominal muscles by alternating leg raises during exhalation

B. Practice inhaling through the nose and exhaling slowly through pursed lips

14. A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room B. Prepare the client to return to the operating room C. Obtain a sample of the drainage to send to the lab D. Auscultate the abdomen for bowel sound activity

B. Prepare the client to return to the operating room

A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next? A. Bring additional sterile dressing supplies to the room B. Prepare the client to return to the operating room C. Obtain a sample of the drainage to send to the lab D. Auscultate the abdomen for bowel sound activity

B. Prepare the client to return to the operating room

17. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods C. Limit oral fluid intake to 500 ml per day D. Increase intake of potassium-rich foods such as bananas or cantaloupe

B. Restrict protein intake by limiting meats and other high-protein foods

The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? A. Increase intake of high-fiber foods, such as bran cereal B. Restrict protein intake by limiting meats and other high-protein foods C. Limit oral fluid intake to 500 ml per day D. Increase intake of potassium-rich foods such as bananas or cantaloupe

B. Restrict protein intake by limiting meats and other high-protein foods

16. A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? A. Begin preparing client for thyroidectomy procedure B. Space the client's care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blankets to prevent heat loss

B. Space the client's care to provide periods of rest

A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heart beat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? A. Begin preparing client for thyroidectomy procedure B. Space the client's care to provide periods of rest C. Assess the client for hyperactive bowel sounds D. Provide warm blankets to prevent heat loss

B. Space the client's care to provide periods of rest

22. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? A. Light yellow coloring of the client's skin and eyes B. The client's blood pressure reading is 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid

B. The client's blood pressure reading is 184/88 mm Hg

The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? A. Light yellow coloring of the client's skin and eyes B. The client's blood pressure reading is 184/88 mm Hg. C. The client vomits 20 ml of clear yellowish fluid D. The IV insertion site is red, swollen, and leaking IV fluid

B. The client's blood pressure reading is 184/88 mm Hg

13. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A. Grafting increases the risk for bacterial infections B. The xenograft is taken from nonhuman sources C. Grafts are later removed by a debriding procedure D. As the burn heals, the graft permanently attaches

B. The xenograft is taken from nonhuman sources

The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? A. Grafting increases the risk for bacterial infections B. The xenograft is taken from nonhuman sources C. Grafts are later removed by a debriding procedure D. As the burn heals, the graft permanently attaches

B. The xenograft is taken from nonhuman sources

27. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Offer ice chips and oral clear liquids B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and narcotic analgesics

B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg

A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) A. Offer ice chips and oral clear liquids B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg E. Administer oral antispasmodics and narcotic analgesics

B. Verify pedal pulses using a doppler pulse device C. Monitor left leg for pain, pallor, paresthesia, paralysis, pressure D. Evaluate the application of the splint to the left leg

A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next?

Blood pressure

To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? SATA a. initiate passive range of motion b. establish a regular routine c. teach the client breathing exercises d. perform chest physiotherapy e. encourage use of incentive spirometer

C, E

35. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A. An old friend with eczema came for a visit B. Recently received an influenza immunization C. A grandson and his new dog recently visited D. Corticosteroid cream was applied to eczema

C. A grandson and his new dog recently visited

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A. An old friend with eczema came for a visit B. Recently received an influenza immunization C. A grandson and his new dog recently visited D. Corticosteroid cream was applied to eczema

C. A grandson and his new dog recently visited

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? A. Teach the client about the importance of hydration B. Report the volume of emesis t the healthcare provider C. Administer ondansetron hydrochloride (Zofran) D. Encourage the client to limit the amount of movement

C. Administer ondansetron hydrochloride (Zofran)

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? A. Encourage the client to ambulate B. Offer ice ships or warm liquids C. Auscultate the client's abdomen D. Assess the client's temperature

C. Auscultate the client's abdomen

32. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Compare the client's pain scale rating with the prescribed dosing D. Ask the client to choose which mediation is needed for pain

C. Compare the client's pain scale rating with the prescribed dosing

A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Document the client's report of pain in the electronic medical record B. Determine which prescription will have the quickest onset of action C. Compare the client's pain scale rating with the prescribed dosing D. Ask the client to choose which mediation is needed for pain

C. Compare the client's pain scale rating with the prescribed dosing

43. During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp the drainage tube for 5 minutes

C. Continue to monitor the fluid output

During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of clear, straw-colored fluid drains within the first hour. What action should the nurse implement? A. Palpate for abdominal distention B. Send fluid to the lab for analysis C. Continue to monitor the fluid output D. Clamp the drainage tube for 5 minutes

C. Continue to monitor the fluid output

The family suspects that AIDS dementia is occurring in their son who is HIV positive. Which symptom confirms their suspicions?

A change has recently occurred in his handwriting.

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) a. Serum creatinine and blood urea nitrogen (BUN) b. Sensation in feet and legs c. Skin condition of lower extremities d. Visual acuity e. Signs of respiratory tract infection

A, B, C, D

An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A. A carotid bruit B. A hypotensive blood pressure C. hyperreflexic deep tendon relexes. D. Decreased bowel sounds

A. A carotid bruit

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? A. Ask for a demonstration of these exercises B. Explain that coughing should be avoided C. Review the client previous surgical history D. Document the clients understanding of teaching

A. Ask for a demonstration of these exercises

2. A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? A. Breath sounds over bilateral lung fields. B. Carotid pulsation during compressions C. Deep tendon reflexes D. Core body temperature

A. Breath sounds over bilateral lung fields.

A client is brought to the ED by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? A. Breath sounds over bilateral lung fields. B. Carotid pulsation during compressions C. Deep tendon reflexes D. Core body temperature

A. Breath sounds over bilateral lung fields.

18. An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin

A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure

An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure D. Document anxiety on the surgical checklist E. Administer a PRN dose of regular insulin

A. Check his fingerstick glucose level B. Assess his skin temperature and moisture C. Measure his pulse and blood pressure

50. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger

A. Collect the blood sample

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? A. Collect the blood sample B. Assess radial pulse volume C. Apply pressure to the site D. Select another finger

A. Collect the blood sample

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? A. Continuous cardiac monitoring B. Perform passive range of motion C. Evaluate level of consciousness D. Assess lung sounds q4 hours.

A. Continuous cardiac monitoring

26. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds

A. Daily weight

When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? A. Daily weight B. Vital signs C. Level of consciousness D. Bowel sounds

A. Daily weight

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? A. Eating patterns and dietary intake B. Level and amount of physical activity C. Color and consistency of feces D. Presence and activity of bowel sounds

A. Eating patterns and dietary intake

31. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? A. Impaired skin integrity B. Fluid volume excess C. Acute pain and anxiety D. Peripheral neurovascular dysfunction

A. Impaired skin integrity

A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained, and leaves the present IV in place. What is the greatest clinical risk related to this situation? A. Impaired skin integrity B. Fluid volume excess C. Acute pain and anxiety D. Peripheral neurovascular dysfunction

A. Impaired skin integrity

6. A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Increase the daily intake of oral fluids to liquefy secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects of mediations occur D. Teach anxiety reduction methods for feelings of suffocation

A. Increase the daily intake of oral fluids to liquefy secretions

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? A. Increase the daily intake of oral fluids to liquefy secretions B. Avoid crowded enclosed areas to reduce pathogen exposure C. Call the clinic if undesirable side effects of mediations occur D. Teach anxiety reduction methods for feelings of suffocation

A. Increase the daily intake of oral fluids to liquefy secretions

53. The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? A. Invite friends over regularly to share in meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the healthcare provider about prescribing an appetite stimulant

A. Invite friends over regularly to share in meal times

The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? A. Invite friends over regularly to share in meal times B. Encourage the client to drink clear liquids between meals C. Coach the client to make an intentional effort to swallow D. Talk to the healthcare provider about prescribing an appetite stimulant

A. Invite friends over regularly to share in meal times

19. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on the skin of the abdomen C. Quarter size blood spot on dressing D. Pitting ankle edema

A. Irregular apical pulse

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Purple marks on the skin of the abdomen C. Quarter size blood spot on dressing D. Pitting ankle edema

A. Irregular apical pulse

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? A. Large waist circumference with central fat B. High serum insulin level C. Hyperpigmentation on neck skin folds D. Poor muscle tone

A. Large waist circumference with central fat

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? A. Manual dexterity and visual acuity B. Capillary refill time and radial pulse volume C. Deep tendon reflexes and skin color D. Skin elasticity and hand grip strength.

