medsurg final

the nurse is caring for several older clients. for which client would the nurse be especially alert for signs and symptoms of pyelonephritis? -a client with urinary tumor -a client with acute renal failure - a client with urinary obstruction. -a client with chronic renal failure

- a client with urinary obstruction.

The nurse is assessing the clients right groin puncture site after a renal angiogram finds a saturated bloody dressing and blood pooling on the sheets. What should be the nurses priorty. -reinforce the dressing with a compression dressing -remove the dressing to further assess the puncture site -have the client flex the right leg to control the bleeding -glove and apply firm pressure directly over the dressing

- glove and apply firm pressure directly over the dressing

a nurse is caring for a client following an open thoracotomy for removal of a large tumor. extensive blood loss during the procedure required fluid resuscitation of the client. the client is cyanotic and in respiratory distress with pink, frothy sputum coming from the mouth. the nurse should immediately -give 200 ml fluid bolus -have the client cough and deep breath -activate the respiratory code system -put the client in high fowlers position

-activate the respiratory code system

which of the following statements by a client to the nurse indicates a risk factor for coronary artery disease? -i smoke 1 pack of cigarettes in one month -i exercise everyday -my cholesterol is 189 -i love hot dogs

-i smoke 1 pack of cigarettes in one month

a nurse is instructing a client who has angina about a new prescription for metoprolol. which of the following statements by the client indicates an understanding of the teaching? -i will report ringing in my ears -i should place the tablet under my tongue -i will with my doctor if my pulse rate is less than 60 -i need to check my clotting time frequently

-i will check with my doctor if my pulse rate is less than 60

you're caring for a patient with pneumonia. the patient has just started treatment for pneumonia and is still experiencing hypoxemia. you know that respiratory acidosis is very common with patients with pneumonia. which arterial blood gases below represent respiratory acidosis? -ph 7.29, PaCO2 55, HCO3 23, PO 2 85 -ph 7.55, PaCO2 63, HCO3 19, PO2 85 -ph 7.48, PaCO2 35, HCO3 22, PO2 85 -ph 7.40, PaCO2 20, HCO3 28, PO2 85

-ph 7.29, PaCO2 55, HCO3 23, PO 2 85

in which statements regarding medications taken by a client diagnosed with COPD do the drug name and the drug category correctly match? select all that apply -dexamethasone is an antibiotic -prednisone is a corticosteroid -ciprofloxacin is an antibiotic -albuterol is a bronchodilator

-prednisone is a corticosteroid -ciprofloxacin is an antibiotic -albuterol is a bronchodilator

the nurse is admitting the client with possible renal trauma after an MVA. In caring for this client, the nurses actions should include the following. select all the apply -teach the client signs of a UTI and prepare for discharge -prepare the client for a CT scan -palpate both flanks for asymmetry -inspect the abdomen and the urethra for gross bleeding -report any abnormal lab findings to the physician

-prepare the client for a CT scan -palpate both flanks for asymmetry -inspect the abdomen and the urethra for gross bleeding -report any abnormal lab findings to the physician

a patient with an advanced laryngeal tumor is to have radiation therapy. the patient tells the nurse, "if i am going to have radiation, i wont need surgery." what is the best response by the nurse? -that is correct. the radiation will eradicate the tumor and you wont have to have further treatment -you dont need radiation that is up to you -radiation is used to shrink the tumor size and is an adjunct to surgery -all patients have radiation before surgery

-radiation is used to shrink the tumor size and is an adjunct to surgery

during a community health fair, a nurse is teaching a group of seniors about promoting health and preventing infection. which intervention would best promote infection prevention for senior citizens who are at risk of pneumococcal and influenza infections? -receive vaccinations -drink 6 glasses of water daily -exercise daily -take all prescribed medications

-receive vaccinations

while admitting an 8- year old with heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses her water pill with the heart pill. when planning for the patients discharge the nurse will facilitate -referral to home health -transfer to dementia unit -arrangements for 24 hour care -tell the physician that the patient is incompetent

-referral to home health

the nurse is planning meals for the client on hemodialysis and fluid restriction secondary to ARF. which afternoon snack should the nurse include? -ham sandwich -small apple -banana -glass of milk

-small apple

which of the following is a modifiable cardiovascular risk factor that should be noted during a patient data collection? -age -gender -smoking -ethnic origin

-smoking

a client learning about COPD self-care at a community health class, asks a nurse why the participants are being taught about the lip breathing. the nurse should respond by explaining that pursed lip breathing can help to -strengthen respiratory muscles -reduce upper airway inflammation -reduce anxiety through humor -increase effectiveness of inhaled medications

-strengthen respiratory muscles

during the acute phase of a cerebrovascular accident, the nurse should maintain the client in which of the following positions? -lateral, with the head of the bed flat -semi prone with the head of the bed elevated 60-90 degrees -prone with the head of the bed flat -supine with the head of the bed elevated 30-45 degrees

