midterm

A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates a need for further teaching?a. "A soft cotton swab is alright to clean my ears with."b. "I make sure my ears are dry after I go swimming." c. "I use good earplugs when I practice with the band." d. "Keeping my diabetes under control helps my hearing.

"A soft cotton swab is alright to clean my ears with."

The client's electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause?a. "Do you feel like something is in your ear?"b. "Do you have frequent ear infections?" c. "Have you been exposed to loud noises?" d. "Have you been told your ear bones don't move?"

"Have you been exposed to loud noises?"

A nurse cares for a client placed in skeletal traction. The client asks, "What is the primary purpose of this type of traction?" How would the nurse responda. "Skeletal traction will assist in realigning your fractured bone."b. "This treatment will prevent future complications and back pain." c. "Traction decreases muscle spasms that occur with a fracture."d. "This type of traction minimizes damage as a result of fracture treatment.

"Skeletal traction will assist in realigning your fractured bone."

A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, "The stool in my pouch is still liquid." How would the nurse respond?a. "The stool will always be liquid with this type of colostomy."b. "Eating additional fber will bulk up your stool and decrease diarrhea." c. "Your stool will become frmer over the next couple of weeks."d. "This is abnormal. I will contact your primary health care provider."

"The stool will always be liquid with this type of colostomy."

The nurse is supervising the staff caring for four clients receiving blood transfusions. Which of the four clients should the nurse see FIRST? - A client vomiting

- A client vomiting

A client comes to the health clinic and tells the nurse that he has been taking acetaminophen (Aspirin-Free excedrin) daily for 5 months. The nurse would be MOST concerned by which of the following lab results? - AST (SGOT) 30 U/L, ALT (SGPT) 27 U/L

- AST (SGOT) 30 U/L, ALT (SGPT) 27 U/L

. The nurse is caring for a client who has just returned to his room after a scleral buckling procedure to repair a detached retina was completed. Which of the following is the MOST important nursing action? - Ask the client if he is nauseous

- Ask the client if he is nauseous

After abdominal surgery a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate? - Aspirate the gastric contents with a syringe

- Aspirate the gastric contents with a syringe

A client on chemotherapy has a WBA count of 1.200/mm3. Which of the following nursing actions should the nurse take FIRST? - Check temperature q4h

- Check temperature q4h

. The nurse is caring for a client in the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil? - Contact the physician

- Contact the physician

The client is admitted with cerebrovascular accident (CVA) and has facial paralysis. Nursing care should be planned to prevent which of the following complications? - Corneal abrasion

- Corneal abrasion

A client received six units of regular insulin three hours ago. The nurse would be MOST concerned if which of the following was observed? - Diaphoresis and trembling

- Diaphoresis and trembling

A 54-year-old client with tertiary syphilis is admitted to a nursing unit. He is exhibiting signs of marked dementia and disorientation. Which of these actions should the nurse do INITIALLY? - Frequently observe the client's behavior

- Frequently observe the client's behavior

The nurse is caring for clients in the student health center. A client confides to the nurse that the client's boyfriend informed her that he tested positive for hepatitis B. Which of the following responses by the nurse is BEST? - Have you had unprotected sex with your boyfriend?

- Have you had unprotected sex with your boyfriend?

A patient is admitted to the surgical unit with a diagnosis of rule out intestinal obstruction. The nurse is preparing to insert a Salem sump NG tube as ordered. In which of the following positions would it be BEST for the nurse to place this patient during the procedure?

