Med Surg Practicum
A clients glucose level is 365 mg/do (365 mmol/L). The health care provider orders 10 units of regular insulin to be administered. The bottle of regular insulin is labeled 100 units/ ml. How many mililiters of insulin ma should the nurse administer? Record your answer using one decimal place.
0.1 ml
A nurse is interpreting a client's ECG strip. If the PR interval measures four small blocks, how many seconds is the PR interval? Record your answer using two decimal places.
0.16 seconds (0.04 x 4)
The nurse is caring for a client who is experiencing an exacerbation of gout. When providing instruction, which dietary modifications are stressed? Select all that apply. 1. Eat a low-purine diet. 2. Limit fluid intake to no more than 1 L/day. 3. Eat a high protein diet, with at least two servings of lean meat per day. 4. Limit sodium intake of 1,500 mg/day 5. Limit alcohol intake
1,5
The nurse is preparing to interpret an ECG rhythm strip. Place the following steps for ECG rhythm analysis from first to last, in chronological order. All options must be used. 1. Measure the QRS duration 2. Interpret the rhythm 3. Analyze the P waves 4. Determine the rate and rhythm 5. Measure the PR interval
4,3,5,1,2
A client who underwent cardiac surgery has been prescribed morphine sulfate 2 mg intravenously for pain. The morphine sulfate is packaged as 2 mg/ml. The nurse dilutes the medication in 4 ml of sterile water and prepares to administer the medication over 5 minutes. If the nurse administers 1 ml of fluid every minute, how many milligrams of morphine will be administered per minute? Record your answer using one decimal point.
0.4 mg/minute
A client is ordered a dose of epoetin alfa to treat anemia related to chemotherapy. The recommended dose is 150 units/kg. The client weighs 60 kg. The vial is labeled 10,000 units/ml. How many milliliters of epoetin alfa would the nurse administer?
0.9 ml
A client who is receiving chemotherapy for breast cancer develops myelosuppression. which instructions would the nurse include in the client's discharge teaching plan? 1. Avoid people who have recently received live vaccines 2. Avoid activities that may cause bleeding 3. Wash hands frequently 4. Increase intake of fresh fruits and veggies 5. Avoid crowded places such as shopping malls 6. Treat a sore throat with natural products like saline gargles
1,2,3,5
A nurse is reviewing updated laboratory data that states that the oncology client has an absolute neutrophil count of less than 1,000 mm3 following the third infusion of chemotherapy. Which interventions would be added to the plan of care? 1. placing an infection control sign on the door requiring a mask/gown/glove 2. placing a sign on the door to keep the door closed at all times 3. encouraging diet of fresh fruits and veggies 4. assuring that visitors have no temperature or flu like symptoms 5. contacting the health care provider to move to the ICU 6. using SBAR to communicate to recommend pegfilgrastim
1,2,4,6
A client with laryngeal cancer has undergone a laryngectomy and is now receiving radiation therapy to the head and neck. The nurse would monitor the client for which adverse effects of external radiation? 1. xerostomia 2. stomatitis 3. thrombocytopenia 4. cystitis 5. mucositis 5. leukopenia
1,2,5
A nurse is caring for a terminally ill cancer client who is being transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? 1. The focus of care is on controlling symptoms and relieving pain 2. A multidisciplinary team provides care 3. Services are provide based on third-party insurance reimbursement 4. Hospice care is provided only in hospice centers 5. Bereavement care is provided to the family 6. Care is provided in the home, independent of health care providers
1,2,5
A nurse has identified the nursing diagnosis situational low self esteem related to hair loss and severe fatigue for a client with cancer. Which nursing interventions would be appropriate for this client's care? 1. Ask how the diagnosis and treatment are affecting the clients personal life and roles. 2. Review any anticipated side effects of treatment with the client 3. Tell the client how to resolve specific concerns related to the effects of treatment on personal life 4. As a behavioral guide, describe the experiences of friends and other clients who have had this disease and treatment 5. Offer information on available counseling services and support groups. If desired explaining that these techniques are helpful to many clients 6. Maintain eye contact with the client use touch during interactions if acceptable to client.
1,2,5,6
The nurse is caring for a client with Cushing's disease. During change of shift report which assessment laboratory data would the nurse anticipate communicating. 1. sodium 2. hemoglobin and hematocrit 3. potassium 4. blood glucose 5. white blood cell count 6. creatinine clearance
1,3,4,5
A client who is experiencing colon cancer is scheduled to undergo a colostomy. Which interventions would be appropriate to include a preoperative teaching plan? 1. Demonstrate turning, coughing, deep breathing, splinting, and leg ROM exercises and provide rationales for each procedure 2. Instruct on dietary guidelines for healing 3. Arrange an enterostonmal therapist to speak with the client about colostomy care 4. Explain the need for early postoperative ambulation 5. Instruct the client on signs and symptoms of intestinal obstruction 6. Encourage the client to express feelings about changes in body image
1,3,4,6
When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the clients diet? 1. Schedule high-nutrient shakes between meals 2. Eat a large lunch with a nutritious snack for dinner 3. Offer small frequent light meals 5 to 6 times a day 4. Encourage a favorite meal of pizza and wings 5. Utilize oral anesthetic 15 minutes prior to meals 6. Offer cool drinks and food as tolerated
1,3,5,6
The nurse is providing an education seminar on skin care to clients and home care families. When discussing interventions which areas have provided effective outcomes in preventing pressure ulcers? 1. Clean the skin with warm water, and a mild cleaning agent and then apply moisturizer. 2.When turning the client. slide and avoid lifting 3. Avoid raising the head of the bed more than 90 4. Turn and position every 1 to 2 hours 5. If the client uses a wheelchair, sit on a rubber or plastic doughnut 6. Use positioning devices to position the client and increase comfort
1,4,6
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution intravenously over 5 minutes. The client weighs 132 lb. How many grams would the nurse administer? Record your answer as a whole number.
