Med Surge (Monica) 200 Questions + Random Banks Q&A

A nurse is teaching a client who is starting to take methotrexate to treat rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching?

"Drink at least 2 liters of water daily." The client should drink 2 to 3 L of water per day because methotrexate can cause kidney damage. Adequate hydration optimizes drug excretion and helps prevent renal damage.

A nurse is providing information about pain control for a client who has acute pain following a subtotal gastric resection. Which of the following client statements indicates an understanding of pain control?

"I will call for pain medication before the previous dose wears off The client should call for pain medication before the previous dose of medication wears off or before the pain becomes severe.

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

"I will feel shaky."Manifestations of hypoglycemia include feeling shaky and nervous.

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

"This procedure will replace my joint to improve function." Arthroplasty is the reconstruction or replacement of a joint. This procedure is done to relieve pain, improve or maintain range of motion, and correct the present deformity.

A nurse is preparing to administer potassium chloride elixir 40 mEq divided into 2 equal doses every 12 hr. Available is 6.7 mEq/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A change in the Glasgow Coma Scale score from 13 to 11 In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is caring for a client who develops an airway obstruction from a foreign body but remains conscious. Which of the following actions should the nurse take first?

Administer the abdominal thrust maneuver. The nurse should immediately begin applying abdominal thrusts to a conscious client who has an airway obstruction and should continue until the obstruction is clear or the client loses consciousness.

A nurse in an emergency department is caring for a client who is bleeding profusely from a deep laceration on his left lower forearm. After observing standard precautions, which of the following actions should the nurse perform first?

Apply direct pressure over the wound. The greatest risk to the client is injury from hemorrhage. Therefore, the first action the nurse should take is to apply firm pressure with a thick, dry dressing material directly over the wound to stop bleeding.

After radiation treatment, a client reports dryness, redness, and scaling of his skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?

Apply hydrating lotions. The nurse should instruct the client to gently apply hydrating lotions that do not contain metal, alcohol, or perfume.

A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?

Basal cell carcinoma is a localized lesion that seldom metastasizes.

A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?

Bleeding from the gums Bleeding from the gums is directly related to myelosuppression due to inhibited bone marrow production of blood cells and platelets.

A nurse is teaching a client who has chronic kidney disease about the process of continuous ambulatory peritoneal dialysis (CAPD). Which of the following information should the nurse include in the teaching?

CAPD requires the client to follow fewer dietary and fluid restrictions than hemodialysis requires.

The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

Change the IV tubing every 24 hr. The nurse should change the client's IV tubing every 24 hr, or per facility protocol, to prevent bacteria from developing in the tubing.

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

Comminuted With a comminuted fracture, the impact fragments the bone into several pieces.

A nurse is teaching a class about providing emergency care for clients who have a sports-related injury. Which of the following information should the nurse include?

Compress the injury for 24 hr. he nurse should apply compression for the first 24 to 48 hr to reduce swelling.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

Cover the area with saline-soaked sterile dressings. The nurse should cover the wound with a sterile, saline-soaked dressing to keep the exposed organs and tissues moist.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?

Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse is caring for a client who has myasthenia gravis. The nurse should recognize that this disease is caused by which of the following types of hypersensitivities?

Cytotoxic The nurse should recognize myasthenia gravis as a cytotoxic hypersensitivity. Other examples of this hypersensitivity include autoimmune hemolytic anemia and Goodpasture's syndrome.

A nurse is assessing a client who is in a body cast. Which of the following manifestations should the nurse identify as possible cast syndrome?

Dilated pupils cast syndrome is a reaction to wearing a large cast, which produces physical and psychological effects on the client, similar to claustrophobia. Cast syndrome can lead to paralytic ileus, or gangrenous bowel.

A nurse is assessing a client who is 24 hr postoperative following an open reduction and internal fixation to repair a fracture of the femur. Which of the following assessment findings is an early manifestation of fat embolism syndrome (FES)?