-supine with the head of the bed elevated 30-45 degrees

a a member of the stroke team, the nurse knows that thrombolytic therapy carries the potential for benefit and for harm. the nurse should be cognizant of what contraindications for thrombolytic therapy? select all that apply -symptom onset greater than 3 hours prior to admission -current anticoagulant therapy -sudden symptom onset -INR above 1.0

-symptom onset greater than 3 hours prior to admission -current anticoagulant therapy

the nurse is caring for a client with trigeminal neuralgia. the care plan for this client reflects the clients problem eating due to jaw pain. to assist the client in meeting the adequate nutritional needs, what should the nurse suggest? -include additional servings of fruits and raw vegetables -include fish, liver, and chicken in diet -take small meals of soft consistency -increase the intake of calcium and protein

-take small meals of soft consistency

a patient with end stage COPD has a nursing diagnosis of impaired gas exchange. which assessment finding shows that interventions have been effective? -the patient is able to move in bed without difficulty -the patients Spo2 is 97% on 2 liters of oxygen -the patient is coughing up copious white sputum -the patient appears comfortable

-that patients Spo2 is 97% on 2 liters of oxygen

a patient with a venous thromboembolism is started on enoxaparin (lovenox) and warfarin (coumadin). the patient asks the nurse why two medications are necessary. which response by the nurse is accurate? -administration of two anticoagulants prevent any future problems" reduces the risk for recurrent venous prevents recurrent thrombus -because of the potential for a pulmonary embolism, it is important for you to have more than one anticoagulant -lovenox will start to dissolve the clot, and coumadin will prevent any more clots from occurring ever. -the lovenox will work immediately, but the coumadin takes several days to have an effect on coagulation

-the lovenox will work immediately, but the coumadin takes several days to have an effect on coagulation

a client diagnosed with TB is takin medication for the treatment of TB. the nurse should instruct the client that he or she will be safe from infecting others approximately how long after initiation of the medication therapy? -results vary with each client -two to three weeks after initiation of medications -after completion of six months of drug therapy -within 48 hours after initiation of medication

-two to three weeks after initiation of medications

a nurse is caring for a client who was admitted with FVE. which nursing assessment should the nurse include in the ongoing monitoring of the client? select all that apply. -vital signs -intake and output -pupil dilation -strength muscle wastiing -nutritional status and diet

-vital signs -intake and output -nutritional status and diet

on the third post operative day following a total laryngectomy, a clients family asks a nurse when the client will be able to eat. which response by the nurse is the best? -we are going to start with a feeding tube, but eventually he will have to learn a different way of swallowing to prevent aspiration -he will probably always have to be fed through a gastrotomy tube in his stomach -because of his surgery it will be several more days before his gastrointestinal tract begins functioning again -we are going to start with a feeding tube, but eventually he should be able to eat normally

-we are going to start with a feeding tube, but eventually he should be able to eat normally again

the nurse is caring for a patient who is receiving IV furosemide (lasix) and morphine for the treatment of acute decompensated heart failure with sever orhtopnea. when evaluating the patient response to the medications, the best indicator that the treatment has been effective is? select all that apply -reductin in patient complains of chest pain -decreased dyspnea with the head of bed at 30 degrees -hourly output greater than 60 ml per hour -weight loss of 2 pounds overnight

-weight loss of 2 pounds overnight -hourly output greater than 60 ml per hour

an adult has developed angina pectoris secondary to coronary artery disease. a low fat, low cholesterol diet is prescribed for the client. the nurse should praise the client for a wise choice if which of the following was selected for an evening snack? -jell o mold with fresh fruit -half tuna fish salad sandwich -cheese and crackers -yogurt with fresh strawberries

-yogurt with fresh strawberries -jello mold with fresh fruit

a patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.1. which of the following medications that the patient has been taking at home, the nurse will be most concerned about? -motrin 400 mg q 6 hours -lopressor (metoprolol) 25 mg po daily -lanoxin 0.25 mg daily -acetaminophen 81 mg po daily

lanoxin 0.25 mg daily

a patient has a mantoux skin test prior to being placed on an immunosuppressant for the treatment of crohns disease. what results would the nurse determine is not significant for holding the medication? -0-4 mm -9 mm -5-6 mm - 7-8 mm

-0-4 mm

the client is to receive cephalexin (ancef) 500 mg in 50 mL of normal saline intravenous piggyback. the medication is to infuse over 30 minutes. how many ml/hr would the nurse set the intravenous piggyback pump? -1.7 -25 -100 -50

-100

thrombolytic therapy should be initiated within what time frame of an ischemic stroke to achieve the best functional outcome? -6 hours -3 hours -9 hours -24 hours

-3 hours

a nurse is teaching a client who has heart failure about the need to limit sodium in the diet to 2000 mg daily. which of the following foods should the nurse recommend for the client? -3 oz roasted chicken breast -2 oz baked ham extremities -1 slice cheddar cheese -3 oz baked salmon