12 g
A 176 lb-client with minimal urine output has been prescribed dopamine at 5 mg/kg/ minute. The premixed medication bag contains 800 mg of dopamine in 500 ml dextrose 5% in water. How many milliliters of solution would the nurse administer each hour? Record your answer as a whole number.
15 ml
A nurse is teaching a community program on breast self examination. The nurse demonstrates the proper procedure for palpating each breast. In what sequence would the following actions be performed? 1. Place the hand over the breast to be examined 2. Lie down with one arm behind the head 3. Palpate the breast in a perpendicular motion, going across the breast from one side to another and top to bottom 4. Use the finger pads of the three middle fingers and touch the breast 5. Use a circular motion to feel the breast tissue
2,1,4,5,3
A client has been diagnosed with breast cancer and is scheduled to begin treatment with the antineoplastic drug, doxorubicin hydrochloride. Which side effects would the nurse anticipate? 1. hair thinning 2. hepatic impairment 3. left ventricular failure 4. complete hair loss within 3 to 4 weeks 5. red discoloration of urine
2,3,4,5
A client returns from the operating room with a partial thickness skin graft on the left arm. The donor tissue was taken from the left hip. In planning immediate postoperative care, which interventions would the nurse include? 1. Change the dressing on the graft site every 8 hours 2. Elevate the left arm and provide complete rest of grafted area 3. Administer pain medication every 4 hours as ordered for pain at the donor site 4. Perform ROM exercises to the left arm every 4 hours 5. Monitor pulse in the left arm every 4 hours 6. Encourage the client to ambulate as desired on the firs postop day
2,3,5
During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The health care provider's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? 1. The disorder is contagious 2. This is an allergic reaction 3. Based on location, it is likely that detergents in the bed linens caused the rash 4. The skin is infected wherever the rash developed 5. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved 6. Washing with antibacterial soap will help the rash
2,3,5
The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concerns? 1. "Did you have any other skin biopsies that day?" 2. "On which day did you have the biopsy completed?" 3. "Can you see describe the drainage that you see?" 4."When is your follow up appointment?" 5 "What is your pain level on a 0-10 scale?" 6. "How are you cleaning the area?"
2,3,5,6
A client with bladder cancer undergoes surgical removal of the bladder with construction of an ileal conduit. During the immediate postoperative period, which assessment findings indicate that the client is developing complications? 1. urinary output greater than 30 cc/hr 2. dusky appearance of stoma 3. stoma protrusion from skin 4. mucus shreds in the urine collection bag 5. edema of the stoma 6. sharp abdominal pain with rigidity
2,3,6
The home health nurse is caring for a client receiving chemotherapy. The client reports anorexia and has a weight loss of 15 lb over 6 weeks. Which client teaching would be helpful? 1. Eat large meals when hungry 2. Obtain calorie dense foods for snack 3. Cook a hot meal for lunch and dinner 4. Have a family prepare and deliver favorite meals 5. Eat small portions of each food group 6. Eat slowly and in a relaxed atmosphere
2,4,5,6
A client presents at the health care provider's office with gray-brown burrows with epidermal curved ridges and follicular papules of the skin. The health care provider diagnoses scabies. Which teaching points would a nurse review with the client? 1. The disease is only actively contagious when the lesions are open. 2. Scabies is transmitted by close person-to-person contact or contact with infected linens and clothing. 3. The most commonly infected areas are hands, feet, and neck. 4. Severe itching of the affected areas, especially at night is a common finding. 5. Only the infected individual needs to use the prescribed medication. 6. All of the client's linens and clothing should be washed immediately in hot water.
2,4,6
The registered nurse is assigned a client with stomach cancer, who has just returned from a subtotal gastrectomy. Which nursing interventions would be delegated to either a LPN or a nursing assistant? Select all that apply. 1. Administer carboplatin 750 mg intravenously 2. Document intake and output in the electronic medical record 3. Assess bowel sounds in all four quadrants 4. Reinforce tape over an abdominal incision 5. Ambulate in the hall for the first time after surgery 6. Provide report for the next shift
2,4,6
The nurse is caring for a newly admitted client with diabetes insipidus. When forming the plan of care, which nursing diagnosis are anticipated? 1. fluid volume excess 2. anxiety 3. impaired physical mobility 4. self-care deficit 5. activity intolerance 6. hyperglycemia
2,5
The nurse is completing a health history review of a client who has received long-term medical steroid therapy for lupus. Which client data does the nurse recognize as potentially linked to the steroid use? Select all that apply. 1. a 16 lb weight loss 2. three infections over the course of the year 3. routine symptoms of nausea 4. an increase in blood pressure 5. acne noted on the forehead, cheeks, and back
2,5
The nurse is assisting a client to ambulate to the bathroom following a bowel resection for diverticulitis. Suddenly the client reports a sharp abdominal pain. The nurse assesses the client and determines the wound has eviscerated. Prioritize the following nursing actions in chronological order to show how the nurse would respond. 1. Assess the client's response 2. Call for assistance from other nursing personnel 3. Document the incident, including the client's condition 4. Cover the wound with sterile, nonadherent dressing moistened with sterile normal saline solution 5. Place the client in low Fowler's position 6. Notify the surgeon
2,5,4,1,6,3
The nurse is caring for a client, newly diagnosed with cancer who speaks limited English. The clients family speaks limited English also and a friend drives him to his doctor appointments. The nurse selects deficient knowledge as a priority. Which nursing interventions are appropriate? 1. ask the clients driver to interpret the conversation 2. Provide a brochure on the cancer and treatment options 3. Work with an interpreter to discuss the situation 4. Assess any community resources for support groups and communication 5. Obtain a type to speak computerized dictionary to express information 6. obtain common pictures to provide a common ground for understanding
3,4,5,6
The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many milliliters of the full strength formula with water? Record your answer as a whole number.