Dyspnea Dyspnea is an early manifestation of FES that occurs due to hypoxemia.

A nurse working in an emergency room is caring for a client who has third degree frostbite to both lower extremities. The nurse should plan to take which of the following actions?

Elevate the legs. When the extremities are rewarmed, it is necessary to handle the injured area carefully because the skin and tissues are fragile. Elevating the client's legs above the level of the heart is done to help prevent an increase in edema.

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Elevated central venous pressure (CVP). CVP is a measurement of the pressure in the right atria or ventricle at the end of diastole. An elevated CVP is indicative of heart failure

A nurse is caring for a client who has just been diagnosed with cancer of the colon. The client asks the nurse several questions about what the provider might be planning to do. Which of the following nursing responses should the nurse make?

Encourage the client to write down questions to ask the provider. The nurse does not know the answers to the client's questions, so helping the client to prepare questions for the provider addresses the client's needs.

A charge nurse is teaching a group of nurses about agonists and antagonists. The nurse should include in the teaching that which of the following agonist medications binds to receptors and causes activation that affects the cardiovascular system?

Epinephrine The nurse should include that epinephrine is an agonist that activates the receptors that affect the cardiovascular system in clients who are at risk for cardiac collapse.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?

Frothy sputum Left-sided heart failure reduces cardiac output and raises pulmonary venous pressure. Manifestations include hacking cough, frothy sputum, wheezing, fatigue, and weakness.

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Gallstones The client's history might reveal biliary obstruction from a gallstone causing bile to inflame the pancreas

A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse expect?

Hacking cough A hacking cough is a manifestation of left-sided heart failure that occurs due to pulmonary congestion.

A client who has a fever of unknown origin Prophylactic antibiotic therapy is not recommended for clients who have a fever of unknown origin.

Hepatomegaly Hepatomegaly, or liver enlargement, is a manifestation of right-sided heart failure.

A nurse is providing teaching to a client who has a new prescription for tamoxifen to treat breast cancer. The nurse should include that which of the following is an adverse effect of this medication?

Hot flashes are a common adverse effect of tamoxifen. Other adverse effects include fluid retention and vaginal discharge. The nurse should advise the client these effects should subside when therapy is discontinued.

A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?

Hyperkalemia The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.

A nurse is providing teaching about ileostomy care to a client. Which of the following statements by the client indicates a need for further teaching?

I will be certain to take enteric-coated medications."

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?

Identify effective stress reduction techniques. Psoriasis is significantly aggravated by stress. The use of effective stress reduction techniques is appropriate to manage this chronic disorder.

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Instruct the client to wiggle his toes. The nurse should observe the client's ability to move his toes when collecting data regarding neurovascular status distal to the fracture. Other means of evaluating neurovascular status include assessing skin color and temperature, sensation, pain, and capillary refill.

A nurse in a provider's office is assessing a client who has rheumatoid arthritis (RA). Which of the following findings is a late manifestation of this condition?

Knuckle deformity ?Joint deformity is a late manifestation of RA.

A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

Lethargy The nurse should identify that lethargy is a manifestation of hypothyroidism. A client who has hypothyroidism reports weakness, fatigue, and somnolence.

This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority..

Limit IM injections. The nurse should plan to limit IM injections or venipunctures to prevent harm to the client. If venipuncture is necessary, the nurse should hold pressure to the site for 10 min afterward.

A nurse is teaching a client who has fibrocystic breast condition (FBC) about strategies to minimize discomfort. Which of the following instructions should the nurse include in the teaching?

Limit your dietary intake of salt prior to menses." The nurse should instruct the client to limit sodium intake before menstruation, which helps minimize swelling and reduces pain and tenderness

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

Lubricate lips with water-soluble ointment is correct. Brush teeth with a soft toothbrush is correct. Blow nose gently is correct.

A nurse is teaching a client who has hepatitis A. Which of the following information should the nurse include?

Manifestations of the virus are similar to flu-like symptoms. The nurse should include in the teaching that the manifestations of hepatitis A are similar to having the flu or a gastrointestinal illness. Often the client is unaware that they have acquired the virus.