-3 oz roasted chicken breast -1 slice cheddar cheese -3 oz baked salmon

a client is prescribed isoniazid syrup 300 mg. the isoniazid is available as 50mg/ml. the nurse should administer -2 ml -3 ml -1 ml -6 ml

-6 ml

a patient who comes to the community clinic for a wellness visit has blood pressure of 164/92. what additional information should the nurse assess from this patient? select all that apply -neurological system -BMI and waist circumference -bowel sounds -heart rate

-BMI and waist circumference -heart rate

a client is experiencing decreasing glomerular filtration. what laboratory values should the nurse expect to follow the change? select all that apply -creatinine clearance decreases -hypokalemia -hypophostameia -serum creatinine increases -BUN increases

-BUN increases -creatinine clearance decreases -serum creatinine increases

the clients serum potassium level is 6. which is the nurses priority during assessment? -ECG results -bowel sounds -respiratory rate -neuromuscular function

-ECG results

an elderly client is hopsitalized with ESRD. which finding in their medical records should the nurse associate with the diagnosis of ESRD? -a urinary output of less than 100 mL in 24 hrs -a serum creatinine level greater than 12.0 -a serum urea nitrogen greater than 100 -a GFR less than 15ml/min/1.73m

-a GFR less than 15ml/min/1.73m

the nurse knows that it is most important for which of the following clients to receive their scheduled medication on time? -a client diagnosed with bipolar disorder receiving lithium -a client diagnosed with parkinsons receiving levodopa -a client diagnosed with myasthenia gravis receiving pyridostigine bromide (mestinon) -a client diagnosed with tuberculosis receiving INH

-a client diagnosed with myasthenia gravis receiving pyrostigine bromise (mestinon)

three weeks after developing ARF following trauma, the hopsitalized client has significantly increased urinary output. which assessment finding should the nurse report to the HCP immediately? -a 3 pound weight loss over 24 hrs -a serum potassium level of 3.7 -absence of adventitious breath sounds -a drop in BP and increase in pulse rate

-a drop in BP and increase in pulse rate

the nurse recognizes health promotion efforts to decrease the risk for ischemic stroke involve encouraging a healthy lifestyle, including -a low fat, low cholesterol diet and increased exercise -a high protein diet and increased weight bearing exercise -eating fish no more than once a month -a low cholesterol, low protein diet and decreased aerobic exercises

-a low fat, low cholesterol diet and increased exercise

a client with a tentative diagnosis of myasthenia gravis is admitted for a diagnostic workup. myasthenis gravis is confirmed by -brudziniskis sign -kernigs sign -positive sweat chloride test -a positive edrophonium (tensilon) test

-a positive edrophonium (tensilon) test

the nurse is preparing to administer an analgesic for short term mild pain to the client who has a history of acute renal insufficiency. which medication should the nurse select from the list of options from HCPs order? -acetaminophen -ibuprofen -morphine sulfate -meperdine

-acetaminophen

an adult client has a history of coronary artery disease and angina pectoris. after walking to the bathroom, she complains of aching substernal pain that radiates to her left should. the nurse should -administer a dose of nitroglycerin po -administer a dose of nitroglycerin post an ecg to rule out MI -assist her to lay down and call the physician -administer a prn dose of nitroglycerin sublingually

-administer a prn dose of nitroglycerin sublingually

stroke volume plays and important part in cardiac output. select all the factors below that influence stroke volume. -afterload -heart rate -preload -contractility -blood pressure

-afterload -preload -contractility

after a laryngectomy, which of the following assessments takes priority? -patience acceptance of surgery -airway patency -nutritional needs -lung sounds

-airway patency

during a teaching session, a patient asks the nurse which inhaler to use for quick relief if there is an asthma attack. what teaching should the nurse review with the patient? -albuterol -theophylline -salmeterol -cromolyn

-albuterol

the nurse is caring for a client who had a hemorrhagic stroke. what assessment finding constitutes an early sign of deterioration? -generalized pain -alteration in level of consciousness -shortness of breath -tonic-clonic seizures

-alterations in level of consciousness

the client who had a kidney transplant has newly prescribed medications. which prescribed medication should the nurse administer for BP control? -amlodipine (norvasc) -tacrolimus (prograf) -epoetin alfa (procrit) -digoxin

-amlodipine (norvasc)

the nurse is planning care for a client who is in heart failure. which of the following are apropriate goals? select all that apply -a decrease in myocardial contractility -an elevation in renal blood flow -an increase in cardiac output -a reduction in the hearts workload

-an elevation in renal blood flow -an increase in cardiac output -a reduction in the hearts workload

an adult is admitted to the coronary care unit to rule out a mycardial infarction. the client sates "i am not sure if it is just angina and i cannot understand the difference between angina and heart attack pain". which response is most appropriate for the nurse to make? -anginal pain usually lasts only 3-5 minutes -anginal pain radiates to the left arm while acute MI pain does not -anginal pain produces clenching of the fist pain while MI does not -anginal pain requires morphine for relief