A. Manual dexterity and visual acuity

28. A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough

A. Pain

A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? A. Pain B. Nocturia C. Dyspnea D. Frequent cough

A. Pain

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? A. Patch one eye and then the other every few hours B. Encourage bedrest until the diplopia is resolved C. Instruct the client to limit intake of oral fluids D. Administer artificial tear drops to both eyes

A. Patch one eye and then the other every few hours

3. After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? A. Reorient client to his room B. Place a patch on one eye C. Evaluate client's ability to swallow D. Perform range of motion exercises

A. Reorient client to his room

After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myselinolysis. Which intervention should the nurse implement first? A. Reorient client to his room B. Place a patch on one eye C. Evaluate client's ability to swallow D. Perform range of motion exercises

A. Reorient client to his room

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? A. Schedule an appointment or the client to see the healthcare provider B. Advise the client to apply plastic wrap over the ointment to promote healing C. Instruct the client to continue the ointment until all erythema is relieved D. Explain the client need to complete all prescribed dose of the medication

A. Schedule an appointment for the client to see the healthcare provider.

An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complication of DM, which assessments should the nurse obtain? (select all that apply) A. Serum creatinine and blood urea nitrogen (BUN) B. Sensation in feet and legs C. Skin condition of lower extremities D. Visual acuity E Signs of respiratory tract infection

A. Serum creatinine and blood urea nitrogen (BUN) B. Sensation in feet and legs C. Skin condition of lower extremities D. Visual acuity

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? A. Serum sodium of 185 mEq/L B. Dry skin with inelastic turgor C. Apical rate of 110 beats/minute D. Polyuria and excessive thirst

A. Serum sodium of 185 mEq/L

The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds

A. Skin integrity B. Functional ability D. Pain scale

37. The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply) A. Skin integrity B. Functional ability C. Heart sounds D. Pain scale E. Bowel sounds

A. Skin integrity B. Functional ability D. Pain scale

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Teach the client to elevate the head of the bed on blocks B. Remind the client to avoid high-fiber foods C. Encourage the client to lie down and rest after meals. D. Instruct the client to use antacids only as a last resort

A. Teach the client to elevate the head of the bed on blocks

10. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? A. left lateral B. Supine, knees flexed C. Dorsal recumbent D. Knee-chest

A. left lateral

The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? A. left lateral B. Supine, knees flexed C. Dorsal recumbent D. Knee-chest

A. left lateral

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose of Humulin N insulin at 0800. At 1600, the client complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first?

Determine the client's current glucose level

The nurse is assessing a client who has tinea pedis. Which question will allow the nurse to gather further information about this condition?

Do you see any improvement when using tolnaftate?

A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 62 hours indicates 5 mm of erythema without induration. What is the best initial nursing action?

Document negative results in the client's medical record

Which food is most important for the nurse to encourage a male client with osteomalacia to include in his daily diet?

Fortified milk and cereals

The nurse is assessing clients in an outpatient diabetic clinic. Which entry provides the best medication that the client is adhering to the prescribed diabetic regimen?

Hemoglobin A1C of 6.2%

A female client is being treated for tuberculosis with rifampin (rifadin) which statement indicates that further teaching is needed?

I will take my usual contraceptive for birth control

44. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? A. Review the client's dietary intake of high-protein foods B. Notify the healthcare provider of the finding immediately C. Discuss approaches to the chronic pain control with the client D. Assess the client's radial pulses and capillary refill time

C. Discuss approaches to the chronic pain control with the client

While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? A. Review the client's dietary intake of high-protein foods B. Notify the healthcare provider of the finding immediately C. Discuss approaches to the chronic pain control with the client D. Assess the client's radial pulses and capillary refill time

C. Discuss approaches to the chronic pain control with the client

15. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output

C. Fluid volume excess

A client with carcinoma of the lung is complaining of weakness and has a serum sodium level of 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? A. Altered urinary elimination B. Impaired gas exchange C. Fluid volume excess D. Decreased cardiac output

C. Fluid volume excess

The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? A. Use a walker when weakness occurs B. Avoid extreme environmental temperatures C. Increase daily intake of sodium in diet D. Take prescribed cortisone accurately

C. Increase daily intake of sodium in diet

24. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter

C. Keep the drainage bag lower than the level of the bladder

Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? A. Avoid coiling the tubing and keep if free of kinks B. Cleanse the perineal area with soap and water twice daily C. Keep the drainage bag lower than the level of the bladder D. Drink 1,000 ml of fluids daily to irrigate catheter

C. Keep the drainage bag lower than the level of the bladder

A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? A. Consult with surgeon about increasing methadone in lieu of parenteral opioids. B. Use minimal parenteral opioids for surgical pain, in addition to oral methadone C. Maintain client's methadone, and medicate surgical pain based on pain rating D. Make no changes in the standard pain management for the surgery and hold methadone.

C. Maintain client's methadone, and medicate surgical pain based on pain rating

9. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? A. Sleep without pillows at night to maintain neck alignment. B. Adjust food intake to three full meals per day and no snacks. C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid participation in any aerobic exercise programs

C. Minimize symptoms by wearing loose, comfortable clothing

What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? A. Sleep without pillows at night to maintain neck alignment. B. Adjust food intake to three full meals per day and no snacks. C. Minimize symptoms by wearing loose, comfortable clothing D. Avoid participation in any aerobic exercise programs

C. Minimize symptoms by wearing loose, comfortable clothing

33. While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence

C. Observe for prolonged periods of apnea

While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Document details of the seizure activity B. Observe for lacerations to the tongue C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence

C. Observe for prolonged periods of apnea

41. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? A. Collect a urine specimen for culture analysis B. Review the client's fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. Obtain a fingerstick blood glucose level

C. Palpate the bladder above the symphysis pubis

An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? A. Collect a urine specimen for culture analysis B. Review the client's fluid intake prior to bedtime C. Palpate the bladder above the symphysis pubis D. Obtain a fingerstick blood glucose level

C. Palpate the bladder above the symphysis pubis

47. After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Call respiratory therapy to give a breathing treatment B. Send another nurse for an emergency tracheotomy set C. Prepare a dose of epinephrine (Adrenalin) D. Review the client's complete list of allergies

C. Prepare a dose of epinephrine (Adrenalin)

After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? A. Call respiratory therapy to give a breathing treatment B. Send another nurse for an emergency tracheotomy set C. Prepare a dose of epinephrine (Adrenalin) D. Review the client's complete list of allergies

C. Prepare a dose of epinephrine (Adrenalin)

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? A. Assist with ambulation in the hallway B. Encourage active range of motion exercises C. Provide a bedside commode for toileting D. Teach to sleep in a slide-laying position

C. Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? A. Teach a family member to administer eye drops B. Encourage deep breathing and coughing exercises C. Provide an eye shield to be worn while sleeping D. Obtain vital signs every 2 hours during hospitalization

C. Provide an eye shield to be worn while sleeping

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? A. Serum electrolytes B. Neutrophils and eosinophils C. Serum iron and ferritin D. Platelet count and hematocrit

C. Serum iron and ferritin

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first A. Sevelamer (RenaGel) one tablet PO. B. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ C. Sodium polystyrene (Kayexalate) 15 grams PO D. Calcium acetate (Phos-Lo) one tablet PO

C. Sodium polystyrene (Kayexalate) 15 grams PO

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? A. Hard pellets of stool B. Clay-colored stool C. Stool with fatty streaks D. Blood in the stool

C. Stool with fatty streaks

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation A. Low-sodium soups. B. Over all fluid intake C. Tea and hot chocolate D. Citrus fruit juices

C. Tea and hot chocolate

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? A. Provide assistive devices to empower client independence B. Implement measures to manage chronic pain C. Teach coping skills for living with a chronic illness D. Schedule rest periods between activates to minimize fatigue.

C. Teach coping skills for living with a chronic illness

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) A. Initiate passive range of motion exercises B. Establish a regular bladder routine C. Teach the client breathing exercises D. Perform chest physiotherapy E. Encourage use of incentive spirometer

C. Teach the client breathing exercises D. Perform chest physiotherapy E. Encourage use of incentive spirometer

7. A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide? A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes. B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack. C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle. D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.

C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.

A cardiac catherterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide? A. Blood supply to the heart is diminished by artherosclerotic lesions, which necessitate lifestyle changes. B. Blood vessels supplying the pumping chamber have blockages indicating a past heart attack. C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle. D. The heart is not receiving enough blood, so there is a risk of heart failure and fluid retention.

C. Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle.