A nurse is caring for a client who is postoperative and is at risk for developing venous thromboembolism (VTE). The nurse should instruct the client to avoid which of the following unsafe actions?

Massaging her legs Massaging an extremity that has a blood clot can cause it to detach and become an embolus. The use of sequential compression devices and antiembolic stockings and therapeutic anticoagulation can help prevent this postoperative complication.

A nurse is admitting a client who is having an exacerbation of his asthma. When reviewing the provider's orders, the nurse recognizes that clarification is needed for which of the following medications?

Medications that block beta-2 receptors, such as propanolol, are contraindicated in clients with asthma.

A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type 1 (HSV-1) lesions. The nurse should assess which of the following areas of the body for the recurrence of HSV-1 lesions?

Mouth HSV-1 most commonly occurs on the mouth.

A nurse in a clinic is caring for a client who has a prescription for digoxin. Which of the following statements indicates the client is experiencing digoxin toxicity?

My vision seems yellow." Blurred and yellow vision is an indication of digoxin toxicity.

A nurse in a provider's office is assessing a client. The nurse should identify that which of the following findings are manifestations of pulmonary tuberculosis? (Select all that apply)

Night sweats is correct. Low-grade fever is correct. Blood in the sputum is correct.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

No fluctuations in the water seal chamber Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following information should the nurse include in the plan? (Select all that apply)

Obtain a urine specimen prior to the procedure is correct. Obtain written, informed consent is correct. Maintain NPO status prior to the procedure is correct. Obtain coagulation studies is correct

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Oliguria Oliguria is present in hypovolemic shock as a result of decreased blood flow to the kidneys.

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

Place a bed cradle on the client's bed. A bed cradle can reduce pain for a client who has diabetic neuropathy by preventing sheets from touching hypersensitive skin.

A nurse is preparing for the admission of client who has suspected active tuberculosis. Which of the following precautions should the nurse plan to implement to safely care for this client?

Place the client in a private room with a special ventilation system. Clients who have active tuberculosis should be assigned to private rooms with negative-pressure airflow via HEPA filtration systems. In these rooms, the air is not returned to the inside ventilation system but is filtered and exhausted directly to the outside.

A nurse is caring for a client who is brought into the emergency department immediately following a snake bite to his forearm. The client suspects the snake to be venomous. Which of the following interventions should the nurse take?

Place the extremity in a dependent position. The affected area should be placed in a dependent position to decrease the circulation of venom.

A nurse in a provider's office is assessing a client who has wrist pain. Which of the following findings is a manifestation of carpal tunnel syndrome?

Positive Phalen's sign If a client who has carpal tunnel syndrome holds his wrist in flexion for 60 seconds, it will produce tingling and numbness over the median nerve, the palmar surface of the thumb, the index finger, the middle finger, and part of the ring finger. This is a positive Phalen's test.

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

Potassium Potassium levels are reduced by the process of diffusion during dialysis.

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings is the highest priority for the nurse to report to the provider?

Presence of peripheral edema. The client who has SLE is at greatest risk for death from lupus nephritis. Therefore, according to the safety and risk reduction priority setting framework, findings that indicate an impairment of renal function are the highest priority to report.

A nurse is caring for a client who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

Purulent dialysate outflow Peritonitis is an inflammation of the peritoneum and a major complication of peritoneal dialysis. Manifestations of peritonitis include cloudy dialysate outflow, fever, nausea, and vomiting. If untreated, the client can become severely ill, progressing to bacterial septicemia and hypovolemic shock. Peritonitis can be prevented with meticulous site care. The nurse and client should wear a mask when accessing the catheter. Strict aseptic technique should be used when connecting and disconnecting the catheter.

A nurse is caring for a client who has just undergone insertion of a femoral head prosthesis. The nurse should instruct the client to avoid which of the following activities?