-anginal pain usually lasts only 3-5 minutes

a client who has recently started on anti tubercular medications reports orange stains on paper tissues when she urinates. which of the following interventions should the nurse do first? -refer the patient immediately to the emergency room -obtain a urine sample for lab studies -notify the primary care provider -ask the patient what she thinks is happening

-ask the patient what she thinks is happening

which of the following should the nurse include in the plan of care for a post op coronary arteriogram client? -assess lunch sounds -assess pedal pulses -provide ambulation -monitor vital signs every 8 hours

-assess pedal pulses

the nurse is planning care for the client who is to undergo extracorporeal shock wave lithrotripsy. which actions should include in the plan of care immediately following the procedure? select all that apply. -give no fluids or foods for 24 hours post ESWL -assess the incision for clean, dry, and intactness -check for flank ecchymosis on the affected side -instruct on the need to measure and strain all urine

-assess the incision for clean, dry, and intactness -check for flank ecchymosis on the affected side -instruct on the need to measure and strain all urine

the nurse is admitting a hospitalized client who has a renal calculi. which should be the nurses priority? -encourage the client to increase the amount of oral fluids -obtain necessary supplies to measure and strain all urine -assess the location and the severity of the clients pain -obtain consent for the extracorporeal shock wave lithrotripsy

-assess the location and the severity of the clients pain

a nurse is caring for a client who has heart failure and reports increased shortness of breath. the nurse increases the oxygen per protocol. which of the following actions should the nurse take first? -auscultate lung sounds -check oxygen saturation with pulse oximeter -assist the client into high fowlers position -obtain the clients weight

-assist the client into high fowlers position

the nurse is caring for the female client experiencing a new onset urge urinary incontinence which interventions should the nurse implement? select all that apply. -give diuretics at supper time so the bladder is empty by bedtime -ensure that the client is taken to the bathroom every 4 hours - avoid lifting when possible and practice pelvic exercises -avoid caffeine and foods or beverages that contain aspartame

-avoid caffeine and foods or beverages that contain aspartame -avoid lifting when possible and practice pelvic exercises

following a thoracotomy to remove a lung tumor, a nurse is preparing a client to be discharged to home. which are appropriate teaching points for the client? select all that apply -expect to return to normal activity and strength within one month -avoid lifting greater than 20 pounds -make time for frequent rest periods and activity -build up exercise endurance

-avoid lifting greater than 20 pounds -make time for frequent rest periods and activity -build up exercise endurance

which finding should a nurse expect when completing an assessment on a client with chronic bronchitis? -barrel chest -minimal sputum cough -pink, frothy sputum -stridor on expiration

-barrel chest

which of the following is NOT a sign and symptom of chronic bronchitis? -cyanosis -hyperventilation -barrel chest -productive cough

-barrel chest

in concern exists about fluid accumulation in a clients lungs, what area of the lungs will the nurse focus on during assessment? -bilateral lower lobes -anterior bronchioles -posterior bronchioles -left lower lobe

-bilateral lower lobes

a client who just experienced a suspected ischemic stroke is brought to the ED by ambualnce. on what should the nurses primary assessment focus? -seizure activity -fluid and electrolyte balance -cardiac and respiratory status -pain

-cardiac and respiratory status

the client has a newly placed left forearm internal arteriovenous fistula for hemodialysis. which interventions should the nurse plan to implement? select all that apply -tell the NA to take BP on the right arm -aspirate blood from the fistula for the lab tests -check left radial pulse, finger movement, and sensations -instruct about the hand exercises that start in about a week -palpate for a thrill over the left forearm fistula

-check left radial pulse, finger movement, and sensations -instruct about the hand exercises that start in about a week -palpate for a thrill over the left forearm fistula -tell the NA to take BP on the right arm

laboratory analysis reveals that the client passed a calcium oxalate stone. to prevent the formation of future stones, the nurse should instruct the client to avoid consuming which food? -lettuce -chocolate -cheese -beans

-chocolate

the nurse is assessing the client receiving peritoneal dialysis. which finding suggests that the client may be developing peritonitis? -cloudy dialysis output -radiating sternal pain -cloudy urine output -abdominal numbness

-cloudy dialysis output

a client has undergone a left hemicolectomy for bowel cancer. which activities prevent the occurence of postoperative pneumonia in this client? -administering pain medication, frequent repositioning, and limiting fluid intake -coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer -coughing, breathing deeply, frequent repositioning, and using an incentive spirometer -administering oxygen, coughing, breathing deeply, and maintaining bed rest

-coughing, breathing deeply, frequent repositioning, and using an incentive spirometer

a client appears to be breathing faster during the last assessment. which of the following actions should the nurse perform? -count the rate of respirations -assess the radial pulse -inquire if there have been any stressful visitors -assist the client to lie down

-count the rate of respirations

the nurse knows that the patient understands teaching related to prevention of an upper respiratory infection (influenza) transmission when the patient demonstrates which behaviors? select all that apply -covering the nose and mouth during coughing or sneezing -avoiding sharing eating utensils with others -washing hands frequently -taking acetaminophen as ordered