375 ml
While undergoing treatment with a caustic chemotherapeutic agent, a client experiences extravasation. Indicate how the nurse would respond to extravasation by placing the following nursing interventions in order. 1. Notify the health care provider 2. follow facility policy for dealing with extravasation 3. implement the health care providers orders 4. Discontinue the infusion 5. Document all the signs and symptoms 6. Monitor the client throughout the shift and give a detailed report to the oncoming shift
4,2,1,3,5,6
A client is admitted with inflammatory bowel syndrome (Crohn's disease). When planning care for the health care team, which would be included? Select all that apply. 1. lactulose therapy 2. high-fiber diet 3. high-protein milkshakes 4. corticosteroid therapy 5. antidiarrheal medications
4,5
A nurse is planning care for a client with HIV. The RN is delegating responsibilities to a LPN. Which statements by the LPN indicate understanding of HIV transmission? Select all that apply. 1. "I will wear a gown, mask, and gloves for all client contact" 2. "I do not need to wear any personal protective equipment because nurses have a low risk of occupational exposure" 3. "I will wear a mask if the client has a cough caused by an upper respiratory infection" 4. "I will wear a mask, gown, gloves when splashing of body fluids is likely." 5. "I will wash my hands after client care"
4,5
A nurse is caring for a client diagnosed with pneumonia, a urinary tract infection, dehydration, and temperature of 101.4. The health care provider orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/ml. The nurse would regulate the intravenous flow rate to deliver how many drops per minute? Round your answer to the nearest whole number.
42 gtt/min
A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin 100 ml of normal saline solution is administered via an infusion pump set at 10 ml/hour. The nurse determines that the client is receiving how many units of insulin each hour? Record your answer using a whole number.
5 units/hour
A nurse is caring for a client who is admitted from home to a long-term care facility. During the admission assessment the nurse documents a stage II pressure ulcer and places a referral to the enterostomal therapist. When gathering supplies for a stage II ulcer, what characteristics would the ET anticipate? 1. the skin is intact 2. full thickness skin loss is evident 3. undermining is present 4. sinus tracts have developed 5. the ulcer is superficial like a blister 6. partial-thickness skin loss of the epidermis is evident
5,6
The nurse is caring for a client who sustained a head injury during a football game? The nurse is completing the following examination, which documentation by the nurse provides normal results of this examination? 1. The client's pupils are equal and reactive to light and accommodation. 2. The client's retina is attached, with no signs of tearing. 3. The client's vision is 20/20 in both eyes. 4. The client's visual field is 360 degrees.
1
A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions would the nurse include in the teaching plan? Select all that apply. 1. Stay out of direct sunlight 2. Do not limit activity between flare ups 3. Monitor body temperature 4. Taper the corticosteroid dosage as prescribed when symptoms are under control 5. Apply cold packs to relive joint pain and stiffness
1,3,4
After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40ml/hr and a triple lumen urinary catheter with normal saline solution infusing at 200,l/hr. A nurse empties the urinary catheter drainage bag 3 times during an 8 hr period, for a total of 2780ml. How many milliliters does the nurse calculate as urine? Round to the nearest whole number. ________ ml
1,180 ml
A client is brought to the emergency department after wandering on the street. The client is confused and verbalizes double vision, headache, and shakiness. Laboratory data reveal a serum blood glucose of 52 mg/dl. Which questions asked by the nurse may reveal more data related to the client's condition? Select all that apply. 1. "What have you eaten today?" 2. "Do you take insulin or oral antidiabetic medication?" 3. "Have you ever felt this way before?" 4. "Do you have a friend/family that supports you?" 5. "Are you having any chest pain?" 6. "Have you been to this hospital before?"
1,2,3
The nurse receives shift handoff on an assigned client who had a surgical procedure. What objective assessment suggests that the client may be developing sepsis and is at risk for septic shock? Select all that apply. 1. temperature increase 2. blood pressure decrease 3. 32 ml of urine in 2 hours 4. pulse rate of 32 beats per minute 5. tachypnea
1,2,3,5
A nurse is counseling a client about risk factors for hypertension. While reviewing the client's history, which information is consistent with the diagnosis of primary hypertension? Select all that apply. 1. obesity 2. glomerulonephritis 3. head injury 4. stress 5. hormonal contraceptive use 6. high intake of sodium or saturated fat
1, 4, 6
The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply. 1. a client who is on complete bed rest following extensive spinal surgery 2. a client who has a large venous stasis ulcer on the right ankle area 3. a client who has recently been admitted with a broken femur and is awaiting surgery 4. a client who has a pleural effusion secondary to infection 5. a client who is receiving supplemental oxygen following shoulder surgery 6. a client who has undergone a total vaginal hysterectomy and is now on estrogen therapy
1,2,3,6
The nurse is caring for a client who is scheduled to undergo a computed tomography (CT) scan to assess recent symptoms of muscle weakness and tingling in extremities. Which information would the nurse include in preprocedural teaching plan? Select all that apply. 1. The test may require removal of watches, bracelets, or earrings. 2. A contrast dye may be given before the test. 3. Throat irritation and facial flushing may occur if contrast dye is used. 4. All medications must be withheld 12 hours prior to the procedure. 5. The CT scan is considered an invasive procedure, but not dangerous. 6. It is necessary to report any known allergies to iodine or seafood prior to the procedure.
1,2,3,6
The nursing is caring for a client with stress incontinence who is ordered a cystometrography. The client inquires about the nature of the procedure. Place in chronological order the sequence of events for this procedure. All options must be used. 1. client is asked to void normally 2. urinary catheter is inserted 3. fluid is instilled into the urinary catheter 4. any residual urine is noted 5. client is asked to void following instillation 6. urge to void is recorded
1,2,3,6,5,4
A client requires behavioral therapies to decrease or eliminate urinary incontinences. Which procedures would the nurse expect to include in the teaching plan for this client? Select all that apply. 1. Kegel exercises 2. scheduled voiding 3. external catheters 4. biofeedback 5. self-catheterization devices 6. postvoid residual monitoring
1,2,4
A nurse is caring for a client newly diagnosed with osteoporosis. Which statements would the nurse include when teaching the client about this disease? Select all that apply. 1. Osteoporosis is common in females after menopause. 2. Osteoporosis is degenerative disease characterized by a decrease in bone density. 3. Daily medication is needed to cure the disease. 4. Osteoporosis can cause pain and injury. 5. Passive ROM exercises can promote bone growth. 6. Limit weight bearing and repetitive exercises.