52. A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? A. Measure urine output hourly to assess for rental perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide a quiet environment with low lighting

C. Use an automated BP machine to monitor for hypotension

A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? A. Measure urine output hourly to assess for rental perfusion B. Request a prescription for pain medication C. Use an automated BP machine to monitor for hypotension D. Provide a quiet environment with low lighting

C. Use an automated BP machine to monitor for hypotension

A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? A. Notify the healthcare provider B. Assure the client that such feelings occur with wound infections C. Visualize the abdominal incision D. Obtain sterile towels soaked in saline

C. Visualize the abdominal incision

12. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness

C. Weakened cough effort

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? A. Inappropriate laughter B. Increasing anxiety C. Weakened cough effort D. Asymmetrical weakness

C. Weakened cough effort

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? A. Elevate the hands on two pillows at night B. Notify the healthcare provider as soon as possible C. Wear braces as both writs during the night D. Apply cold compresses for 30 min before bedtime

C. Wear braces as both writs during the night

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which laboratory value is most important for the nurse to monitor following the procedure? A. Serum creatinine B. Blood urea nitrogen (BUN) C. White blood cell count D. Serum glucose

C. White blood cell count

11. A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider. A. Belching B. Amber urine C. Yellow sclera D. Flatulence

C. Yellow sclera

A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider. A. Belching B. Amber urine C. Yellow sclera D. Flatulence

C. Yellow sclera

A 70-year-old male client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?

Check the insides and linings of all enclosed shoes before putting the shoes on

After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?

Clamp the catheter for 30 minutes prior to irrigating with saline

A male client with pernicious anemia takes supplemental folate and self-administers monthly Vitamin B12 injections. He reports feeling increasingly fatigued. Which laboratory value should the nurse review?

Complete blood count

Which clinical manifestation further supports an assessment of a left-sided brain attack? A) Visual field deficit on the left side. B) Spatial-perceptual deficits. C) Paresthesia of the left side. D) Global aphasia.

D) Global aphasia.

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? A. Auscultate for presence of bowl sounds. B. Monitor hemoglobin and hematocrit C. Encourage turning and deep breathing D. Administer IV antibiotics as prescribed.

D. Administer IV antibiotics as prescribed

21. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer PRN oral antipyretic

D. Administer PRN oral antipyretic

A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? A. Obtain oxygen saturation level B. Encourage incentive spirometry C. Assess lower extremity circulation D. Administer PRN oral antipyretic

D. Administer PRN oral antipyretic

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? A. Encourage frequent mouth care B. Cleanse the tongue and mouth with glycerin swabs C. Obtain a soft diet for the client D. Administer a topical analgesic per PRN protocol.

D. Administer a topical analgesic per PRN protocol.

5. An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high-flow venturi mask D. Assist her to an upright position

D. Assist her to an upright position

An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Encourage client to drink water C. Apply a high-flow venturi mask D. Assist her to an upright position

D. Assist her to an upright position

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement? A. Palpate the abdomen B. Measure hourly urine output C. Ambulate client in hallway D. Auscultate bowels sounds.

D. Auscultate bowels sounds.

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? A. Uses only lactose-free dairy products. B. Enjoys fat free yogurt as an occasional snack food C. No longer includes grains in his daily diet D. Carefully cleans and peels all fresh fruit and vegetables

D. Carefully cleans and peels all fresh fruit and vegetables

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? A. Determine clients last dose of corticosteroids B. Determine neurological baseline prior to the fall C. Administer a PRN IV antiemetic as prescribed D. Complete head to toe neurological assessment.

D. Complete head to toe neurological assessment.

36. While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem? A. Irritation of nerve endings B. Diminished blood flow C. Ischemic tissue changes D. Compression of a nerve

D. Compression of a nerve

While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. what is the etiology of this problem? A. Irritation of nerve endings B. Diminished blood flow C. Ischemic tissue changes D. Compression of a nerve

D. Compression of a nerve

20. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal

D. Continue to monitor the fingers until color returns to normal

An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? A. Apply a cool compress to the affected fingers for 20 minutes B. Secure a pulse oximeter to monitor the client's oxygen saturation C. Report the finding to the healthcare provider as soon as possible D. Continue to monitor the fingers until color returns to normal

D. Continue to monitor the fingers until color returns to normal

46. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? A. Stabilization of blood pressure ranges B. Cessation of chest pain C. Reduce heart rate D. Decreased frequency of episodes of VT

D. Decreased frequency of episodes of VT

Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? A. Stabilization of blood pressure ranges B. Cessation of chest pain C. Reduce heart rate D. Decreased frequency of episodes of VT

D. Decreased frequency of episodes of VT

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? A. Encourage the family to offer to feed the client when she does not eat her entire meal. B. Suggest that the family bring foods from home that the client enjoys C. Explain that weight loss will be reversed after the acute phase of the stroke has ended. D. Demonstrate the use of visual scanning during meals to the client and family.

D. Demonstrate the use of visual scanning during meals to the client and family

51. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement? A. Soak nasogastric tube in warm water B. Insert tube with client's head tilted back C. Apply suction while inserting tube D. Elevate head of bed 60 to 90 degrees

D. Elevate head of bed 60 to 90 degrees

A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement? A. Soak nasogastric tube in warm water B. Insert tube with client's head tilted back C. Apply suction while inserting tube D. Elevate head of bed 60 to 90 degrees

D. Elevate head of bed 60 to 90 degrees

23. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. Cold and dry skin D. Further decline in level of consciousness

D. Further decline in level of consciousness

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? A. Facial puffiness and periorbital edema B. Hematocrit of 30% C. Cold and dry skin D. Further decline in level of consciousness

D. Further decline in level of consciousness

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Deliver another defibrillator shock C. Administer IV Epinephrine per ACLS protocol D. Give IV dose of adenosine rapidly over 1-2 seconds.

D. Give IV dose of adenosine rapidly over 1-2 seconds

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? A. Assist the lien tot a high Fowler's position in bed B. Observe the client for the presence of a barrel chest C. Prepare to transfer the client to a critical care unit D. Instruct the client to pursed lip breathing techniques

D. Instruct the client in pursed lip breathing techniques

45. A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? A. Weakness and fatigue B. Intestinal cramping C. Weight loss D. Jaundiced sclera

D. Jaundiced sclera

A client who took a camping vacation two weeks ago in a county with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? A. Weakness and fatigue B. Intestinal cramping C. Weight loss D. Jaundiced sclera

D. Jaundiced sclera

55. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output

D. Monitor urinary stream for decrease in output

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use incentive spirometer C. Restrict physical activities D. Monitor urinary stream for decrease in output

D. Monitor urinary stream for decrease in output

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? A. Slight blood-tinged sputum B. Dyspnea and dysphagia C. Sore throat and hoarseness D. No gag reflex after thirty minutes

D. No gag reflex after thirty minutes

40. A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing

D. Pain when swallowing

A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? A. Elevated temperature B. Generalized weakness C. Diminished lung sounds D. Pain when swallowing

D. Pain when swallowing

A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first? A. Evaluate distal capillary refill for delayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pretibial regions for pitting edema D. Palpate the abdomen for tenderness and rigidity

D. Palpate the abdomen for tenderness and rigidity

54. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minutes,. Which assessment should the nurse implement first? A. Evaluate distal capillary refill for delayed perfusion B. Check the extremities for bruising and petechiae C. Examine the pretibial regions for pitting edema D. Palpate the abdomen for tenderness and rigidity

D. Palpate the abdomen for tenderness and rigidity ...

34. A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement. A. Provide a warming pad (Aqua-pad or K-pad) to feet B. Medicate the client with a prescribed sedative C. Use a bed cradle to hold the covers off the feet D. Place warm blankets next to the client's feet

D. Place warm blankets next to the client's feet

A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement. A. Provide a warming pad (Aqua-pad or K-pad) to feet B. Medicate the client with a prescribed sedative C. Use a bed cradle to hold the covers off the feet D. Place warm blankets next to the client's feet

D. Place warm blankets next to the client's feet

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. Glucose of 350 mg/dl B. White blood cell count of 15, 000 mm3 C. Blood PH of 7.30 D. Potassium of 2.5 mEq/L

D. Potassium of 2.5 mEq/L

42. Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement? A. Remove all sources of liquids from the client's room B. Allow family to give client a measured amount of ice chips C. Restrict family visiting until the client's condition is stable D. Provide the client with oral swabs to moisten his mouth

D. Provide the client with oral swabs to moisten his mouth

Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement? A. Remove all sources of liquids from the client's room B. Allow family to give client a measured amount of ice chips C. Restrict family visiting until the client's condition is stable D. Provide the client with oral swabs to moisten his mouth

D. Provide the client with oral swabs to moisten his mouth

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse? A. True urinary output of 50ml/hr B. Lower abdominal tenderness C. Blood urine output with clots D. Urine leaking around the meatus

D. Urine leaking around the meatus

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? A. Reports subjective symptom's during hemodialysis B. Documents his oral intake during dialysis treatments C. Demonstrates self-care of the arteriovenous (AV) Shunt D. Verbalizes understanding of the reasoning for dialysis

D. Verbalizes understanding of the reasoning for dialysis

The nurse is teaching the importance of an exercise regime that includes walking daily for a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary rehabilitation clinic. Which rationale should the nurse include when motivating the clients?