-covering the nose and mouth during coughing or sneezing -avoiding sharing eating utensils with others -washing hands frequently

a gerontologic nurse is analyzing the data from a clients focused respiratory assessment. the nurse is aware that the amount of respiratory dead space increases with age. what is the effect of this physiologic change? -increased oxygen levels -decreased diffusion capacity for oxygen -increased diffusion gases -decreased shunting of blood

-decreased diffusion capacity for oxygen

the nurse is caring for the client who developed ARF. which findings supper the nurses conclusion that the client is in the recovery phase of ARF? select all that apply? -absense of urine -decreased serum creatinine level -decreased serum potassium level -increased urine specific gravity

-decreased serum creatinine level -decreased serum potassium level -increased urine specific gravity

a nurse is reviewing the health record of a client who is being evaluated for possible valvular heart disease. the nurse should recognize which of the following data as risk factors for this condition? select all that apply -diastolic murmur present -ineffective endocarditis -weight gain of 10 pounds in the past year -hypertension for 5 years

-diastolic murmur present -ineffective endocarditis -hypertension for 5 years

the nurse is preparing a patient for a renal/bladder ultrasound. which explanation is most appropriate? -void immediately before the procedure; a full bladder impairs seeing important structures -a urinary catheter is necessary for this procedure -you will be asked to void during the procedurein order to obtain the best results -do not void before the procedure, a full bladder helps to identify important structures

-do not void before the procedure, a full bladder helps to identify important structure

the nurse is concerned that a patient with heart failure is decomensating. what assessment finding supports the nurses clinical decision? -weak peripheral pulse -increased urine output -dry persistent cough -dyspnea and coughing

-dyspnea and coughin

the nurse is education a patient with recurrent uti about perineal hygiene. the nurse's rationale for including this component is that 80% of cases of uti are caused by which bacteria? -e coli -staph aureus -klebsiella -strepococcus

-e coli

a client stops breathing during sleep as a result of repetitive upper airway obstruction. to help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to -sleep on the back -eliminate alcohol ingestion -use nasal oxygen at night -take a hypnotic medication at hours of sleep

-eliminate alcohol ingestion

a nurse is planning care for a client who has chronic kidney disease. which of the following should the nurse include in the plan of care? select all that apply. -evaluate intake and output -monitor daily weight -encourage compliance with fluid restrictions -monitor for constipation due to fluid restriction -instruct on restricting calories from carbohydrates

-evaluate intake and output -monitor daily weight -encourage compliance with fluid restrictions -monitor for constipation due to fluid restriction

the nurse identifies the nursing diagnosis of decreased cardiac output related to valvular insufficiency for the patient with ineffective endocarditis based on the assessment finding of -fever, chills, and diaphoresis -petechiae of bucchal mucosa -urine output. less than 30 ml -increase pulse rate with activity

-fever, chills diaphoresis

the nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take antibiotic for 10 days. on day 4, the client is feeling better and plans to stop taking the medication. what information should the nurse provide to this client? -discontinue the medication if the fever is gone -finish all the antibiotics to eliminate the organism completely -keep the remaining tablets for an infection at a later time -dispose of the remaining medication in a biohazard receptacle

-finish all the antibiotics to eliminate the organism completely

the nurse is caring for the client who was newly diagnosed with renal cell carcinoma. the nurse should assess for which specific symptoms? -hematuria and nocturia -suprapubic pain and foul smelling urine -abdominal pain and dysuria -flank pain and hematuria

-flank pain and hematuria

hydrochlorothiazide (diuretic) is prescribed to treat high blood pressure. the nurse knows that the client understands the dietary modifications she needs to make if she states that she will increase her intake of which food in her diet? -fresh oranges -cola drinks -cranberry juice -cold cereals

-fresh oranges

what two factors are used to calculate cardiac output? select all that apply -heart rate -blood pressure -mean arterial pressure -stroke volume

-heart rate -stroke volume

a client hospitalized for severe case of pneumonia, is asking a nurse why a sputum sample is needed. the nurse should reply that the primary reason is to -differentiate between pneumonia and atelectasis -encourage expectoration of secretions -help select the appropriate antibiotic -complete the first of three samples to be collected

-help select the appropriate antibiotic

a patient was admitted to the intensive care unit 48 hrs ago for treatment of a gunshot wound. the patient has recently developed a productive cough and a fever of 104.3. the patient is breathing on their own and doesnt require mechanical ventilation. on assessment you note course crackles in the right lower lobe. a chest x-ray shows infiltrates with consolidation in the right lower lobe. based on this specific patient scenario, this is known as what type of pneumonia? -aspiration pneumonia -ventilator acquired pneumonia -community acquired pneumonia -hospital acquired pneumonia

-hospital acquired pneumonia

the nurse is preparing an education program on risk factors for kidney disorders. which of the following risk factors would be inappropriate for the nurse to include in the teaching program? -diabetes -neuromuscular disorders -pregnancy -hypotension