1,2,4
A nurse is caring for a client with retroperitoneal abscess who is receiving gentamicin 300 mg intravenously every 8 hours. Which client data would the nurse monitor? Select all that apply. 1. hearing 2. urine output 3. HCT 4. BUN and creatinine levels 5. serum calcium levels 6. muscle tone
1,2,4
A nurse is performing an admission assessment on a client who has been diagnosed with diabetes insipidus. Which findings does the nurse anticipate during the assessment? Select all that apply. 1. extreme polyuria 2. excessive thirst 3. elevated systolic blood pressure 4. low urine specific gravity 5. bradycardia 6. elevated serum potassium level
1,2,4
A nurse is caring for a client with T5 complete spinal cord injury. Upon assessment the nurse notes flushed skin, diaphoresis above T5, and blood pressure of 174/100 mm Hg. The client reports a severe, pounding headache. Which nursing interventions would be appropraite for this client? Select all that apply. 1. Elevate the head of the bed to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication as ordered 6. Administer morphine as ordered
1,2,4,5
A nurse is caring for a client with history of heart failure and presenting with symptoms indicating a pulmonary embolism. The nurse documents admission findings of sudden shortness of breath, chest pain, and immobility. Which nursing diagnoses are admission priorities? Select all that apply. 1. activity intolerance related to inadequate oxygenation 2. anxiety related to breathlessness 3. disturbed sleep pattern related to restlessness in the night 4. ineffective breathing pattern related to hypoxia 5. risk for decreased cardiac output related to failure of the left ventricle 6. impaired nutrition: less than body requirements related to anorexia
1,2,4,5
The nurse is caring for a client who has been newly diagnosed with systemic lupus erythematosus (SLE). Which information would be included in a teaching plan that focuses on home care? Select all that apply. 1. Avoid exposure to sunlight. 2. Keep exercise to a minimal level 3. Report the development of a butterfly rash on the face 4. Avoid OTC medications unless approved by the health care provider 5. take rest periods as needed
1,2,4,5
A client with suspected pulmonary embolus is brought to the emergency department stating shortness of breath and chest pain. Which additional signs and symptoms are anticipated? Select all that apply. 1. anxiety 2. irregular heartbeat 3. bradycardia 4. frothy sputum 5. tachycardia 6. blood-tinged sputum
1,2,5,6
When reviewing the urinalysis report of a client with newly diagnosed diabetes mellitus. the nurse would expect which urine characteristics to be abnormal? 1. amount 2. odor 3. pH 4. specific gravity 5. glucose level 6, ketone bodies
1,2,5,6
A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse would be alert for which occurrence? Select all that apply. 1. Trousseau's sign 2. cardiac arrhythmias 3. constipation 4. decreased clotting time 5. drowsiness and lethargy 6. fractures
1,2,6
The nurse is caring for a client who possibly may need kidney dialysis. When evaluating the client's renal function to report the health care provider, which data will the nurse use? Select all that apply. 1. a client's 24 hour urinary output 2. glomerular filtration rate 3. trending vital signs 4. a client's flank pain level 5. the blood count report 6. serum creatinine level
1,2,6
A nurse is evaluating a client with primary pulmonary hypertension for a heart-lung-transplant. Which medication treatment would the nurse anticipate to be included in the plan of care? Select all that apply. 1. oxygen therapy 2. aminoglycosides 3. diuretics 4. vasodilators 5. antihistamines 6. sulfonamides
1,3,4
The nurse is evaluating the cardiac function of a client with history of left ventricular hypertrophy and new diltiazem administration. Which client statements indicate therapeutic use of diltiazem leading to adequate cardiac functioning? Select all that apply. 1. "I am sleeping well in the second floor bedroom" 2. "I am tolerating my new low-fat diet" 3. "My blood pressure has been consistently in the 130/70 range" 4. "I am completing all of my activities of daily living independtly" 5. "In the morning, I notice 2 plus edema in my ankles" 6. "My lab results reveal a serum potassium of 3.5 mEq/L (3.5 mmol/L)
1,3,4
A client comes to the clinic verbalizing a weight loss of 20 lb over the last month, even with a "ravenous" appetite with no change in activity level. The client is diagnosed with Graves' disease. Which other signs and symptoms of Graves' disease would the nurse assess? Select all that apply. 1. rapid, bounding pulse 2. orthopnea 3. heart intolerance 4. mild tremors 5. nervousness 6. constipation
1,3,4,5
A nurse is providing discharge instructions on phenytoin to a female client with tonic-clonic seizure disorder. Which instructions would the nurse include? Select all that apply. 1. Monitor the body for any skin rash. 2. Maintain adequate amounts of fluid and fiber in the diet. 3. Perform good oral hygiene including daily brushing and flossing. 4. Receive necessary periodic blood work. 5. Report any problems with walking or coordination, slurred speech, or nausea.
1,3,4,5
The nurse is caring for a client who is scheduled to undergo a bone marrow aspiration to assess the progression of a hematologic disorder. Which interventions would the nurse include as part of the preprocedural teaching plan? Select all that apply. 1. Explain the procedure to the client 2. Maintain a pressure dressing over the aspiration site 3. Encourage the client to ask questions before obtaining the signed informed consent 4. Explain that the client will receive an analgesic prior to the procedure 5. Administer an anxiety-relieving medication prior to the procedure 6. Instruct the client to save all voided urine for 24 hours after procedure
1,3,4,5
While managing a client's immediate post-cardiac catheterization period, which interventions are priorities? Select all that apply. 1. Monitor vital signs every 15 minutes for the first hour. 2. Assess all peripheral pulses frequently. 3. Restrict the client to bed rest for 2 to 6 hours. 4. Assess the catheter insertion site every 30 minutes for 4 hours. 5. Note any limb discoloration and reported numbness. 6. Assess for any signs of hematoma formation.