- Head of bed elevated 60-90

. An order has been received to obtain a stool specimen and test for occult blood. The nurse would be MOST concerned if the client made which of the following statements? - I take Feosol every day

- I take Feosol every day

A 48-year-old man with an endotracheal tube needs suctioning. Which of the following statements is an accurate description of how the nurse should perform the procedure? - Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn

- Insert the suction catheter until resistance is met, then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn

The nurse is caring for a patient with a head injury. Appropriate nursing interventions for minimizing the risk of increasing intracranial pressure include. - Keeping the patient's head from flexing or rotating, elevating the head of the bed 30, and avoiding frequent suctioning for more than 15 seconds

- Keeping the patient's head from flexing or rotating, elevating the head of the bed 30, and avoiding frequent suctioning for more than 15 seconds

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body? - Maintain aseptic technique during procedures

- Maintain aseptic technique during procedures

The nurse is caring for an 80- year-old client with Parkinson's disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? - Maintain optimal function within the client's limitations

- Maintain optimal function within the client's limitations

A client who had an appendectomy 4 days ago complains of severe abdominal pain. During the initial assessment he states, "I have had two amost-black stools today" which of the following nursing actions is MOST important? - Notify the physician.

- Notify the physician.

A client is admitted to the outpatient unit in the Cancer Center for chemotherapy. The client is lethargic, weak, and pale. During chemotherapy, which of the following nursing intervention would be MOST important? - Perform hand washing prior to care

- Perform hand washing prior to care

A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential? - Potassium chloride for IV administration

- Potassium chloride for IV administration

A client has a history of oliguria, hypertension, and peripheral edema. Current lab values are: BUN -25, K+ - 4.0mEq/L. Which nutrient should be restricted in the client's diet? - Protein

- Protein

. The clinic nurse is performing diet teaching with a 67- year-old client with acute gout. The nurse should teach the client to limit his intake of - Red meat and shellfish

- Red meat and shellfish

The nurse plans to care for a 36- years-old woman with Grave's disease. The nurse knows which of the following foods or fluids should be restricted for this client? - Tea

- Tea

An 80 year-old client is admitted with a possible fractured right hip. During the initial nursing assessment, which of the following observations if the right leg would validate or support this diagnosis? - The leg appears to be shortened and is abducted and externally rotated

- The leg appears to be shortened and is abducted and externally rotated

37. The nurse is caring for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked" the nurse should assess which of the following cranial nerves? - VII

- VII

The nurse teaches assistive personnel (AP) about care of an older adult diagnosed with osteoporosis. What teaching would the nurse include?a. "Teach the client to eat high-calcium foods in the diet."b. "Assist the client with activities of daily living." c. "Osteoporosis places the client at risk for fractures." d. "The client should stay in bed to prevent falling."

. "Osteoporosis places the client at risk for fractures."

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision, but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma

. Macular degeneration.

. The nurse assesses a patient who is recovering from an ileostomy placement. Which assessment finding would alert the nurse to immediately contact the primary health care provider?a. Pale and bluish stoma b. Liquid stoolc. Ostomy pouch intact d. Blood-tinged output

. Pale and bluish stoma

28. The ___________ is the surgical technique that uses ultrasonic impulses to pulverize the lens and irrigate and aspirate cataract particles.a. A-scanb. phacoemulsification c. Schiötz tonometerd. direct ophthalmoscope

. phacoemulsification

7. A nurse assesses a client with a brain tumor. The client opens his eyes when the nurse calls his name, mumbles in response to questions, and follows simple commands. How would the nurse document this client's assessment using the Glasgow Coma Scale shown? a. 8 b. 10 c. 12 d. 14

12

The client has an order for IV fluid of D5 0.45% normal saline 1,000 cc to run from 9 am to 9 pm. The drip factor on the delivery tubing is 15 gtts/min. The nurse should adjust the IV to infuse at - 25 gtts/min

25 gtts/min

The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see FIRST? - A 19-year-old with a fever of 103.8F (39.8C) who is able to identify her sister but not the place and time

A 19-year-old with a fever of 103.8F (39.8C) who is able to identify her sister but not the place and time

The nurse is caring for clients in the medical/surgical unit. The nurse identifies which of the following clients would be MOST at risk for developing herpes zoster

A 62-year-old heart transplant with suspected rejection

The nurse is caring for clients in the skilled nursing facility. Which of the following clients require the client's the nurse's IMMEDIATE attention? - A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago

A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin (Coumadin) expired two days ago