-hypotension

which of these statements made by a patient with coronary artery disease after the nurse has completed teaching about the therapeutic lifestyle changes diet indicates that further teaching is needed? -i can have a cup of coffee if i want -i will switch from whole milk to 1% or nonfat milk -i will miss my peanut butter sandwiches -im going to eat fresh salmon more often

-i can have a cup of coffee if i want

You are about to hang a bag of intravenous Vancomycin for a patient who has severe pneumonia. which statement by the patient causes you to hold the bag of Vancomycin and notify the doctor immediately? -my head hurts -im seeing yellow halos around the light -my mouth tastes like metal -i have this constant ringing in my ears

-i have this constant ringing in my ears

a nurse is evaluating discharge teaching that has been completed for a client following total laryngectomy. which statement made by the client indicated that the client does not accept or understand the teaching? -i probably will not be able to go swimming -i will cheek the batteries on our smoke detectors -i will make sure to carry an extra supply of facial tissues with me -i will schedule an appointment for closure of my tracheostomy

-i will schedule an appointment for closure of my tracheostomy

which statements indicates the client diagnosed with asthma understands the discharge teaching concerning medication regime? -i need to take my oral glucocorticoids everyday to prevent my asthma attacks -if i have an asthma attack i need to use my albuterol, a beta2 agonist inhaler -i need to take singulair, a leukotriene, everyday to prevent allergic asthma attacks -i will only watch for asthma attacks when im exercising

-if i have an asthma attack i need to use my albuterol, a beta2 agonist inhaler -i need to take singulair, a leukotriene, everyday to prevent allergic asthma attacks

the client with cystic fibrosis is visiting with the nurse in preparation for leaving home for college. which client statement should the nurse clarify? -ill bring cough medication to use at night -ill use hand hygiene and stay away from sick friends -ill check and make sure i find a place where i can exercise -ill contact the college health center and pass on my health records

-ill bring cough medication to use at night

a client admitted to the facility for treatment for tuberculosis receives instructions about the disease. which statement made by the client indicates the need for further instruction? -ill stay in isolation for 6 weeks -this disease may come back later if i am under stress -ill always have a positive TB test -ill have to take the medications for up to a year

-ill stay in isolation for 6 weeks

a home health nurse is visiting a client whose chronic bronchitis has recently worsened. which instruction should the nurse reinforce with this client? -increase fluid intake -increase amount of bedrest -reduce home oxygen use -decrease caloric intake

-increase fluid intake

after a diagnosis of CRF, the client was started of epoetin alfa. which finding indicates that the medication has been effective? -decrease in blood pressure -increase in serum hematocrit -increase in white blood cells -decrease in serum creatinine levels

-increase in serum hematocrit

a nurse is caring for a client with COPD. the clients medication regimen has been recently changed and the nurse is assessing for therapeutic effect of a new bronchodilator. therapeutic effects of this medication would include which of the following? select all that apply. -increased respiratory rate -relief of dyspnea -increased viscosity of lung secretion -negative sputum culture

-increased respiratory rate -relief of dyspnea

cerebrospinal fluid studies would indicate which of the following in a patient suspected of having meningitis? select all that apply -increased white blood cells -decreased protein -decreased glucose -increased protein

-increased white blood cells -decreased glucose -increased protein

a client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. what is the priority nursing concern with this client? -activity intolerance -excess fluid volume -ineffective breathing pattern -acute pain

-ineffective breathing pattern

the nurse is caring for an adult client who is being treated for myocardial infarction. oxygen is ordered. administering oxygen to this client is related to which of the following client problems? -alteration in heart rate, rhythm, or conduction -anxiety -ineffective myocardial perfusion -chest pains

-ineffective myocardial perfusion

a patient is hospitalized following renal trauma. the nurse should assess for signs of which complication first? -electrolyte imbalance -hypertension -anuria -internal bleeding

-internal bleeding

the nurse is caring for a client with Guillain-Barre syndrome. the client also has an ascending paralysis. knowing the potential complications of the disorder, what should the nurse keep always ready at bedside? -blood pressure apparatus -nebulizer and thermometer -incentive spirometer -intubation tray and suction apparatus

-intubation tray and suction apparatus

identify which drugs are included in primary treatment for TB. select all that apply -isoniazid -ofloxacin -rifampin -pyrazinamid

-izoniazid -rifampin -pyrazinamid

which of the following assessment finding by the nurse indicates right venticular failure in a client? -jugular venous distention -crackles -shortness of breath -paroxysmal nocturnal dyspnea

-jugular venous distention

the client with acute pyelonephritis of the left kidney is hospitalized. the nurse monitor for which most frequently occurring symptom? -bradycardia -low grade fever -right quadrant rebound tenderness -left sided flank pain

-left sided flank pain

a client newly diagnosed with asthma is preparing for discharge. which point should a nurse emphasize during the clients discharge? -limit exposure to sources that trigger an attack -contact care provider only if nighttime wheezing becomes a concern -use peak flow meter only if symptoms are worsening -use inhaled steroid medication as a rescue inhaler