Putting on shoes and socks The client should not bend over to put on shoes and socks. It increases the risk of dislocation of the prosthesis to create more than 90º of flexion at the hip. The client should use an assistive or adaptive device for putting on shoes and socks.

A nurse is caring for a client who has HIV. Which of the following laboratory tests should the nurse monitor to assess the effectiveness of therapy?

Quantitative RNA assay A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

Respiratory acidosis Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.

A nurse is providing postoperative teaching with a client who had a surgical correction of hallux valgus. Which of the following information should the nurse include in the teaching?

Rest frequently with your foot elevated." The client should rest and elevate the foot to help reduce discomfort and prevent edema.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?

Restrict fluid intake to 1,000 mL per day. Clients who have SIADH have an increased amount of antidiuretic hormone, which results in excess fluid volume. This excess fluid dilutes the sodium level in the blood, causing dilutional hyponatremia. Oral fluids are restricted in an attempt to restore the fluid balance and the sodium level in the blood. The nurse should offer this client frequent oral care to prevent discomfort and breakdown of the oral mucosa.

A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?

Review the client's electrolyte values. The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen A rigid, boardlike abdomen is a manifestation of peritonitis.

A nurse is caring for a male client who has chronic glomerulonephritis. Which of the following findings should the nurse expect?

Serum creatinine 7 mg/dL A serum creatinine of 7 mg/dL is a critical value that indicates serious impairment of renal function. Clients who have chronic glomerulonephritis usually develop the disease over 20 to 30 years. Gradual changes occur in the kidney resulting in atrophy and a decreased number of functioning nephrons

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?

Small drops of clear fluid in left ear Clear fluid in the ear canal might be cerebrospinal fluid (CSF) and indicates a basilar skull fracture. CSF drainage is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents. This finding should be reported to the provider.

A nurse is teaching a client who has a pelvic fracture about manifestations of fat embolism syndrome. The nurse should include which of the following findings as an early manifestation?

Tachypnea Tachypnea, dyspnea, and hypoxemia are early manifestations of fat emboli syndrome.

A nurse is preparing to administer warfarin to a client. Which of the following information should the nurse recognize prior to administering the medication?

The client should be observed for manifestations of hemorrhage. The nurse should observe for manifestations of hemorrhage because it is an adverse side effect of warfarin, which has anticoagulant and anti-inflammatory actions.

A nurse is reviewing the laboratory results for four clients. The nurse should recognize that which of the following clients has a manifestation of primary hyperparathyroidism?

The client who has an increased magnesium level Magnesium level is increased in a client who has primary hyperparathyroidism.

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

The client's bladder becomes distended. Autonomic dysreflexia (sometimes called hyperreflexia) can occur in clients with a spinal cord injury at or above the T6 level. Autonomic dysreflexia happens when there is an irritation, pain, or stimulus to the nervous system below the level of injury. There are many kinds of stimulation that can precipitate autonomic dysreflexia.

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

The fourth heart sound (S4) S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle.

A nurse is teaching a client about the intradermal purified protein derivative (PPD). Which of the following information should the nurse include?

The nurse should assess whether the client has tested positive to a prior PPD test. For clients who have tested positive, chest x-ray is performed to determine exposure

A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? (Select all that apply.)

Tingling in the arms is correct. . Shoulder pain is correct. Stiff neck is correct

A nurse is caring for a client who has a Jackson-Pratt (JP) drain in place after surgery for an open reduction and internal fixation. The nurse should understand that the JP drain was placed for which of the following purposes?

To prevent fluid from accumulating in the wound The purpose of a JP drain is to promote healing by draining fluid from a wound. This prevents pooling of blood and fluid, which can contribute to discomfort, delay healing, and provide a medium for infection. The JP drainage tube is threaded through the skin into the wound near the surgical incision and is held in place by sutures.

A nurse is planning care for a client who has pernicious anemia. Which of the following interventions should the nurse plan to implement?

Vitamin B12 injections The nurse should administer vitamin B12 injections to treat pernicious anemia when diet fails to improve the anemia due to poor absorption.