12. A nurse is caring for four clients with leukemia. After the hand-off report, which client would the nurse assess first? a. Client who had two bloody diarrhea stools this morning. b. Client who has been premedicated for nausea prior to chemotherapy. c. Client with a respiratory rate change from 18 to 22 breaths/min. d. Client with an unchanged lesion to the lower right lateral malleolus

A client who had two bloody diarrhea stools this morning

The nursing team includes two RNs, one LPN/LVN, and one nursing assistant. The nurse should consider the assignment appropriately if the nursing assistant is assigned to care for - A client with Alzheimer's requiring assistance with feeding

A client with Alzheimer's requiring assistance with feeding

The nurse is caring for a client in the Emergency Department of an acute care facility. Four clients have been admitted in the last 10 minutes. Which of the following admissions should the nurse see FIRST? - A client with third-degree burn to the face

A client with third-degree burn to the face

The nurse has just received a report from the previous shift. Which of the following patients should the nurse see FIRST? - A patient who is one-day postoperative and has an epidural

A patient who is one-day postoperative and has an epidural

A client is given morphine 6 mg IV push for postoperative pain. Following administration of this drug, the nurse observes the following: pulse 68, respiration 8, BP 100/68, client sleeping quietly. Which of the following nursing actions is MOST appropriate? - Administer naloxone (Narcan)

Administer naloxone (Narcan)

The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development?a. Heart diseaseb. Glaucoma c. Diabetes mellitus d. Advanced age

Advanced age

A client had a thoracotomy 3 hours ago. For the past 2 h there has been 100 cc per hour of bloody chest drainage/ which of the following actions should the nurse take FIRST? - Advise the physician of the amount of drainage

Advise the physician of the amount of drainage

After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA) there is a decrease in muscle tone. Which of the following nursing diagnoses would be a priority to include in his care plan? - Alteration in skin integrity related to decrease in tissue oxygenation

Alteration in skin integrity related to decrease in tissue oxygenation

A client in cardiogenic shock after a myocardial infarction (MI). Which of the following is a correctly stated nursing diagnosis for this client? - Altered tissue perfusion related to decreased heart pumping action

Altered tissue perfusion related to decreased heart pumping action

A permanent demand pacemaker, set at a rate of 72, is implanted in a client for persistent third-degree block. The nurse would be MOST concerned if which of the following was observed? - Apical pulse rate regular at 68

Apical pulse rate regular at 68

The nurse is caring for a client who has just returned to the postsurgical unit following abdominal surgery for cancer of the colon. It is MOST appropriate for the nurse to take which of the following actions? - Ask the client to lift his dead off the pillow

Ask the client to lift his dead off the pillow

The nurse enters the room and discovers that the client has slurred speech, right-side paralysis, and unequal pupils. Which of the following actions should the nurse take FIRST? - Assess the respiratory status

Assess the respiratory status

A client is begin discharge with sublingual nitroglycerin (Nitrostat) the client should be cautioned by the nurse to - Avoid abrupt changes in posture

Avoid abrupt changes in posture

A client with a peptic ulcer had a partial gastrectomy and vagotomy (BiltrochI) in planning the discharge teaching, the client should be cautioned by the nurse about which of the following? - Avoid eating large meals that are high in simple sugars and liquids

Avoid eating large meals that are high in simple sugars and liquids

The nurse is caring for a client recovering from lower bowel surgery. The nurse determines that teaching has been successful if the client selects which of the following menus? - Baked chicken, buttered rice, plain gelatin

Baked chicken, buttered rice, plain gelatin

A client who has clear lung sounds and unlabored breathing is receiving aminophylline IV. Which of the following would be the MOST appropriate nursing actions if the client's IV infiltrates? - Call the physician and recommend that the IV medications be changed to PO

Call the physician and recommend that the IV medications be changed to PO

The nurse is caring for a client in alcohol withdrawal. The nurse would expect the doctor to order which of the following oral medications to assist the client in decreasing the severity of the symptoms? - Chlordiazepoxide (Librium)

Chlordiazepoxide (Librium)