1,3,4,5,6
A multidisciplinary oncology team of health care providers, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis? Select all that apply. 1. decreased white blood cells 2. increased white blood cells 3. decreased platelets 4. increased platelets 5. decreased RBCS 6. increased RBCS
1,3,5
A nurse is caring for a client following gastric bypass surgery. At the 6 week appointment the client reports symptoms of nausea, abdominal pain and cramping following meals, and shakiness and sweating up to 3 hours later. Which nursing interventions would help reduce the symptoms and be included in the plan of care? Select all that apply. 1. Eat small, frequent meals 2. Limit sodium intake 3. Reduce high concentrated sugars 4. Ingest fluids at the end of meals 5. Refer the client to a dietician
1,3,5
A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate that thyroid replacement therapy has been inadequate? Select all that apply. 1. ECG changes 2. tachycardia 3. low body temperature 4. nervousness 5. bradycardia 6. dry mouth
1,3,5
The school nurse in a middle school (ages 12-15) is reinforcing client goals on a newly placed insulin pump. Which are included? 1. having fewer injections of insulin 2. needing to obtain glucometer checks each morning 3. continuing to snack before physical activity 4. understanding the side effects of long acting insulin 5. self-adjusting basal rate upon activity / illness 6. changing between insulin types
1,3,5
A nurse is comparing the neuroglial status of a client who suffered a head injury with the status on the previous shift. Using the Glasgow Coma Scale, the nurse determines that the client's score has changed from 11 to 15. Which responses did the nurse assess in this client? Select all that apply. 1. spontaneous eye opening 2. tachypnea, bradycardia, and hypotension 3. unequal pupil size 4. orientation to place, person, and time 5. pain localization 6. incomprehensible sounds
1,4
A client who suffered a brain injury falling off a ladder has recently developed syndrome of inappropriate antidiuretic hormone (SIADH). Which findings indicate that the treatment being received for SIADH is effective? Select all that apply 1. decrease in body weight 2. rise in blood pressure and drop in heart rate 3. absence of wheezing 4. increase in urine output 5. decrease in urine osmolarity
1,4,5
A nurse is caring for a client with a traumatic injury and developing tension pneumothorax. Which assessment data would be of concern? Select all that apply. 1. decreased cardiac output 2. flattened neck veins 3. tracheal deviation to the affected side 4. hypotension 5. tracheal deviation to the unaffected side 6. bradypnea
1,4,5
A nurse is caring for a client diagnosed with Alzheimer's disease, who scored a 7 (high risk) on the Hendrich II Fall Risk Model. Which nursing interventions would the nurse implement? Select all that apply. 1. Implement a bed alarm 2. Place the overbed table next to the bed 3. Instruct the client to ask for help before ambulating 4. Maintain the bed in the lowest position 5. Offer toileting every 2 to 3 hours 6. Advise family to notify staff when leaving
1,4,5,6
A nurse is caring for a client with Raynaud's phenomenon secondary to systemic lupus erythematosus. Which of the client statements demonstrates an understanding of the nurse's teaching about this disorder? Select all that apply. 1. "My hands get pale and bluish and feel numb and painful when I'm really stressed". 2. "I can't continue to wash dishes and do my cleaning because of this problem." 3. "I don't need to report any other skin problems with my fingers or hands to my health care provider." 4. "I probably got this disorder because I am also diagnosed with lupus." 5. "This problem is caused by a temporary lack of circulation in my hands." 6. "I will have to discuss medication that might treat this problem with my health care provider."
1,4,5,6
The nurse is caring for a client with nephropathy. The health care provider orders a 24-hour urine collection. Which actions are necessary to ensure proper collection of the specimen? Select all that apply. 1. Collect the urine in a preservative-free container and keep on ice. 2. Inform the client to discard the last voided specimen at the conclusion of urine collection. 3. Ask the client what his/her weight is for documentation. 4. Request an order for insertion of an indwelling catheter. 5. Encourage daily amounts of fluids. 6. Discard the initial voiding but save all others for 24 hours.
1,5,6
A nurse is presenting health information at a community organization when one of the attendees passes out. The nurse assess the attendee as being unresponsive. Indicate how the nurse would respond by placing the following actions in chronological order. All options must be used. 1. Appoint a person to call 911 2. Check for a pulse 3. Deliver two rescue breaths 4. Check for normal breathing 5. Perform chest compressions 6. Perform head tilt-chin maneuver
1,5,6,4,3,2
The nurse is providing discharge teaching for a client with a compromised immune system and on neutropenic precautions. When discussing types of fruits and vegetables that the client likes, which are encouraged? Select all that apply. 1. canned peaches 2. carrot sticks 3. broccoli florets 4. bananas 5. a green salad 6. cooked corn
1,6
A client is admitted to the trauma center with a spinal cord transection at T4. Which of the physical limitations does the nurse anticipate when planning care? 1. The client will need ventilator support. 2. The client will be unable to ambulate independently. 3. The client will have no control of the bladder 4. The client will need assistance with feeding 5. The client will be unable to speak 6. The client will be cognitively impaired
2,3
A nurse is caring for a client who is being discharged for a thyroidectomy. Which discharge instructions would be appropriate for this client? Select all that apply. 1. Report signs and symptoms of hypoglycemia. 2. Take thyroid replacement medications as ordered. 3. Watch for changes in body functioning such as lethargy, restlessness, sensitivity to cold, and dry skin and report these changes to the physician. 4. Avoid all OTC medications 5. Carry injectable dexamethasone at all times.