Daily exercise and walking enhances cardiovascular fitness

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement?

Determine if the client is using an inhaler before exercising

A female client who was involved in a motor vehicle collision with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? Select all that apply

Monitor left leg for pain, pallor, paresthesia, paralysis, pressure. Verify pedal pulses using a doppler pulse device. Evaluate the application of the splint to the left leg

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?

Pain related to joint inflammation

The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider?

Rapid weight gain

A client with chronic kidney disease (CDK) arrives at the clinic reporting shortness of breath on exertion and extreme weakness. Vital signs are temperature 100.4 F (38 C), heart rate 110 beats/minute, respirations 28 breaths/minute, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory results should the nurse report to the healthcare provider immediately?

Potassium 6.5 mEq/L (mmol/L)

The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse implement prior to taking the client into the operative area?

Replace latex-containing devices in the OR with alternate synthetic materials

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN), which instruction should the nurse include in the dietary teaching?

Restrict sodium intake

A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement?

Review most recent thyroid function test results

A female client who received partial-thickness and full-thickness burns over 40% of her body in a house fire is admitted to the inpatient burn unit. What fluid should the nurse prepare to administer during the acute phase of the client's burn recovery?

Ringer's Lactate

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care?

Teach the client techniques for performing intermittent catheterization

A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority?

Tell the client to remain in bed

A client with unstable asthma had an emergent cardiac catheterization. Which complication should the nurse monitor for in the initial 24 hours after the procedure?

Thrombus formation

An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. Which action is most important for the nurse to implement?

Use a doppler to assess bilateral pedal pulses

A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client?

Use a space heater to keep the workspace warm

A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement?

Protect cornea with lubricant and eye shields

A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement?

Provide an overhead trapeze to the bed for the client to use

A client with draining skin lesions of the lower extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse include in the plan on care? (Select all that apply.)

Institute contact precautions for staff and visitors. Send wound drainage for culture and sensitivity. Monitor the client's white blood cell count.

During preoperative teaching for a male client schedule for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understand the need to perform coughing and deep breathing exercise after surgery. How should the nurse respond? a. Ask for a demonstration of these exercises b. Explain that coughing should be avoided c. Review the client previous surgical history d. Document the clients understanding of teaching

a. Ask for a demonstration of these exercises

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Eating patterns and dietary intake b. Level and amount of physical activity c. Color and consistency of feces d. Presence and activity of bowel sounds

a. Eating patterns and dietary intake

The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? a. Large waist circumference with central fat b. High serum insulin level c. Hyperpigmentation on neck skin folds d. Poor muscle tone

a. Large waist circumference with central fat

The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? a. Manual dexterity and visual acuity b. Capillary refill time and radial pulse volume c. Deep tendon reflexes and skin color d. Skin elasticity and hand grip strength.

a. Manual dexterity and visual acuity

Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? a. Patch one eye and then the other every few hours b. Encourage bedrest until the diplopia is resolved c. Instruct the client to limit intake of oral fluids d. Administer artificial tear drops to both eyes

a. Patch one eye and then the other every few hours

A client uses triamcinolone (Kenalog), a corticosteroid ointment, to manage pruritus caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Schedule an appointment or the client to see the healthcare provider b. Advise the client to apply plastic wrap over the ointment to promote healing c. Instruct the client to continue the ointment until all erythema is relieved d. Explain the client need to complete all prescribed dose of the medication

a. Schedule an appointment or the client to see the healthcare provider

A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? a. Serum sodium of 185 mEq/L b. Dry skin with inelastic turgor c. Apical rate of 110 beats/minute d. Polyuria and excessive thirst

a. Serum sodium of 185 mEq/L

Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? a. Teach the client to elevate the head of the bed on blocks b. Remind the client to avoid high-fiber foods c. Encourage the client to lie down and rest after meals. d. Instruct the client to use antacids only as a last resort

a. Teach the client to elevate the head of the bed on blocks

A client receives prescriptions for a multidrug regimen for the treatment of tuberculosis. Which information should the nurse prioritize? a. adherence to the regimen is imperative b. medications should be taken with food c. serum liver panels are collected regularly d. enhanced sun protection measures will be needed

a. adherence to the regimen is imperative

An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. assist client to an upright position b. administer a prescribed sedative c. apply a high-flow venturi mask d. encourage client to drink water

a. assist client to an upright position

A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? a. collect a clean catch specimen b. palpate the suprapubic region c. instruct to wipe from front to back d. inquire about recent sexual activity

a. collect a clean catch specimen

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider b. explain the need for using lead shields for 2 to 3 weeks after the treatment c. describe the signs of goiter because this is a common side effects of radioactive iodine d. explain that relief of the signs/ symptoms of hyperthyroidism will occur immediately

a. describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider? a. distended, hard, and rigid abdomen b. clay-colored stool c. radiating, sharp pain in right shoulder d. bile-stained emesis

a. distended, hard, and rigid abdomen

The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi? a. eats a vegetarian diet with cheese 2 to 3 times a day b. experiences additional stress since adopting a child c. jogs more frequently than usual daily routine d. drinks several bottles of carbonated water daily

a. eats a vegetarian diet with cheese 2 to 3 times a day

The health care provider prescribe a medication for an older adult client who is complaining of insomnia. And instructs the client to return in 2 weeks. The nurse should question which prescription? a. Eszoplicone (Lunesta)10 mg orally at bed time b. Zolpidem 10 mg orally at bed time c. Temazepan orally at bed time d. Ramelteon orally at bedtime

a. eszoplicone (Lunesta) 10mg PO at bedtime

A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? a. explain specific reason for urgent notification b. preface the report by stating the clients name and admitting diagnosis c. communicate the pre-transfusion temperatures d. optain prn prescription for acetaminophen for fever 101f

a. explain specific reason for urgent notification

The therapeutic effect of insulin in treating type 1 diabetes mellitus is based on which physiologic action? a. Facilitates transport of glucose into the cell b. Increases intracellular receptor site sensitivity c. Stimulates function of beta cells in the pancreas d. Delays carbohydrates digestion and absorption

a. facilitates transport of glucose into the cell

The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. family members can help with regular foot exams b. heating pads are useful if on the lowest setting c. aching feet may be soaked in lukewarm water for one hour or more d. shoes should be worn outside the house, but it is fine to be barefoot inside

a. family members can help with regular foot exams

Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? a. fortified milk and cereals b. citrus fruits and juices c. green leafy vegetables d. red meats and eggs

a. fortified milk and cereals

A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which interventions should the nurse implement? (Select all that apply.) a. have the client describe a typical day at work, home, and social activities b. determine if the client is using a new insulin needle each administration c. evaluate the client's asthma medications that can elevate the blood glucose d. ask the client if they want a different manufacturer's glucose monitoring device e. have the client demonstrate technique used to monitor blood glucose levels

a. have the client describe a typical day at work, home, and social activities e. have the client demonstrate technique used to monitor blood glucose levels