-limit exposure to sources that trigger an attack

patients with chronic bronchitis and emphysema can most commonly experience what type of acid-base imbalance? -low oxygen level and low carbon dioxide level -high oxygen level and low carbon dioxide level -high oxygen level and high carbon dioxide level -low oxygen level and high carbon dioxide level

-low oxygen level and high carbon dioxide level

select the medications used to treat pneumonia that are narrow spectrum? select all that apply -fluroquinolones -macrolides -penicillins -tamiflu

-macrolides -penicillins

which of the following is NOT a treatment for chronic bronchitis or emphysema? -spirvia -metoprolol -theophyline -albuterol

-metoprolol

a nurse is admitting a client to the coronary care unit following placement of a temporary pacemaker. which of the following nursing actions should the nurse use to promote client safety? select all that apply -wear gloves when handling pacemaker leads -minimize clients shoulder movements -keep the lead wire taut and secure -verify the use of three pronged grounding plugs

-minimize clients shoulder movements -keep the lead wire taut and secure -verify the use of three pronged grounding plugs

a client experiencing an asthmatic attack is prescribed methylprednisolone intravenously. what action should the nurse take? -monitors blood glucose -encourage the client to decrease caloric intake due to increased appetite -informs the client to limit fluid intake due to fluid retention -aspirates for blood return before injecting medication

-monitors blood glucose

which of the following is a normal value for oxygen saturation? -86-95% -61-85% -less than 60% -more than 95%

-more than 95%

a nurse is administering client lasix 40 mg daily. what time of day should the nurse plan to give this medication? -before dinner -bedtime -after lunch -morning

-morning

a client is receiving baclofen for management of symptoms associated with multiple sclerosis. the nurse evaluates the effectiveness of this medication by assessing which of the following? -appetite -mood and affect -muscle spasms -sleep pattern

-muscle spasms

which clinical manifestation would be exhibited by a client follwoing a hemorrhagic stroke of the right hemisphere? -inability to move right arm -neglect on the left side -expressive aphasia -neglect on the right side

-neglect on the left side

the client is concerned about having brown colored urine after starting nitrofurantoin for treating a UTI. which response by the nurse is most appropriate? -stop taking nitrofurantoin and make an appointment to have a urine culture -you probably have blood in urine which sometimes happen with a UTI -your urine is too concentrated. take only one half the dose. -nitrofurantoin normally does discolor urine; continue taking it as prescribed.

-nitrofurantoin normally does discolor urine; continue taking it as prescribed

the nurse is preparing medications for a patient experiencing an acute myocardial infarction. which medication will dilate the patients coronary blood vessels? -heparin -beta blockers -fibrinolytics -nitroglycerin

-nitroglycerin

a few days after an acute myocardial infarction, a patient complains of stabbing chest pain that increased with deep breathing. which action will the nurse take first? -auscultate the heart sounds -notify the patients health care provider -check the patients oral temperature -give the ordered acetaminophen (tylenol)

-notify the patients health care provider

a 45 year old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. the nurse should recognize the manifestations of what health problem? -adenitis -obstructive sleep apnea -laryngeal cancer -chronic tonsilitis

-obstructive sleep apnea

the nurse is caring for the client experiencing a possible hospital aquired bladder infection. Which nursing action should the nurse perform first? -obtain a urine speciment for culture and sensitivity -administer the prescribed antibiotic medication -teach the client to wipe the perineum front to back -prepare the client for removal of the urinary catheter

-obtain and urine speciment for culture and sensitivity

which of these prescriptions written by the health care provider for a patient admitted with ineffective enocarditis and a fever should the nurse implement first? -obtain a transesophageal echocardiogram -give acetaminophen (tylenol) PRN for fever -administer ceftriaxone (rocephin) 1 g IV -order blood cultures drawn from two sites

-order blood cultures drawn from two sites

a client newly diagnosed with COPD tells the nurse, "I cant believe I have COPD; I only had a cough. are there other symptoms I should know about?" which is the nurses best response -you can expect weight gain -there are no other symptoms -other symptoms you may develop are shortness of breath upon exertion and sputum production -as your COPD develops, you will frequently develop infections

-other symptoms you may develop are shortness of breath upon exertion and sputum production

which assessment finding by the nurse who is caring for a patient who has had coronary artery bypass grafting using a right radial artery graft is most important to communicate to the physician? -crackles audible at both lung bases -complaints of chest pain -pallor and weakness of the right hand -pallor and weakness of the left hand

-pallor and weakness of the right hand

the nurse is caring for a client admitted with a diagnosis of bacterial pharyngitis. the nurse anticipates the client will be ordered which medication? -tylenol -penicillin -robitussin DM -morphine

-penicillin

a nurse is teaching a client about protein needs when on dialysis. which of the following instructions should the nurse include in the teaching? select all that apply. -amino acids are protein and are lost in the dialysate -protein intake should include biologic source of protein in include eggs, milk, fish, poulty, and soy -protein can be increased as much as the patient would like -protein consumption increases phosphorus intake. phosphate binders are recommended with meals.