The nurse is aware of the most recent American Cancer Society Screening Guidelines for colon cancer, which include which accepted testing modalities for people over the age of 50? (Select all that apply.)a. Colonoscopy every 10 years b. Endoscopy every 5 years c. Computed tomography (CT) colonography every 5 years d. Double-contrast barium enema every 10 years e. Flexible sigmoidoscopy every 5 years

Colonoscopy every 10 years Computed tomography (CT) colonography every 5 years Flexible sigmoidoscopy every 5 years

A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse. The physician orders include: 1200- calories- ADA diet, 15 units of NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the client at 5 PM, the nurse observes the man performing a blood sugar analysis. The result would is 50 mg/dl. The nurse would expect the client to be - Confused with cold, clammy skin and pulse of 110

Confused with cold, clammy skin and pulse of 110

The nurse is monitoring the fluid status of a 63- year-old woman receiving IV fluid following surgery. Which of the following symptoms would suggest to the nurse that the patient has fluid volume overload?

Cool skin, respiratory crackles, pulse 86 and bounding

. A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client?a. b. Fluorescein angiography c. Ophthalmoscopy d. Tonometry

Corneal staining

4. The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? a. Expressive aphasia b. Ptosis (eyelid drooping) c. Slurred speech d. Severe facial pain

D.severe facial pain

6. A nurse assesses a client and notes the client's position as indicated in the illustration below: How would the nurse document this finding? a. Decorticate posturing b. Decerebrate posturing c. Atypical hyperreFLexia d. Spinal cord degeneration

Decoration posturing

25. The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.)a. Decreased eye muscle toneb. Development of arcus senilis c. Increase in far point of near vision d. Decrease in general color perception e. Increase in point of near vision

Decreased eye muscle toneb. Development of arcus senilis d. Decrease in general color perception e. Increase in point of near vision

19. The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client?a. Projectile vomitingb. Dilated and nonreactive pupils c. Severe hypertension d. Decreased level of consciousness

Decreased level of consciousness

A 23-year-old man is admitted with a subdural hematoma and cerebral edema after a motorcycle accident. Which of the following symptoms should the nurse expect to see INITIALLY? - Decreased level of consciousness

Decreased level of consciousness

A client is being treated for thrombophlebitis with heparin sodium infusion at 800 U/h. the nurse would be MOST concerned if which of the following was observed? - Decreased level of consciousness

Decreased level of consciousness

. The nurse is admitting a client with possible Haemophilus influenzae- meningitis. It is MOST important for the nurse to take which of the following actions? - Dim the lights in the room and minimize environmental stimuli

Dim the lights in the room and minimize environmental stimuli

The nurse is obtaining a health history on a client in the medical clinic. The client states "I think I have an ulcer" which of the following responses by the nurse is BEST? - Do you have a burning pain in the epigastric region

Do you have a burning pain in the epigastric region

. A 32 year old man comes to the clinic for a glycosylated hemoglobin assay (HbA1c). The result is 6%. The nurse should - Document the finding in the chart

Document the finding in the chart

The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6L/min. Results show: pH 7.37, HCO3 26 mEq/L, pCO2 42mmHg, pO2 90 mmHg. The nurse should - Document the results in the chart

Document the results in the chart

A 34-year-old man is seen in the physician's office for follow-up after treatment for renal calculi. The nurse discusses methods to prevent a recurrence of the problem. Which of the following instructions by the nurse is MOST beneficial? - Drink at least 3,000 ml of fluid a day

Drink at least 3,000 ml of fluid a day

The physician prescribes sulfisoxazole (Ganstrisin) 2 g PO qid for a client. Which of the following instructions is MOST important for the nurse to include when teaching the client about this medication?