A nurse is talking with a client who has to come to the clinic for HIV testing. The nurse should explain that, after the laboratory has the enzyme-linked immunosorbent assay (ELISA) results, it will use which of the following tests to confirm the diagnosis?

Western blot analysis The Western blot analysis is used to confirm seropositivity when the ELISA test has a positive result. ELISA is inexpensive and accurate with few false-positives. Western blot is expensive, so is done only for confirmation.

A nurse is caring for a client who has acute pancreatitis. After treating the client's pain, which of the following should the nurse address as the priority intervention?

Withhold oral fluids and food. o rest the pancreas and reduce secretion of pancreatic enzymes, NPO status must be initiated and maintained during the acute phase of pancreatitis. This is the priority intervention to address after the client's pain has been treated.

A nurse is preparing a presentation about ginkgo biloba to a group of clients. Which of the following information should the nurse include in the teaching?

"Ginkgo biloba can improve memory." Ginkgo biloba can improve memory by improving blood flow due to ginkgo-induced vasodilation.

A nurse is teaching a client who has a new prescription for topical betamethasone to treat contact dermatitis. Which of the following instructions should the nurse include?

"Use the cream for a few days after the area has healed." The client should continue to apply steroid cream to affected area for a few days after the area has healed to reduce the risk for reoccurrence.

A nurse is providing discharge teaching for a client who is to perform peritoneal dialysis at home. Which of the following information should the nurse include?

"You should anticipate pain the first week during the inflow of dialysate." Abdominal pain is expected during inflow of the dialysate during the first few weeks of therapy.

A nurse is preparing a presentation at a community center about osteoarthritis. The nurse should plan to include which of the following information? (Select all that apply.)

Affects weight-bearing joints is correct. Crepitus can occur in affected joints is correct. Causes joint stiffness is correct. Causes joint pain is correct.

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

Carbon monoxide poisoning These findings are consistent with a moderate level (21% to 41%) of carbon monoxide poisoning.

A nurse is assessing a client's wound dressing, and observes a watery red drainage. The nurse should document this drainage as which of the following?

Serosanguineous Watery red drainage should be documented as serosanguineous.

A nurse is caring for a client who is postoperative and in skeletal traction. When assessing the client, the nurse should expect which of the following findings? (Select all that apply.)

Slight pain at the insertion site is correct. Serous drainage on the dressing is correct. Minimal edema around the pin is correct.

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

The client needs total nursing care. A client who has a score of 6 on the Glasgow Coma Scale is in a comatose state and will require total nursing care.

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

"Avoid speaking for long periods." The client should avoid speaking for long periods to promote gas exchange

A nurse is providing teaching to a client about preventing skin cancer. Which of the following client statements indicates a need for further teaching?

"Eating a high fiber diet will reduce my risk for developing skin cancer." A high-fiber diet is recommended to reduce the risk for colon cancer.

A nurse is providing preoperative teaching to a client who is to undergo an open bowel resection at 1300 next week. Which of the following statements by the client indicates the need for further teaching?

"I will be able to eat solid food when I wake up from anesthesia Clients who undergo open abdominal surgery will usually have an NG tube in place. The client will remain NPO until the nurse removes the tube. Once the nurse removes the tube, the client can start to drink clear liquids and progress to more solid fluids as she is able to tolerate them

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

"I will need to wipe my perineal area from back to front after urination." Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN). The nurse notices that the solution bag is almost empty and there is not another bag of TPN to administer. Which of the following IV solutions should the nurse administer until the next bag of TPN solution is available?

10% dextrose in water (D10W) TPN solution has a high concentration of glucose and protein and is hyperosmotic; therefore, the nurse should administer D10W or 20% dextrose in water if there is not another bag of TPN solution available. This will ensure that the client receives the adequate amount of glucose and a solution with the appropriate osmolarity until another TPN solution is available.

A nurse is reviewing guidelines for prophylactic antibiotics. The nurse should identify that prophylactic antibiotic therapy is not recommended for which of the following clients?