An elderly post-operative female client is receiving morphine sulfate via a PCA pump. Which assessment finding should prompt a nurse to administer the prescribed PRN medication naloxone? a. her respiratory rate is 7 breath/minute b. she indicates that she feels as if she cannot get enough air to breath c. she has intercostal retractions and bilateral wheezing is auscultated d. her pulse oximeter is 89% on room air

a. her respiratory rate is 7 breaths/minute

During spring break, a young adult presents to the urgent care clinic and reports a stiff neck, a fever for the past 6 hours, and a headache. Which intervention is the most important for the nurse to implement first? a. initiate isolation precautions b. administer an antipyretic c. draw blood cultures d. prepare for a lumbar puncture

a. initiate isolation precautions

A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report? a. jaundice sclera b. intestinal cramping c. weakness and fatigue d. weight loss

a. jaundice sclera

Following involvement in a motor vehicle collision, a middle aged adult client is admitted to the hospital with multiple facial fractures. The client's blood alcohol level is high on admission. Which PRN prescription should be administer if the clients begins to exhibit signs and symptoms of delirium tremens (DT s)? a. Lorazepam (Ativan) 2mg IM b. Chlorpromazine (thorazine) 50 mg IM c. Prochlorperazine (Compazine) 5 mg IM d. Hydromorphone (Dilaudid) 2 mg IM

a. lorazepam (Ativan) 2mg IM

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain

a. low back pain and hypotension

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client? a. maintain prescribed eye drop regimen b. avoid frequent eye pressure measurements c. wear prescription glasses d. east a diet high in carotene

a. maintain prescribed eye drop regimen

The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. medicate for pain and monitor vital signs according to protocol b. administer intravenous fluid bolus as prescribed by the healthcare provider c. apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter d. encourage the client to splint the incision with a pillow to cough and deep breathe

a. medicate for pain and monitor vital signs according to protocol

A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take? a. monitoring catheter drainage b. decreasing the flow rate c. irrigating the catheter manually d. discontinuing infusing solution

a. monitoring catheter drainage

The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. notify the healthcare provider of the client's medication history b. observe the heparin injections sites for signs of bruising c. have the client sign the surgical and transfusion permits d. ensure that the potential for bleeding is explained to the client

a. notify the healthcare provider of the client's medication history

A male adult comes to the urgent care clinic 5 days after being diagnosed with influenza. He is short of breath, febrile, and coughing green colored sputum. Which intervention should the nurse implement first? a. Obtain a sputum sample for culture b. Check his oxygen saturation level c. Administer an oral antipyretic d. Auscultate bilateral lung sound

a. obtain a sputum sample for culture

In caring for a client with diabetes insipidus who is receiving an antidiuretic hormone intranasal which serum lab test is most important for the nurse to monitor? a. osmolality b. calcium c. platelets d. glucose

a. osmolality

To reduce the risk for pulmonary complication for a patient with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply.) a. perform chest physiotherapy b. teach the client breathing exercises c. initiate passive range of motion exercises d. establish a regular bladder routine e. encourage use of incentive spirometer

a. perform chest physiotherapy b. teach the client breathing exercises e. encourage use of incentive spirometer

The nurse is caring for a client who is postoperative for a femoral head fracture repair. Which intervention(s) should the nurse plan to administer for deep vein thrombosis prophylaxis? (Select all that apply.) a. pneumatic compression devices b. incentive spirometry c. assisted ambulation d. patient-controlled analgesia e. calf-pump exercises f. prescribed anticoagulant therapy

a. pneumatic compression devices e. calf-pump exercises f. prescribed anticoagulant therapy

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care of the portal site should the nurse provide? a. protect the skin of the radiation portal site from sunlight exposure b. apply moisture lotions daily to the radiation portal site c. avoid washing the skin inside the radiation portal site d. remove the ink marks of the portal after each radiation treatment

a. protect the skin of the radiation portal site from sunlight exposure

The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider? a. rapid weight gain b. abdominal striae c. moon facies d. gastric irritation

a. rapid weight gain

A client is caring for a client with diabetes insipidus (DI). What data warrants the MOST immediate intervention by the nurse? a. serum sodium of 185 mEq/L (185 mmol/L) b. dry skin with inelastic tugor c. apical rate of 110 beats per minute d. polyuria and excessive thirst

a. serum sodium of 185 mEq/L (185 mmol/L)

The healthcare provider prescribes diagnostic tests for a client whose chest xray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the MOST therapeutic treatment of the pneumonia? a. sputum culture and sensitivity b. blood cultures c. arterial blood gases (ABGs) d. computerized tomography (CT) of the chest

a. sputum culture and sensitivity

A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the client's blood pressure drops from 150/90 mmHg to 80/30 mmHg. Which action should the nurse take first? a. stop the dialysis treatment b. administer 5% albumin IV c. monitor blood pressure q45 minutes d. lower the head of the chair and elevate the feet

a. stop the dialysis treatment

A male client is receiving pilocarpine hydrochloride (Isopto Carpine) ophthalmic drops for glaucoma. He calls the clinic and ask the nurse why he has difficulty seeing at night. What explanation should the nurse provide? a. The eye drops slow pupil response to accommodate for darkness b. The drops increase the fluid in the eyes and cloud the visual field ( possible answer) c. The drug can cause lens to become more opaque d. The medication causes pupils to dilate which reduces night vision

a. the eye drops slow pupil response to accommodate for darkness

The nurse is providing preoperative education for a jewish client schedule to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? a. the xenograft is taken from nonhuman sources b. grafting increases the risk for bacterial infection c. as the burn heals the graft permanently attaches d. grafts are later removed by debriding procedure

a. the xenograft is taken from nonhuman sources

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis? a. upper mid abdominal gnawing and burning pain b. severe abdominal cramps and diarrhea after eating spicy foods c. marked loss of weight and appetite over the last few months d. use of chewable and liquid antacids for indigestion

a. upper mid abdominal gnawing and burning pain

Which assessment finding indicates to the nurse that the muscarinic agent bethanechol (Urecholine) is effective for a client diagnosed with urinary retention? a. urinary output equal to intake b. no terminal urinary dribbling c. denies stress incontinence d. absence of xerostomia

a. urinary output equal to intake

A client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that the client's distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) a. verify pedal pulses using a doppler pulse device b. evaluate the application of the splint to the left leg c. offer ice chips and oral clear liquids d. monitor left leg for pain, pallor, paresthesia, paralysis, pressure e. administer oral antispasmodics and narcotic analgesics

a. verify pedal pulses using a doppler pulse device b. evaluate the application of the splint to the left leg d. monitor left leg for pain, pallor, paresthesia, paralysis, pressure

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. white blood cell (WBC) count b. platelet count c. blood pH level d. hematocrit

a. white blood cell (WBC) count

A client who is taking and oral dose of tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. toasted wheat bread and jelly b. cheese and crackers c. cold cereal with skim milk d. fruit flavored yogurt

a.toasted wheat bread and jelly

A male client who reports feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? a) cheese pasta and a lettuce and tomato salad b) beef steak with steamed broccoli and orange slices c) broiled white fish with a baked sweet potato d) grilled shrimp and seasoned rice with asparagus salad

b) beef steak with steamed broccoli and orange slices

When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the HCP? a) slight blood-tinged sputum b) dyspnea and dysphagia c) sore throat and hoarseness d) no gag reflex after thirty minutes

b) dyspnea and dysphagia

A hospitalized client with peripheral arterial disease (PAD) is instructed regarding leg and foot care. Which statement by the client indicates to the nurse that learning has occurred? a. "whenever I am sitting in a chair I will keep my legs up to reduce swelling" b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown" c. "I will try to keep moving if leg pain occurs to help promote good circulation" d. "I will use my swimming pool early in the day while the water is still very cool"

b. "I can use a mirror to check the bottoms of my feet for any signs of breakdown"

A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. I t is most important for the nurse to emphasize the need to observe for changes in which characteristic? a. Elasticity of the skin b. Appearance of any moles c. Muscle aches and pains d. Pigmentation of the skin

b. Appearance of any moles

A male client who reports feeling chronically fatigued has a hemoglobin of 11.0 grams/dl (110mmol/L), hematocrit of 34%, and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? a. Cheese pasta and a lettuce and tomato salad b. Beef steak with steamed broccoli and orange slices c. Broiled white fish with a baked sweet potato d. Grilled shrimp and season rice with asparagus salad

b. Beef steak with steamed broccoli and orange slices

A nurse assists a male client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? a. Re-orient the client to his present location and circumstances b. Confirm that this is an effective technique to help with ambulation c. Assist the client to a carpeted area where he can walk more easily. Plan to assess the client's cognition after returning to his room.

b. Confirm that this is an effective technique to help with ambulation

A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. a. Strong foul-smelling flatus b. Gastroccult positive emesis c. Complaint of poor night vision d. Loose bowel movements

b. Gastroccult positive emesis

When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? a. Provide assistive devices to empower client independence b. Implement measures to manage chronic pain c. Teach coping skills for living with a chronic illness d. Schedule rest periods between activates to minimize fatigue.

b. Implement measures to manage chronic pain

In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? a. Black ulcers and dependent rubor b. Irregular ulcer shapes and severe edema c. Absent pedal pulses and shiny skin d. Hairless lower extremities and cool feet

b. Irregular ulcer shapes and sever edema

An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? a. IV pentamidine may offer protection to other AIDS-related conditions, such as Kaposi's sarcoma b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month c. IV pentamidine will be given until oral pentamidine can be tolerated d. AZT (Azidothymidine) therapy must be stopped when IV or aerosol pentamidine is being used.