Drink plenty of fluids

. When assisting with a bone marrow aspiration, the nurse should - Drop additional sterile supplies onto a sterile tray

Drop additional sterile supplies onto a sterile tray

The nurse reviews the laboratory results for a client who has possible appendicitis. Which laboratory test finding would the nurse expect?a. Decreased potassium levelb. Increased sodium level c. Elevated leukocyte count d. Decreased thrombocyte count

Elevated leukocyte count

A client had a mitral valve replacement three days ago. It is MOST important for the nurse to take which of the following actions? - Encourage early activity to promote ventilation and improve quality of circulation

Encourage early activity to promote ventilation and improve quality of circulation

The nurse prepares a 67-year-old man for an intravenous pyelogram (IPV). the client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on the knowledge that the primary purpose of an IVP is to. - Examine the urinary tract by x-ray

Examine the urinary tract by x-ray

For a client with a neurological disorder, which of the following nursing assessment will be MOST helpful in determining subtle changes in the client's level of consciousness? - Glasgow coma scale

Glasgow coma scale

An older woman comes to the outpatient clinic because she has not been feeling well for several days. During the admission interview, the nurse learns that the client has a history of congestive heart failure (CHF) , is on a low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg PO daily for 6 months. Diagnostic tests indicate sodium 127 mEq/L potassium 3.8 mEq/L glucose 110 mg/dl, and normal chest x-ray. The signs and symptoms the nurse would expect the client to exhibit include - Headache, apprehension, and lethargy

Headache, apprehension, and lethargy

A client is taking timolol eye drops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority?a. Ask the client about excessive salivation.b. Take the client's blood pressure and temperature. c. Give the drops using punctal occlusion. d. Hold the eyedrops and notify the primary health care provider.

Hold the eyedrops and notify the primary health care provider.

. A woman has been recently diagnosed with systemic lupus and shared with the nurse, "I am thinking about getting pregnant but I don't know how I will be able to tolerate a pregnancy since I have lupus" Which of the following responses by the nurse is BEST? - How long have you been in remission?

How long have you been in remission?

The nurse is performing dietary teaching for a client with asymptomatic diverticular disease. The nurse knows that further teaching is required if the client makes which of the following statements? - I'm glad that I can eat the tomatoes from my garden

I'm glad that I can eat the tomatoes from my garden

Which of the following statements by an adult client indicates to the nurse a need for further teaching regarding care of a sigmoid colostomy? - I'm irrigating my colostomy after each meal

I'm irrigating my colostomy after each meal

A 32-year-old male with acute lymphocytic leukemia is admitted with shortness of breath, anemiaandtachycardia.TheMOST appropriatelystatednursingdiagnosiswouldbe - Impaired gas exchange related to decreased RBCs

Impaired gas exchange related to decreased RBCs

. When using palpation techniques during the physical assessment of an adult female with abdominal pain, which of the following actions should the nurse take FIRST? - Inform the client to breathe slowly

Inform the client to breathe slowly

The nurse counsels a 70 year-old woman who comes to the outpatient clinic for a routine examination. The history indicates the client takes a laxative tablet twice a day. The nurse should suspect the client. - Is experiencing excessive concern with body function due to physical changes

Is experiencing excessive concern with body function due to physical changes

The nurse is preparing to insert a Foley catheter into a patient. It would be MOST important for the nurse to take which of the following actions? - Keep the field holding the supplies in front of the nurse

Keep the field holding the supplies in front of the nurse

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should:a. Examine the retina to determine the number of Voaters.b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal fndings, and refer him to an ophthalmologist. d. Know that Voaters are usually insignifcant and are caused by condensed vitreous fbers

Know that Voaters are usually insignifcant and are caused by condensed vitreous fbers

. The nurse is caring for a client immediately after an abdominal aortic aneurysm repair. Vital signs are: blood pressure 100/70, pulse 120, respiration 24, urine output 75 cc during the past 3 h. Which of the following would be a priority nursing action(s) for this client? - Maintain bedrest and evaluate for a decrease in CVP reading

Maintain bedrest and evaluate for a decrease in CVP reading

. A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma. Although the client complains of a severe headache, he is alert and answers questions appropriately. The nurse would question which of the following orders?