2,3
A nurse is explaining self-catheterization to a female client who has been diagnosed with urogenic bladder. Which instructions would the nurse include in home teaching? Select all that apply. 1. Tampons may remain in place during menstruation. 2. The meatus would be cleaned with a towelette or soapy washcloth and then rinsed. 3. Sterile technique is not required 4. A new intermittent catheter set would be used each time 5. Finding the urinary meatus always requires visualization with a mirror
2,3
The nurse is reviewing a client's urine culture and sensitivity test results. Which findings would the nurse expect to see in small amounts in normal urine? Select all that apply. 1. ketones 2. protein 3. white blood cells 4. crystals 5. nitrates 6. bilirubin
2,3
A client is being discharged to a rehabilitation care facility following a hip replaceent using the posterior surgical approach. When reporting to the LPN which nursing actions would the orthopedic nurse stress as essentials? Select all that apply. 1. Place the client in high fowler's position 2. Avoid any hip flexion exercises 3. Place two pillows between the client's knees 4. Place a raised toilet seat in the bathroom 5. Keep the client's feet elevated 6. Maintain the client on bed rest until the incision heals
2,3,4
The nurse is assessing laboratory values to identify if medical treatment and nursing interventions have improved kidney function in a client with renal disease. Which laboratory tests will the nurse monitor to determine the functioning status of the kidneys? Select all that apply. 1. urine culture 2. urine albumin 3. glomerular filtration rate (GFR) 4. creatinine clearance 5. basic metabolic panel (BMP) 6. hemoglobin A1C
2,3,4,5
A nurse is preparing a staff education program on innovative devices in pulmonary circulation. Beginning with basic concepts, place the following structures in chronological order to trace the pathway of normal pulmonary circulation. All options must be used. 1. pulmonary vein 2. right ventricle 3. pulmonary artery 4. arterioles 5. alveoli 6. left atrium
2,3,4,5,1,6
A nurse assesses a client with suspected bacterial menigitis. Which documented findings of meningeal irriation suggest this diagnosis? Select all that apply. 1. tinnitus 2. nuchal rigidity 3. positive Brudzinski's sign 4. positive Kernig's sign 5. Babinski's reflex 6. photophobia
2,3,4,6
A client is prescribed lisinopril for the treatment of hypertension. The client asks a nurse about possible adverse effects. Which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors would the nurse include in the teaching? Select all that apply. 1. constipation 2. dry cough 3. headache 4. hyperglycemia 5. hypotension 6. impotence
2,3,5
A client with chronic obstructive pulmonary disease (COPD) is being evaluated for a lung transplant. Which initial assessment data would the nurse anticipate. Select all that apply. 1. decreased respiratory rate 2. dyspnea on exertion 3. barrel chest 4. shortened expiratory phase 5. unintended weight loss 6. fever
2,3,5
A nurse is assessing a client's extraocular eye movements as part of evaluating neurological functioning. The documents the status of which cranial nerves? Select all that apply. 1. optic (II) 2. oculomotor (III) 3. trochlear (IV) 4. trigeminal (V) 5. abducens (VI) 6. acoustic (VIII)
2,3,5
A nurse is calling report to the medical-surgical floor staff regarding a patient with acute diverticulitis. Which symptoms does the nurse anticipate? Select all that apply. 1. esophagitis 2. cramping in the left lower abdominal quadrant 3. bowel irregularity 4. heartburn 5. intervals of diarrhea 6. hiccupping
2,3,5
The nurse is caring for several clients on the respiratory unit who are receiving the b-adrenergic agonist bronchodilator albuterol in the prescribed nebulizer treatments. Which side effects would the nurse expect to assess following administration? Select all that apply. 1. increased tachypnea 2. irritability and nervousness 3. tachycardia 4. increased somnolence 5. insomnia 6. anxiety
2,3,5,6
The nurse is instructing a client following a right knee replacement on how to use crutches. Which instructions are included? Select all that apply. 1. Let your armpits support your weight 2. Have your elbows bent when holding the crutch handles 3. Place crutches 1 foot in front of you 4. Step forward first on your right leg 5. Pivot on your left leg 6. Swing your left foot forward
2,3,5,6
A client presents to the emergency department with right facial droop and drooling. A diagnosis of Bell's Palsy is confirmed by a neurological exam and MRI. When instructing the spouse on interventions needed to care for the client, which spouse statements need clarification by the nurse? Select all that apply. 1. "I will buy a clothing protector for feedings" 2. "I will obtain a walker in case symptoms progress" 3. "I will instill eye drops to prevent symptoms of dry eyes" 4. "I will watch for further symptoms of a stroke" 5. "I will reinforce that symptoms are usually temporary" 6. "I will provide sunglasses during the daytime"
2,4
While preparing a client for an upper GI endoscopy the nurse would be correct to implement which intervention? Select all that apply. 1. Administer a preparation to cleanse the GI tract such as Golytely or Fleets Phospho-Soda 2. Instruct not to eat or drink for 6-12 hours before the procedure 3. Teach only to ingest a clear-liquid diet for 24 hours before the procedure 4. Inform the client of receiving a sedative before the procedure 5. Encourage the client to eat and drink immediately after the procedure
2,4
A nurse is caring for a client with low calcium level. Place the following options in chronological order to indicate the regulatory feedback mechanism of parathyroid hormone (PTH) release in relation to calcium levels. 1. High serum calcium level inhibits PTH secretion. 2. Low serum calcium level stimulates parathyroid gland. 3. Calcium is reabsorbed 4. Parathyroid gland releases PTH
2,4,3,1
A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis. Which medical facts about RA are essential in developing a plan of care? Select all that apply. 1. Onset is acute and usually occurs between ages 20 and 40. 2. The client experiences stiff, swollen joints, bilaterally. 3. The client may not exercise once the disease is diagnosed. 4. Erythrocyte sedimentation rate (ESR) is elevated and x-rays show erosions and decalcification of involved joints. 5. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators. 6. The first line treatment is gold salts and methotrexate.