b. It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month

The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? a. Glucose b. Platelet count c. White blood cell count d. Amylase

b. Platelet count

Which client has the highest risk for developing skin cancer? a. a 70-year-old fair-skinned client who works as a secretary b. a 65-year-old fair-skinned client who is a construction worker c. a 16-year-old dark-skinned client who tans in tanning beds once a week d. a 25-year-old dark-skinned client whose mother had skin cancer

b. a 65-year-old fair-skinned client who is a construction worker

The family suspects that acquired immune deficiency syndrome (AIDS) dementia is occurring in their son who is human immunodeficiency virus (HIV) positive. Which symptom confirms their suspicions? a. he has begun to sleep 18 out of 24 hours b. a change has recently occurred in his handwriting c. he refuses to see any of his friends or to return their phone calls d. he exhibits angry outbursts when the subject of dying is approached

b. a change has recently occurred in his handwriting

A client with a history of peptic ulcer disease (PUD) is admitted after vomiting bright red blood several times over the course of 2 hours. In reviewing the laboratory results, the nurse finds the client's hemoglobin is 12 g/dL (120 g/L) and the hematocrit is 35% (0.35). Which action should the nurse prepare to take? a. continue to monitor for blood loss b. administer 1,000 mL (1 L) normal saline c. transfuse 2 units of platelets d. prepare the client for emergency surgery

b. administer 1,000 mL (1 L) normal saline

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first? a. remove all of the morphine patches b. administer a narcotic antagonist c. apply oxygen per face mask d. measure the client's blood pressure

b. administer a narcotic antagonist

A male client reports to the nurse that he is experiencing GI distress from high dose of a corticosteroid and is planning to stop taking the medication. In response to the client's statement what nursing action is most important for the nurse to take? a. Encourage the client to take medication with food to decrease GI distress b. Advice the client that the medication should be stopped gradually rather than abruptly. c. Review the clients dosing schedule to ensure he is taking the prescribed amount d. Assess the client for other indication of adverse effects of corticosteroid

b. advise the client that the medication should be stopped gradually rather than abruptly

Two days after an abscess of the chin was drained the client returns to the clinic with fever chills and a maculopapular rash with pruritis. The client has taken an oral antibiotic and cleansed the wound today with provide iodine (Betadine) solution. Which intervention should the nurse implement first? a. determine if the client has a history of diabetes b. assess airway patency and oxygen saturation c. review recent medication history and allergies d. obtain samples for complete blood count and cultures

b. assess airway patency and oxygen saturation

Antibiotic resistant organism are a major infection control problems. To help minimize the emergence of resistant bacteria what instruction should the nurse provide to the clients? a. stop taking prescribed antibiotics when symptoms decrease b. avoid using antibiotics when suffering from colds or the flu c. ask the healthcare provider to prescribe the newest antibiotic when needed d. request a prescription for first time vancomysin for a sore throat

b. avoid using antibiotics when suffering from colds or the flu

The home health nurse provides teaching about insulin self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? (Please view the video to select the option that applies. To review the video, click the play button again.) a. select a different injection site b. continue with the insulin injection c. keep the skin flat rather than bunched d. lie down flat for better skin exposure

b. continue with the insulin injection

The nurse administer donepezil hydrochloride (Aricept) to a client with Alzheimer's disease as an intervention for which client problem? a. fluid volume excess b. disturbed thought processes c. chronic pain d. altered breathing patterns

b. disturbed thought processes

A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. eat high protein foods to achieve ideal body weight b. drink at least 8 cups (1920 mL) of water per day c. use electric heating pad when pain is at its worse d. encourage active range of motion to limit stiffness

b. drink at least 8 cups (1920 mL) of water per day

An obese client with emphysema who smokes at least a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and it is determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. methods for weight loss b. guidelines for oxygen use c. approaches to conserve energy d. strategies for smoking cessation

b. guidelines for oxygen use

A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? a. purple marks on the side of the abdomen b. irregular apical pulse c. quarter size blood spot on dressing d. pitting ankle edema

b. irregular apical pulse

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today? a. sexual activities may be resumed upon return home b. light housekeeping is permitted but avoid heavy lifting c. use a metal eye shield on operative eye during the day d. administer eye ointment before applying eye drops

b. light housekeeping is permitted but avoid heavy lifting

A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was casually met. Which action should the nurse implement? a. observe the perineal area for a chancroid-like lesion b. obtain a specimen of urethral drainage for culture c. assess for perineal itching, erythema, and excoriation d. identify all sexual partners in the last four days

b. obtain a specimen of urethral drainage for culture

A client with Herpes Zoster (shingles) on the thorax tells the nurse of having difficulty sleeping. Which is the probable etiology of this problem? a. frequent cough b. pain c. nocturia d. dyspnea

b. pain

A client is hospitalized with heart failure (HF). Which intervention should the nurse implement to improve ventilation and reduce venous return? a. perform passive range of motion b. place the client in a high Fowler position c. administer oxygen per nasal cannula d. increase the client's activity level

b. place the client in a high Fowler position

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. red blood cell count b. platelet count c. hemoglobin levels d. white blood cell count

b. platelet count

A client in the operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? a. hold a prescription for dantrolene until fever is reduced b. prepare ice packs for placement in the client's axillary area c. call the PACU nurse to prepare for prolonged ventilatory support d. determine if prescribed antibiotics were administered preoperatively

b. prepare ice packs for placement in the client's axillary area

A client with symptoms of influenza that started the previous day ask the clinic nurse about taking oseltamivir (Tamiflu) to treat the infection. Which response should the nurse provide? a. Advise the client once symptoms occur is too late to receive an influenza vaccination b. Refer the client to the healthcare provider at the clinic to obtain a medication prescription c. Explain to the client that antibiotics are not useful in treating viral infections such as influenza d. Instruct the client that over the counter medications are sufficient to manage influenza symptoms

b. refer the client to the healthcare provider at the clinic to obtain a medication prescription

When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? a. select a protein rich food daily b. restrict sodium intake c. eat high potassium foods d. Avoid foods high in carbohydrate

b. restrict sodium intake

Fifteen minutes after receiving sulfa athenozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement? a. Auscultate lung sounds for wheezing b. Review the clients list if drugs allergies c. Add sulfamethinozole to clients allergies d. Check neurological vital signs

b. review the clients list of drug allergies

An older client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. Which assessments would the nurse complete to determine if a patient with type 2 diabetes mellitus (DM) is experiencing long term complications? (Select all that apply.) a. signs of respiratory tract infection b. sensation in feet and legs c. skin condition of lower extremities d. serum creatinine and blood urea nitrogen (BUN) e. visual acuity

b. sensation in feet and legs c. skin condition of lower extremities e. visual acuity

A client with acute renal injury (AKI) weighs 50 kg and has a potassium of 6.7 mEq/L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first? a. calcium acetate one tablet by mouth b. sodium polystyrene sulfonate 15 grams by mouth c. epoetin alfa, recombinant 2,500 units subcutaneously d. sevelamer one tablet by mouth

b. sodium polystyrene sulfonate 15 grams by mouth

Which instructions should the nurse include in the teaching plan of a client who is taking the diuretic spironolactone (Aldactone)? a. call the healthcare provider if you develop gynecomastia b. Take the medication in the morning c. Avoid caffeine and smoking d. Increase your consumption of bananas and oranges

b. take the medication in the morning (You would want to decrease your consumption of potassium)

Two days following abdominal surgery a client c/o of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? a) encourage pt to ambulate b) offer ice chips or warm liquids c) auscultate abdomen d) assess temperature

c) Auscultate the client's abdomen

A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? a. Teach the client about the importance of hydration b. Report the volume of emesis t the healthcare provider c. Administer ondansetron hydrochloride (Zofran) Encourage the client to limit the amount of move

c. Administer ondansetron hydrochloride (Zofran)

Two days following abdominal surgery a client begins to report camping abdominal pain, and the nurse's inspection the abdomen indicates slight distention. Which action should the nurse implement first? a. Encourage the client to ambulate b. Offer ice ships or warm liquids c. Auscultate the client's abdomen d. Assess the client's temperature

c. Auscultate the client's abdomen

A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Teach client to use pursed lip breathing when episodes occur b. Assess client for signs and symptoms of upper airway infection c. Determine if the client is using an inhaler before exercising d. Review the client's routine asthma management prescriptions.