A client who has a fever of unknown origin Prophylactic antibiotic therapy is not recommended for clients who have a fever of unknown origin.

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Blood pressure 115/68 mmHg The sympathetic nervous system is stimulated, resulting in the release of epinephrine and norepinephrine. These catecholamines help maintain the client's blood pressure remains within normal limits during the compensatory stage of shock.

A nurse is teaching a client who is to begin long-term therapy with prednisone to treat rheumatoid arthritis. The nurse should instruct the client to take which of the following supplements while taking this medication?

Calcium and vitamin D Long-term use of glucocorticoids, such as prednisone, places the client at risk for osteoporosis. The nurse should instruct the client to take calcium and vitamin D supplements to reduce this risk.

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

Clients should have a yearly test for fecal occult blood. According to the American Cancer Society, all clients should have a yearly test to check for fecal occult blood.

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Encourage the use of the wide grip utensils The nurse should encourage the client to use wide grip utensils, but this action does not resolve the problem of homonymous hemianopsia.

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Increase fluid intake. The client who has had a lumbar puncture is at risk for continued leaking of CSF from the puncture site. This results in a decreased amount of circulating CSF. Increasing fluids is helpful in quickly replacing the cerebrospinal fluid that was removed during the procedure and increasing fluids will facilitate resolution of the headache. The client should also be instructed to remain in a prone position for 6 hours to prevent leaking of CSF fluid

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

Packed RBCs Packed RBCs are given to restore blood volume and replace hematocrit and hemoglobin levels in clients who have hypovolemic shock.

A nurse is assessing a client following the application of a leg cast for the treatment of a fracture. If the cast is too tight, which of the following findings should the nurse expect to observe first?

Pallor of the toes. If a cast is too tight it will increase pressure on the blood vessels, impairing circulation. When this occurs, pallor of the toes is the initial finding. The nurse should immediately report this finding to the provider.

A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?

Perform a 12-lead ECG ?The nurse should perform a 12-lead ECG when a client complains of chest pain to determine if the client is experiencing a myocardial infarction

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head. The nurse should place a small pillow or other soft padding under the client's head to protect the client from injury during the seizure, and turn his head to the side to keep the airway clear.

A nurse is caring for a client who has a herniated lumbar disc and reports pain. The nurse should assist the client into which of the following positions to help reduce the pain?

Semi-Fowler's with a pillow under her knees Low back pain is an expected manifestation of a herniated lumbar disc. Sitting partially upright with knee flexion helps to relax the lumbar muscles and takes pressure off the spinal nerve root, which promotes comfort for the client.

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Skin tenting present A client who has dehydration has poor skin turgor, or skin tenting, which the nurse should observe for over the sternum or the back of the hand.

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Slurred speech is correct. Bone pain is correct. Pruritus is correct.

A nurse is caring for a client who is scheduled for a bone marrow aspiration. The client asks the nurse about the sites the provider might use for the procedure. Which of the following locations should the nurse identify as one of the sites used for this procedure?

Sternum Providers most often extract bone marrow from the iliac crest of adults, but they sometimes use the sternum.

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

The nurse should expect a client who has a mild traumatic brain injury, such as a concussion, to have sensitivity to light and noise

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

Thyroid stimulating hormone (TSH) The nurse should anticipate that TSH will be elevated.

A client is prescribed 1 g potassium phosphate IV to be infused continuously over 6 hr. Available is 1 g potassium phosphate in 250 mL dextrose 5% water (D5W). The nurse should set the IV pump to run at how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

X mL/hr = 41.6666 mL/hr

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

color is correct. Temperature is correct. Sensation is correct.

A nurse is preparing to administer a unit of red blood cells. The nurse's responsibility is to compare and verify the information on the blood label with the client's information. The nurse should use which of the following as the priority source of verification?

identification wristband This is the best option of the four to ensure that the nurse will deliver the correct unit of blood to the client to whom the provider prescribed it. Thus, this is the nurse's highest priority..