2,4,5
A nurse is putting groceries in the car when an older adult client falls off a curb. The nurse assesses the client and has a bystander call for an ambulance. Which assessment findings provide data of a suspected right hip fracture? Select all that apply. 1. The right leg is longer than the left leg 2. The right leg is shorter than the left leg 3. The right leg is abducted 4. The right leg is adducted 5. The right leg is externally rotated 6. The right leg is internally rotated
2,4,5
Two weeks after a partial thyroidectomy, a client is being seen for the postoperative follow-up appointment. Which symptoms are screened for as an adverse reaction to the surgical procedure? Select all that apply. 1. heat intolerance 2. hair loss 3. hyperactivity 4. dry skin 5. cold intolerance 6. fatigue
2,4,5,6
A nurse is caring for a client with a new prescription for digoxin. Which client statement would require further teaching about digoxin? Select all that apply. 1. "I will take the digoxin at 9 am daily" 2. "I will take the digoxin with my antacids at night." 3. "I will take my pulse before each dose of digoxin" 4. "If I forget a dose, I will catch up by doubling the next dose" 5. "I will notify my health care provider if experiencing increased fatigue or muscle weakness" 6. "I understand that I will need annual blood work to check therapeutic levels"
2,4,6
The nurse is caring for a senior citizen who lives alone. When evaluating the effectiveness of adding fluticasone propionate salmeterol to the COPD client's medication regimen, which client statements would support symptom improvement? Select all that apply. 1. "I have noticed an increased sputum production" 2. "I have begun walking upstairs to use the bathroom" 3. "I can rely on medications when I have an exacerbation of symptoms" 4. "I seem to feel nervous and shaky making me more productive" 5. "I can now push my granddaughter on the swings when she visits" 6. "The nurse aid no longer comes to the house to help me bathe"
2,5,6
The nurse is caring for a client newly diagnosed with HIV obtained from unprotected sex. The nurse is in the room when the client is explaining the disease to another person. Which statement by the client would the nurse clarify? Select all that apply. 1. "My sexual practices will have to change" 2. "I am afraid that I will give this disease to my nephew." 3. "The disease can be also spread by body fluids" 4. "I could pass this on to a baby before I give birth" 5. "I will have this for the rest of my life" 6. "Medications can cure the disease"
2,6
The nurse is caring for a client administering insulin for diabetes mellitus for the first time. The nurse is instructing the client on mixing Humulin N insulin and Humulin R insulin in one syringe. Arrange the instructions in order. 1. Withdraw Humulin N insulin 2. Wipe with alcohol and inject air into the Humulin N insulin 3. Gently roll both insulins between your hands 4. Wipe with alcohol and inject air into the Humulin R insulin 5. double check the total number of units in syringe 6. Withdraw Humulin R
3,2,4,6,1,5
A fireman is admitted with superficial skin wounds and a sprained back following an intense fire. No respiratory concerns are verbalized. Nearly 24 hours after admission, the fireman reports dyspnea, a harsh cough, and hoarseness. Which nursing interventions would the nurse add to the plan of care? Select all that apply. 1. Monitor for fever 2. Prepare the chest for chest tube insertion 3. Auscultate the lungs for adventitious breath sounds 4. Assess for increased pulse rate 5. Monitor for increased anxiety levels
3,4,5
The nurse is assisting the client in filling a pillbox. A client has been prescribed indomethacin for the treatment of gouty arthritis. The orders state 25 mg. TID for the first 5 days and then increase by 25 mg per dose at weekly intervals until the daily dose reaches a maximum of 250 mg. The client is on week 3 of treatment and has tolerated the medication without any incident thus far. By week 3, what would the daily dose of medication be? Record your answer as a whole number.
225 mg.
A nurse is caring for a client with pneumonia who was prescribed ceftriaxone oral suspension 600 mg once daily. The medication label indicates that the strength is 125 mg/ 5 ml. How many milliliters of medication would the nurse pour to administer the correct dose? Record your answer as a whole number.
24 ml
A client with deep vein thrombosis is receiving an intravenous infusion of heparin sodium at 1,500 units/hour. The concentration in the bag is 25,000 units/500 ml. How many milliliters would the nurse document as intake from this infusion for an 8-hour shift? Record your answer using a whole number.
240 ml
A nurse is caring for a client with pulmonary edema whose respiratory status is declining. Chronologically arrange the nursing interventions to prioritize care. All options must be used. 1. Initiate oxygen via nasal cannula at 2 L/minute 2. Call the health care provider 3. Position the client upright at a 45 degree angle 4. Prepare suctioning equipment at the bedside 5. Administer furosemide 40 mg intravenously STAT 6. Insert an indwelling urinary catheter
3,1,4,2,5,6
The nurse is awaiting the arrival of a client from the emergency department. The client has a left ventricular myocardial infarction and is being admitted. In caring for this client, the nurse should be alert for which signs and symptoms of left-sided heart failure? 1. Jugular vein distention 2. Hepatomegaly 3. Dyspnea 4. Crackles 5. Tachycardia 6. skin tenting
3,4,5
A client is admitted to the emergency department after reporting acute chest pain radiating down the left arm. The client appears anxious, dyspneic, and diaphoretic. Which laboratory studies would the nurse anticipate? Select all that apply. 1. hemoglobin and hematocrit 2. serum glucose 3 creatine kinase (CK) 4. troponin T and troponin I 5. myoglobin 6. blood urea nitrogen (BUN)
3,4,5 Myoglobin elevation is an early indicator of myocardial damage.