-protein consumption increases phosphorus intake. phosphate binders are recommended with meals. -protein intake should include biologic source of protein in include eggs, milk, fish, poulty, and soy -amino acids are protein and are lost in the dialysate

to assist the patient with coronary artery disease in making appropriate dietary changes, which of these nursing interventions will be most effective? -assist the patient to modify favorite high fate recipes by using monosaturated oils when possible -instruct the patient that a diet containing no saturated fat and minimal sodium will be necessary -provide the patient with a list of low sodium, low cholesterol foods that should be included in the diet -emphasize the increased risk for cardiac problems unless the patient makes the dietary changes

-provide the patient with a list of low sodium, low cholesterol foods that should be included in the diet

the nurse is reviewing a patients sign and symptoms including laboratory findings. what findings does the nurse assess that are consistent with acute glomerulonephritis? select all that apply -cola colored urine -polyuria -red blood cells in the urine -proteinuria -edema

-red blood cells in the urine -cola colored urine -proteinuria -edema

a nurse is completing discharge teaching about diet and fluid restrictions to a client who has a calcium oxalate based kidney stone. which of the following should the nurse include in teaching? -reduce intake of strawberries -limit consumption of whole grain foods -decrease broccoli intake -increase intake of juice rich in vitamin c

-reduce intake of strawberries

a nurse is teaching a client who has pre-stage chronic kidney disease about dietary management. which of the following information should the nurse include in the instructions? -restrict protein intake -maintain a high phosphorus diet -increase intake of foods high in potassium -limit dairy products to 1 cup per day

-restrict protein intake

The HCP writes orders for the newly hospitalized client who has polycystic kidney disease and dull flank pain, nocturia, and low urine specific gravity dilute urine. which admission order should the nurse clarify with the HCP? -metoprolol 12.5 mg po bid -restrict sodium intake to 500 mg daily -initiate referal for genetic counseling -fluid intake of at least 200 ml daily

-restrict sodium intake to 500 mg daily

a client is being assessed to rule out cardiovascular problem. the nurse understand that some of the common symptoms associated with cardiovascular disease are -dyspnea, ches discomfort, sputum production -shortness of breath, chest discomfort, palpitations -fatigue, weight changes, mood swings -fainting, chest pain, anxiety, tremors

-shortness of breath, chest discomfort, palpitations

which of the following positions is recommended for a patient experiencing a nosebleed? -lying down with a pillow under head -sitting up with neck fully extended -lying down with feet elevated -sitting up leaning slightly forward

-sitting up leaning slightly forward

a patient is diagnosed with carotid artery disease. for which potential health problem should the nurse prepare teaching for this patient? -hypertension -diabetes -dyslipedmia -stroke

-stroke

a client is transferred to a nursing home following a CVA. the client has a right sided paralysis and has been experiencing dysphagia. the nurse observes an aide prepare the client to eat lunch. which of the following situations would require an intervention by the nurse? -the clients head and neck are positioned slightly forward -the aide liquifies the pudding to help the client swallow -the side puts the food in the back of his mouth on the unaffected side -the client is in bed in high-fowlers position

-the aide liquifies the pudding to help the client swallow

the nurse is caring for the postoperative client diagnosed with lung cancer recovering from a thoracotomy. which data require immediate intervention by the nurse? -the client complains of a sore throat and is hoarse -the client refused to perform shoulder exercises -the client has crackles that clear with a cough -the client is coughing up pink frothy sputum

-the client is coughing up pink frothy sputum

the client diagnosed with tuberculosis has been treated with antitubercular medications for 6 weeks. which data would indicate the medications have been effective? -the clients symptoms are improving -a decrease in the white blood cells in the sputum -no change in the chest x ray -the skin test is now negative

-the clients symptoms are improving

a client is receiving theophylline for long term control and prevention of asthma symptoms. client education related to this medication will include -development of hyperkalemia -taking the medication at least 1 hr prior to meals -monitoring liver function -the importance of blood tests to monitor serum concentration

-the importance of blood tests to monitor the serum concentration

a client has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. when planning the clients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? select all that apply -urinary frequency -high fever -hematuria -diarrhea -acute pain

-urinary frequency -hematuria -acute pain

the nurse is teaching the client newly diagnosed with asthma. which instructions should the nurse include to reduce allergic triggers? select all that apply -vacuum frequently to remove dust and mites -clean the albuterol MDI daily under hot running water -use dust covers on mattresses and pillows -keep house fresh with a scented deodorizer

-vacuum frequently to remove dust and mites -use dust covers on mattresses and pillows

a client is newly diagnosed with relapsing remitting multiple sclerosis. which instruction should the nurse provide? -you must avoid stress and extreme fatigue because these can trigger a relapse -you should take your medications only during times of relapse -you will have a steady and gradual decline in function -your type of ms is in the least common, making it difficult to manage

-you must avoid stress and extreme fatigue because these can trigger a relapse