c. Determine if the client is using an inhaler before exercising

A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care? a. Continuous cardiac monitoring b. Perform passive range of motion c. Evaluate level of consciousness d. Assess lung sounds q4 hours.

c. Evaluate level of consciousness

1. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? a. Consult with surgeon about increasing methadone in lieu of parenteral opioids. b. Use minimal parenteral opioids for surgical pain, in addition to oral methadone c. Maintain client's methadone, and medicate surgical pain based on pain rating d. Make no changes in the standard pain management for the surgery and hold methadone.

c. Maintain client's methadone, and medicate surgical pain based on pain rating

An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care? a. Assist with ambulation in the hallway b. Encourage active range of motion exercises c. Provide a bedside commode for toileting d. Teach to sleep in a slide-laying position

c. Provide a bedside commode for toileting

An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? a. Teach a family member to administer eye drops b. Encourage deep breathing and coughing exercises c. Provide an eye shield to be worn while sleeping d. Obtain vital signs every 2 hours during hospitalization

c. Provide an eye shield to be worn while sleeping

An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (Feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? a. Serum electrolytes b. Neutrophils and eosinophils c. Serum iron and ferritin d. Platelet count and hematocrit

c. Serum iron and ferritin

A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/L (6.7 mmol/l) is admitted to the hospital. Which prescribed medication should the nurse administer first a. Sevelamer (RenaGel) one tablet PO. b. Epoetin alfa, recombinant (Epogen) 2, 500 units SUBQ c. Sodium polystyrene (Kayexalate) 15 grams PO d. Calcium acetate (Phos-Lo) one tablet PO

c. Sodium polystyrene (Kayexalate) 15 grams PO

A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed assistive personnel (UAP) to report which finding related to the client's bowel movements? a. Hard pellets of stool b. Clay-colored stool c. Stool with fatty streaks d. Blood in the stool

c. Stool with fatty streaks

A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? a. Low-sodium soups. b. Over all fluid intake c. Tea and hot chocolate d. Citrus fruit juices

c. Tea and hot chocolate

To reduce the risk for pulmonary complication for a client with Amyotrophic Lateral Sclerosis (ALS), what interventions should the nurse implement? (Select all that apply) a. Initiate passive range of motion exercises b. Establish a regular bladder routine c. Teach the client breathing exercises d. Perform chest physiotherapy e. Encourage use of incentive spirometer

c. Teach the client breathing exercises e. Encourage use of incentive spirometer

1. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? a. Notify the healthcare provider b. Assure the client that such feelings occur with wound infections c. Visualize the abdominal incision d. Obtain sterile towels soaked in saline

c. Visualize the abdominal incision

A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? a. Elevate the hands on two pillows at night b. Notify the healthcare provider as soon as possible c. Wear braces as both wriSts during the night d. Apply cold compresses for 30 min before bedtime

c. Wear braces as both wriSts during the night

A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which lab value is most important for the nurse to monitor following the procedure? a. Serum creatinine b. Blood urea nitrogen (BUN) c. White blood cell count d. Serum glucose

c. White blood cell count

A client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. monitor hemoglobin and hematocrit b. encourage turning and deep breathing c. administer IV antibiotics as prescribed d. auscultate for presence of bowel sounds

c. administer IV antibiotics as prescribed

A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? a. offer the client reassurance that this information indicates that the clients cancer cells are benign b. explain that these tissue cells often respond more effectively to radiation than to chemotherapy c. ask the client if the healthcare provider has given her any information about the classification of her cancer d. help the client make plans to begin immediate treatment since her cancer is likely to spread quickly

c. ask the client if the healthcare provider has given her any information about the classification of her cancer

After taking orlistat (Xenical) for one week a female client tells the home health nurse that she is experiencing increasingly frequent oily stools and flatus. What action should the nurse take? a. obtain stool specimen to evaluate for occult blood and fat content b. instruct the client to increase her intake of saturated fats over the next week c. ask the client to describe her dietary intake history for the last several days d. advice the client to stop taking the drug and contact the healthcare provider

c. ask the client to describe her dietary intake history for the last several days

Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? a. elevate the extremities on pillows b. evaluate edema for pitting c. assess pulses with a vascular doppler d. wrap the feet with warmed blankets

c. assess pulses with a vascular doppler

A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client? a. take a multi vitamin supplement daily b. use an astringent for superficial bleeding c. avoid going barefoot especially outside d. include large amounts of spinach in the diet

c. avoid going barefoot, especially outside

Twenty minutes after the nurse starts a secondary IV infusion of cafepime (maxipime) 2 grams using an infusion pump to deliver the dose in one hour, the client reports feeling nauseated. What action should the nurse implement? a. stop medication infusion and notify the healthcare provider of the adverse effect b. increase the rate of the infusion to complete the dose of the medication more rapidly c. continue the infusion and administer a prn antiemetic prescription d. reassure the client that the nausea is not related to the iv infusion

c. continue the infusion and administer a PRN antiemetic prescription

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? a. have small frequent meals and sit up for at least two hours after meals b. eat a bland diet and avoid spicy foods c. eat a high-fiber diet and increase fluid intake d. eat a soft diet with increased intake of milk and milk products

c. eat a high-fiber diet and increase fluid intake

The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. presence and activity of bowel sounds b. color and consistency of feces c. eating patterns and dietary intake d. level and amount of physical activity

c. eating patterns and dietary intake

The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrate with the nursing staff. Which intervention should the nurse implement? a. teach the client use of basic sign language b. speak slowly to the client c. encourage client's use of picture charts d. ask the client simple questions

c. encourage client's use of picture charts

A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is MOST important for the nurse to instruct the client about self-care? a. call the clinic if undesirable side effects of medication occur b. avoid crowded enclosed areas to reduce pathogen exposure c. increase the daily intake of oral fluids to liquefy secretions d. teach anxiety reduction methods for feelings of suffocation

c. increase the daily intake of oral fluids to liquefy secretions

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP). What is the BEST initial nursing action? a. provide additional oral fluid intake b. measure the client's intake and output c. increase the flow of the bladder irrigation d. administer a PRN dose of an antispasmodic agent

c. increase the flow of the bladder irrigation

An adult male client is admitted for pneumocystis carinil pneumonia (PCP) secondary to aids. While hospitalized he receives IV pentamidine isethionate therapy. In preparing this client for discharge what important aspect regarding his medication therapy should the nurse explain? a. AZT therapy must be stopped when IV aerosol pentamine is being used. b. IV pentamine will be given until oral pentamine can be tolerated c. It will be necessary to continue prophylactic doses of IV or aerosol pentamine every month d. IV pentamine may offer protection to others aids related conditions such as kaposis sarcoma

c. it will be necessary to continue prophylactic doses of IV or aerosol pentamine every month

An elder male client tells the nurse that he is loosing sleep because he has to get up several times at night to go to the bathroom that he has trouble starting his urinary stream and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. collect a urine specimen for culture analysis b. obtain a fingerstick blood glucose level c. palpate the bladder above the symphysis pubis d. review the client fluid intake

c. palpate the bladder above the symphysis pubis

A client who had a myocardial infarction is admitted to the coronary critical care unit (CCU) with a nitroglycerin drip infusing. The clients last blood pressure measurements was 78/36. What action should the nurse implement? a. obtain blood pressure q5 minutes using duranap machine b. change the dilution of the nitroglycerin infusion c. reduce the rate of the nitroglycerin infusion d. begin dopamine infusion at 5mcg/kg per minute

c. reduce the rate of the nitroglycerin infusion

An adult client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate 325 mg PO daily. Which laboratory values should the nurse monitor? a. platelet count and hematocrit b. serum electrolytes c. serum iron and ferritin d. neutrophils and eosinophils

c. serum iron and ferritin

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/minutes, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is MOST critical? a. irregular pulse rate b. bile colored emesis c. st-elevation in three leads d. complaint of radiating jaw pain

c. st-elevation in three leads

A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? a. monitor bp q45 minutes b. lower the head of the chair and elevate feet c. stop dialysis treatment d. administer 5% albumin IV

c. stop dialysis treatment

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client? a. the nurse will encourage the client to walk thirty minutes every day b. the client's family will state signs and symptoms about the disease c. the client's daily blood pressure will be less than 140/80 mmHg this month d. the client's blood pressure readings will be less than 160/90 mmHg

c. the client's daily blood pressure will be less than 140/80 mmHg this month

A client with orthopnea expresses concern about the ability to "get enough air" during a scheduled thoracentesis. On which information should the nurse's response be based? a. a thoracentesis is a brief procedure that has minimal discomfort b. orthopnea is frequently caused by a client's uncontrolled anxiety c. the procedure is performed with the client in an upright position d. extra pillows can be used if needed to elevate the client's head