A client with Addison's disease is scheduled for discharge after being hospitalized for an adrenal crisis. Which statements by the client would indicate that the nurse's teaching has been effective? Select all that apply. 1. "I have to take my steroids for 10 days" 2. "I need to weigh myself daily to be sure I don't eat too many calories" 3. "I need to call my doctor to discuss my steroid needs before I have dental work" 4. "I will call the doctor if I suddenly feel weak or dizzy" 5. "If I feel like I have a virus I will carry on as usual because it is over in a day or so" 6. "I need to obtain and wear a Medic Alert bracelet"
3,4,6
A nurse is evaluating the 12-lead ECG of a client experiencing an inferior wall myocardial infarction (MI). While conferring with the health care team, which ECG changes associated with an evolving MI does the nurse correctly identify? Select all that apply. 1. notched T wave 2. presence of a U wave 3. T-wave inversion 4. prolonged PR interval 5. ST segment elevation
3,5
The registered nurse (RN) is assisting the LPN in performing a PPD test on a nursing home resident. Which statements about this test is correct? Select all that apply. 1. A PPD test is done to test for allergies. 2. Always aspirate before injecting the PPD solution. 3. The PPD test is an intradermal test. 4. Hold the syringe at a 45 degree angle to the skin. 5. The preferred injection site is the ventral surface of the forearm. 6. No wheal should appear at the site following injection.
3,5
A nurse is caring for a client with moderate RA. Which nonpharmacological interventions would a nurse include in the care plan? Select all that apply. 1. massage inflamed joints 2. avoiding repetitive exercises 3. applying splints to inflamed joints 4. using assistive devices at all times 5. selecting clothing that has velcro fasteners 6. applying moist heat to joins
3,5,6
A client arrives in the clinic with a possible parathyroid hormone deficiency. When analyzing client lab data which electrolytes would the nurse anticipate to be abnormal? Select all that apply. 1. sodium 2. potassium 3. calcium 4. chloride 5. glucose 6. phosphorus
3,6
A client is to receive a blood transfusion of packed RBCs for severe anemia. Place the following steps in the order a nurse would follow to administer this product. 1. Flush the intravenous tubing with normal saline solution. Begin blood administration. 2. Verify the blood bag identification, ABO group and Rh compatibility against the client information 3. Record baseline vital signs 4. Remain with the client and watch for signs of transfusion reaction 5. Put on gloves, a gown, and a face shield 6. Check the packed cells for abnormal color, clumping, gas bubbles, and expiration date
3,6,2,5,1,4
A nurse is preparing discharge instructions for an above-the-knee amputation client. Which instructions would be a priority for home care? Select all that apply. 1. Massage the residual limb in a motion away from the suture line. 2. Avoid using heat application to ease the pain. 3. Immediately report twitching, spasms, or phantom limb pain. 4. Avoid exposing the skin around the residual limb to excessive perspiration. 5. Be sure to perform the prescribed exercises. 6. Rub the residual limb with a dry washcloth for 4 minutes three times daily if the limb is sensitive to touch.
4,5,6
The rehabilitation nurse is caring for a client with a health history of multiple sclerosis (MS) for 10 years. Recently, the nurse has seen a significant decline in the client's function. When reevaluating the client's plan of care, the nurse considers the client's physiological changes associated with the decline. Arrange the following degenerative changes in order in which they occur. All options must be used. 1. degeneration of axons 2. demyelination throughout the central nervous system 3. periodic and unpredictable exacerbations and remissions 4. plaque formation that interrupts nerve impulses 5. the immune system attacks myelin
5,2,1,4,3
A nurse is preparing to teach students in a health class about hearing pathways. Place the following steps in chronological order to match how the nurse would describe the normal pathway of sound wave transmission and hearing to the class. 1. interpretation of sound by the cerebral cortex 2. transmission of vibrations through the hammer, anvil, and stirrup 3. stimulation of nerve impulses in the inner ear 4. transmission of vibrations to the auditory area of the cerebral cortex 5. collection of the sound waves in the pinna
5,2,3,4,1
A client is scheduled to undergo cerebral angiography to allow for examination of the cerebral arteries. Place the following interventions in the order in which the nurse would perform them. All options must be used. 1. Administer antianxiety medication if ordered 2. Confirm no allergies to iodine, seafood, or radiopaque dyes 3. Make sure the client has signed an informed consent form 4. Maintain the affected extremity in straight alignment for 6 hours as ordered 5. Encourage the client to verbalize questions about the procedure with nurse and healthcare provider
5,3,2,1,4
The nurse is caring for a client during the postsurgical period after having a right femoral-popliteal bypass graft. The nurse enters the room to conduct a nursing assessment and care. Order the nurse's actions according to priority. All options must be used. 1. Offer clear fluids 2. Assess pain/obtain medication 3. Assess incision site 4. Assess lung fields 5. Assess peripheral pulses 6. Instruct on client positioning
5,3,4,2,6,1
A client is scheduled for an open reduction internal fixation of the right hip. Place the following nursing interventions in chronological order to show the sequence in which the nurse would perform them. 1. Initiate a home care teaching plan. 2. Complete a preoperative checklist. 3. Encourage coughing, turning, and deep breathing 4. Make sure the client has signed informed consent form 5. Monitor vital signs every 15 minutes x 4 every 30 minutes x 2 and every hour x2 6. Complete a history and physical examination
6,4,2,5,3,1
A client returns from the operating room after extensive abdominal surgery. He has 1,000ml of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125ml/hr plus the total output of the previous hour. The drip factor of the tubing is 15gtt/min. The client's output for the previous hour was 75m. via Foley catheter, 50ml via NG tube, and 10ml via Jackson-Pratt tube. How many drops per minute should the nurse set the I.V. flow rate at to deliver the correct amount of fluid? Record as a whole number. ______ ggt/minute.
65
A client with sepsis and hypotension is being treated with dopamine hydrochloride. A nurse asks a colleague to double-check the dosage that the client is receiving. The 250-ml bag contains 400 mg of dopamine, the infusion pump is running at 23 ml/hour and the client weighs 80 kg. How many micrograms per kilogram per minute is the client receiving? Record your answer using one decimal point.
7.7 micrograms/kg/minute
A nurse is preparing to administer phenytoin to a 99-lb (45 kg) client with a seizure disorder. The medication administration record documents phenytoin 5mg/kg/day to be administered in three divided doses. How many milligrams of phenytoin would be administered in the first dose? Record your answer as a whole number.
75 mg