A nurse in the emergency room is caring for a client who presents with manifestations that indicate a myocardial infarction. Which of the following prescriptions should the nurse take first?

initiate oxygen therapy. The greatest risk to the client's safety is myocardial ischemia and cellular death; therefore, the priority action the nurse should take is to administer oxygen to help minimize this possibility.

A nurse is discussing kidney transplant with a client who has end-stage renal disease (ESRD). Which of the following should the nurse identify as a contraindication for this treatment?

Alcohol use disorder The nurse should identify that a substance use disorder is a contraindication for kidney transplant

A nurse in an emergency department is caring for a client who has anaphylaxis following a bee sting. Which of the following actions should the nurse take first?

Auscultate for wheezing. When using the airway, breathing, circulation approach to client care, the nurse should place the priority on assessing the client's respiratory status. Bronchoconstriction or closure of the upper airway may occur, which places the client at risk for respiratory arrest.

A nurse is educating coworkers about how to minimize back strain and avoid repeated episodes of low back pain. Which of the following strategies should the nurse include? (Select all that apply.)

Avoid prolonged sitting is correct. Staying in any one position for too long, even lying down, can worsen back pain. Changing positions frequently is essential. Sleeping in a side-lying position with flexed knees is correct. Try padded shoe insoles is correct.

nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Decreased serum calcium level A decreased serum calcium level is an expected finding for FES, although the reason for this finding is unknown.

A nurse is preparing an in-service for coworkers about various herbal supplements clients might report using. The nurse should include in the presentation that which of the following herbal supplements is used to help the client lose weight?

Ephedra The nurse should identify that ephedra is an extremely dangerous weight loss supplement; however, clients may still report using it for weight loss

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Facial rash SLE causes a characteristic facial "butterfly" rash that is dry, scaly, red, and raised.

check .......A quantitative RNA assay measures the viral load and is useful in monitoring HIV disease progression and treatment effectiveness.

Fat embolism The nurse should suspect that client has fat embolism syndrome. This complication develops within 12 to 48 hr of a fracture and can cause dyspnea, respiratory distress, alterations in mental status, tachycardia, and other manifestations. Older adults who have hip fractures are at greater risk.

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks. These are a vital aspect of care for the client who has a sustained a fracture and should be monitored every hour for the first 24 hr. Circulation can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client. The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is teaching a client who has gout about medications. The nurse should teach the client to avoid the use of which of the following types of medication?

Salicylates Salicylates, such as aspirin, and diuretics can trigger gout attacks.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

Verify the most recent calcium level. A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

A nurse is assessing a client 1 day postoperative following abdominal surgery. Suddenly the client reports a pulling sensation and pain in his surgical incision. Which of the following actions should the nurse take?

"I will lie on my right side to sleep at night." Sleeping in a right side-lying position helps reduce the manifestations of nighttime reflux. The client can also elevate the head of the bed about 10.2 cm (4 in) to 30.5 cm (12 in) on blocks

A nurse is performing discharge teaching for a client who has systemic lupus erythematosus (SLE). Which of the following instructions should the nurse include?

"Wash your hair with a mild protein shampoo." Clients who have SLE are prone to hair loss and should use a mild protein shampoo and avoid treatments that can damage the hair and scalp, such as dyes and permanents.

A nurse assessing a client who has multiple fractures in his left leg notes increasing edema. The nurse should recognize this finding as an early manifestation of which of the following complications?

Acute compartment syndrome Edema is an early manifestation of acute compartment syndrome, which is a complication that involves increased pressure within the fascia that leads to reduced circulation to the affected area.

A nurse is teaching a client who has gout about dietary recommendations. The nurse should teach the client that which of the following beverages can trigger an attack?

Alcohol Alcohol can trigger painful gout attacks.

A nurse is caring for a client following exposure to inhalational anthrax due to bioterrorism. Which of the following medications should the nurse expect as a common medication to treat anthrax? (Select all that apply.)