c. the procedure is performed with the client in an upright position

The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? a. frequent use of chewable and liquid antacids for indigestion b. severe abdominal cramps and diarrhea after eating spicy foods c. upper mid-abdominal pain described as gnawing and burning d. marked loss of weight and appetite over the last 3 or 4 months

c. upper mid-abdominal pain described as gnawing and burning

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client to take the glucagon? a. after meals to increase endogenous insulin secretion b. after insulin administration to prevent hypoglycemia c. when recognized signs of severe hypoglycemia occur d. when unable to eat during sick days

c. when recognized signs of severe hypoglycemia occur

To prevent deep vein thrombosis following knee replacement surgery, an adult male client is receiving enoxaparin (Lovenox) subcutaneously daily. Which laboratory finding requires immediate action by the nurse? a. blood urea nitrogen (BUN) 20mg/dl or 7.1 mmol/L (SI) b. Hematocrit 45% c. Serum creatinine 1.0 mg/dl or 88.4 mol/L (SI) d. Platelet count of 100,000/mm3 or 100x10??/ L (SI)

d

After administering dihydroergotamine (Migranal) 1 mg subcutaneously to a client with a severe migraine headache the nurse should explain that relief can be expected within what time frame? a. 2 hours b. 5 minutes c. 1 hour d. 15 minutes

d. 15 minutes

An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Auscultate for the presence of bowel sounds. b. Monitor hemoglobin and hematocrit c. Encourage turning and deep breathing d. Administer IV antibiotics as prescribed

d. Administer IV antibiotics as prescribed

A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? a. Encourage frequent mouth care b. Cleanse the tongue and mouth with glycerin swabs c. Obtain a soft diet for the client d. Administer a topical analgesic per PRN protocol.

d. Administer a topical analgesic per PRN protocol.

Two days after a nephrectomy, the client reports abdominal pressure and nausea, which assessment should the nurse implement? a. Palpate the abdomen b. Measure hourly urine output c. Ambulate client in hallway d. Auscultate bowels sounds.

d. Auscultate bowels sounds.

The nurse is evaluating a male client understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? a. Uses only lactose-free dairy products. b. Enjoys fat free yogurt as an occasional snack food c. No longer includes grains in his daily diet d. Carefully cleans and peels all fresh fruit and vegetables

d. Carefully cleans and peels all fresh fruit and vegetables

An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? a. Determine clients last dose of corticosteroids b. Determine neurological baseline prior to the fall c. Administer a PRN IV antiemetic as prescribed d. Complete head to toe neurological assessment.

d. Complete head to toe neurological assessment.

An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? a. Encourage the family to offer to feed the client when she does not eat her entire meal. b. Suggest that the family bring foods from home that the client enjoys c. Explain that weight loss will be reversed after the acute phase of the stroke has ended. d. Demonstrate the use of visual scanning during meals to the client and family.

d. Demonstrate the use of visual scanning during meals to the client and family.

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? a. Prepare for transcutaneous pacing b. Deliver another defibrillator shock c. Administer IV Epinephrine per ACLS protocol d. Give IV dose of adenosine rapidly over 1-2 seconds.

d. Give IV dose of adenosine rapidly over 1-2 seconds.

An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? a. Assist the lien tot a high Fowler's position in bed b. Observe the client for the presence of a barrel chest c. Prepare to transfer the client to a critical care unit d. Instruct the client to pursed lip breathing techniques

d. Instruct the client to pursed lip breathing techniques

An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? a. BUN creatinine specific gravity b. White blood count, hemoglobin hematocrit c. PH,PCO2, HC03 d. LDH OR LD, SGOT OR ALT, SGPT OR AST

d. LDH or LD, SGOT or ALT, SGPT or AST acetaminophen is processed by the liver

When providing care for a client following bronchoscopy, which assessment finding should he nurse immediately report to the healthcare provider? a. Slight blood-tinged sputum b. Dyspnea and dysphagia c. Sore throat and hoarseness d. No gag reflex after thirty minutes

d. No gag reflex after thirty minutes

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. Glucose of 350 mg/dl b. White blood cell count of 15, 000 mm3 c. Blood PH of 7.30 d. Potassium of 2.5 mEq/L

d. Potassium of 2.5 mEq/L

1. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Use a walker when weakness occurs b. Avoid extreme environmental temperatures c. Increase daily intake of sodium in diet d. Take prescribed cortisone accurately

d. Take prescribed cortisone accurately

A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse? a. True urinary output of 50ml/hr b. Lower abdominal tenderness c. Blood urine output with clots d. Urine leaking around the meatus

d. Urine leaking around the meatus

A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? a. Reports subjective symptom's during hemodialysis b. Documents his oral intake during dialysis treatments c. Demonstrates self-care of the arteriovenous (AV) Shunt d. Verbalizes understanding of the reasoning for dialysis

d. Verbalizes understanding of the reasoning for dialysis

During a home visit the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? a. an old friend with eczema came for visit b. recently received an influenza immunization c. corticosteroid cream was applied to eczema d. a grandson and his new dog recently visited

d. a grandson and his new dog recently visited

When preparing to apply a fentanyl (Duragesic) transdermal patch the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. What action should the nurse take? a. Remove the patch and consult with the healthcare provider about the client pain resolution b. Place the patch on the clients shoulder and leave both patches in place for 12 hours c. Administer an oral analgesic and evaluate its effectiveness before applying a new patch d. Apply a new patch in a different location after removing the original patch

d. apply a new patch in a different location after removing the original patch

A male client who is 24hr post operative for an exploratory laparoctomy complains that he is starving because he has had no real food since before surgery. Prior to advancing his diet which intervention should the nurse implememt? a. discontinue intravenous therapy b. Assess for abdominal distension and tenderness c. Obtain a prescription for a diet change d. Auscultate bowel sound in all four quadrants

d. auscultate bowel sounds in all four quadrants

A client with hypertension who has been taking labetalol for two weeks, reports a five pound (2.2 kg) weight gain. Which follow up assessment is most important for the nurse to obtain? a. capillary refill b. body temperature c. muscle strength d. breath sounds

d. breath sounds

A client diagnosed with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tablets 5 min apart? a. drive to the nearest emergency department b. take another NTG SL tablet and lie down until angina subsides c. call primary healthcare provider d. call 911 if pain is unrelieved and chew a tablet of aspirin 325mg

d. call 911 if pain is unrelieved and chew a tablet of aspirin 325 mg

While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the client's hand grips. The client reports joint pain and trouble twisting a door knob due to weakness. Which action should the nurse take in response to these findings? a. explain that relief of the migraine pain will reduce related symptoms b. gather additional assessment data about the pain and weakness c. implement fall precautions to reduce the client's risk for injury d. consult with the occupational therapist for a functional assessment

d. consult with the occupational therapist for a functional assessment

A young adult male who has had type 2 diabetes mellitus (DM) is admitted to the intensive care unit with hyperglycemic nonketotic syndrome (HHNS). A sliding scale protocol for an isotonic IV solution with regular insulin is prescribed based on the results of a continuous blood glucose monitoring device that is attached to the client's central venous catheter. When the client's respirations become labored and his lungs sound indicate crackles what action should the nurse take? a. collect a specimen for a white blood cell count and cultures b. determine the clients glycosylated hemoglobin (A1C) c. administer insulin IV push until the clients fluid volume is adjusted d. decrease infusion rate to address fluid overload

d. decrease infusion rate to address fluid overload

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. hyperaldosteronism causing an increased sodium reabsorption in renal tubules b. decreased portacaval pressure with greater collateral circulation c. decreased renin-angiotensin response to an increase in renal blood flow d. hypoalbuminemia that results in a decreased colloidal oncotic pressure

d. hypoalbuminemia that results in a decreased colloidal oncotic pressure

The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client's eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in this client's plan of care? a. assess for signs of increased intracranial pressure b. prepare to administer levothyroxine c. review the client's serum electrolyte values d. obtain a prescription for artificial tear drops

d. obtain a prescription for artificial tear drops

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit? a. complaints of chest pain and shortness of breath b. hypotension and venous pooling in the extremities c. profuse diaphoresis and severe, pounding headache d. pain and a burning sensation upon urination and hematuria

d. pain and a burning sensation upon urination and hematuria

An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? a. blood ph of 7.30 b. glucose of 350 mg /dl c. white blood cell count of 15000mm d. potassium of 2.5 meq/l

d. potassium of 2.5 meq/l