Ciprofloxacin is correct. Doxycycline is correct. Amoxicillin is correct.

A nurse is providing dietary teaching to a client who has a history of recurring calcium oxalate kidney stones. Which of the following instructions should the nurse include in the teaching?

Drink 3 L of fluid every day. The nurse should instruct the client to drink at least 3 to 4 L of fluid every day to dilute the urine and reduce the risk for stone formation.

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing

Increased respiratory rate When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in in the teaching

Instruct the client about the use of a sequential compression device. The nurse should instruct the client about the use of a sequential compression device to prevent deep-vein thrombosis, a postoperative complication

A nurse is planning care for a client who is to undergone a stem cell transplant. Which of the following actions should the nurse plan to take?

Keep blood pressure equipment in the client's room. The nurse should keep and use dedicated equipment, such as blood pressure monitor, stethoscope and thermometer in the client's room to prevent the spread of infection from client to client.

A nurse is caring for a client who has just returned from the PACU after a traditional cholecystectomy. In which of the following positions should the nurse place the client?

Semi-Fowler's The nurse should expect a prescription to place the client in semi-Fowler's position following a traditional cholecystectomy to facilitate lung expansion as well as coughing and deep breathing. This position will place minimal stress on the abdomen and increase comfort.

A nurse is caring for a client who is 8 hr postoperative following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

Semi-Fowler's with neck in a neutral position Semi-Fowler's is the most comfortable position for a client who has had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the sutures. A neutral position is essential.

A nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. Which of the following statements should the nurse include in the teaching?

You may experience drowsiness while taking this medication." The nurse should instruct the client that drowsiness can occur while taking this medication and to exercise caution while performing activities that require alertness.

A nurse is caring for a client who is two days postoperative following creation of an ileal conduit. Which of the following is an unexpected finding associated with this procedure?

Feces in the drainage appliance Feces in the drainage appliance is an unexpected finding associated with this procedure. The ileal conduit procedure incorporates implantation of the ureters into a portion of the ileum that has been resected from its anatomical position and now functions as a reservoir or conduit for urine. Feces should not be draining from the conduit.

A nurse in an allergy clinic is caring for a client who has a history of seasonal allergy symptoms. The client had a radioallergosorbent test (RAST) completed on a previous visit. The nurse should recognize that an elevation in which of the following immunoglobulins indicates a positive result?

Immunoglobulin E (IgE) A RAST involves measuring the quantity of IgE present in the serum after exposure to specific antigens that are selected based on the client's symptom history. An elevated IgE indicates a positive response to a RAST.

A nurse is assessing a client who reports ear pain for the past 3 days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Perforated tympanic membrane The client has manifestations of otitis media with a perforated tympanic membrane (eardrum). Ear pain is reduced when fluid and pus drain from the eardrum due to the perforation.

A nurse in a provider's office is providing teaching to a client about modifiable risk factors for osteoporosis. Which of the following factors should the nurse include? (Select all that apply.)

Sedentary lifestyle is correct. Carbonated beverages is correct. Caffeine intake is correct Smoking tobacco products is correct.

A nurse is caring for a client who is hospitalized with active pulmonary tuberculosis and is started on ethambutol therapy. The nurse should understand that which of the following should be monitored?

Visual acuity A significant adverse effect of ethambutol is optic neuritis, vision loss, and loss of color discrimination, especially red and green. Baseline vision testing should be performed before use, and visual acuity monitored at regular intervals.

A nurse is reviewing a client's laboratory values. Which of the following values should the nurse report to the provider

WBC 1,700/mm3 A WBC count of 1,700/mm3 is a critical value that indicates the client is susceptible to infection. The nurse should report this value to the provider.

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Airway protection When assessing and treating a client who has trauma, a systematic approach is taken during the primary survey. It begins with the assessment and interventions necessary to ensure a patent airway.

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?

Paraplegia Paraplegia, or paralysis of both legs, is seen after a spinal cord injury below T1.