Morphine sulfate 10 mg IM q3-4h

A client awakens during the night with dyspnea, severe anxiety, jugular vein distention (JVD), and frothy pink sputum. After the nurse begins oxygen at 4 L per nasal cannula, which of the following actions is MOST appropriate? - Notify the physician about the change in the client's conditions

Notify the physician about the change in the client's conditions

The nurse notes that the right foot is pale and cool to the touch, and the client continues to complain of pain even though an analgesics was administered 45 minutes ago. What is the FIRST action the nurse should take? - Notify the physician immediately

Notify the physician immediately

. A nurse cares for a client with a recently fractured tibia. Which assessment would alert the nurse to take immediate action?a. Pain of 4 on a scale of 0-10b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

Numbness in the extremity

10. A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringer's solution

O.45% normal saline

One hour after receiving 7U of regular insulin, the client presents with diaphoresis, pallor and tachycardia. The priority nursing action would be to - Offer the client milk and crackers

Offer the client milk and crackers

9. The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect? a. Infection b. Pallor c. Pain d. Fatigue

Pain

. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply.a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Excavation of the optic nerve e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.f. IOP (Intraocular pressure) of 28 mmHg 36. A nurse is teaching a client about ear hyg

Patient experiences tunnel vision in the late stages. Excavation of the optic nerve IOP (Intraocular pressure) of 28 mmHg

If a client develops cor pulmonale (right side heart failure) the nurse expects to observe - Peripheral edema and anorexia

Peripheral edema and anorexia

A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period? - Position the client on the right side the head slightly elevated

Position the client on the right side the head slightly elevated

A postoperative cataract client is cautioned about not making sudden movements or bending over. The nurse understands that the rationale for this recommendation is to prevent which of the following? - Pressure on the ocular suture line

Pressure on the ocular suture line

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority? - Provide adequate hydration.

Provide adequate hydration.

3. The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? a. Pupil constriction b. Deep tendon reflexes c. Upper muscle strength d. Speech and language

Pupil construction

The nurse is caring for a client with probable colorectal cancer (CRC). What assessment findings would the nurse expect? (Select all that apply.)a. Weight gainb. Rectal bleeding c. Anemiad. Change in stool shape e. Electrolyte imbalances f. Abdominal discomfort

Rectal bleeding c. Anemiad. Change in stool shape f. Abdominal discomfort

The nurse is performing health screening at a shelter for the homeless. Which of the following nursing observations would most likely indicate the need for teaching about personal hygiene? - Red, swollen gums

Red, swollen gums

A client has received IV antibiotics every eight hours for four days. It is mixed in 100 cc D5W. Which of the following would cause the nurse to be concerned about IV antibiotics every eight hours? - Reddened area or red streaks at the site

Reddened area or red streaks at the site

. The nurse finds a client unresponsive and making funny sounds. His arms and legs are stiff and jerking and there is no verbal response. Which of the following actions should the nurse take FIRST? - Remain with the client and prevent him from injuring himself or falling out of bed

Remain with the client and prevent him from injuring himself or falling out of bed

The nurse is caring for a post cholecystectomy client who had the T-Tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. Is it MOST appropriate for the nurse to take which of the following actions? - Remove the dressing and replace it with a more absorbent dressing

Remove the dressing and replace it with a more absorbent dressing

The client has been receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, would indicate an allergic reaction? - Respiratory wheezing

Respiratory wheezing

A client is scheduled for a left lower lobectomy. The physician has ordered diazepam (valium) 2 mg IM for anxiety. The nurse would determine that the medication is appropriate if the client displays which of the following symptoms? - Restlessness and increased heart rate

Restlessness and increased heart rate

Which information should the nurse recognize as being the MOST pertinent to the diagnosis of cholecystitis? - Right upper abdominal pain

Right upper abdominal pain

. The nurse assesses a client who has appendicitis. Which assessment finding would the nurse expect?a. Severe, steady right lower quadrant painb. Abdominal pain associated with nausea and vomiting c. Marked peristalsis and hyperactive bowel sounds d. Abdominal pain that increases with knee Vexion

Severe, steady right lower quadrant pain

When assessing the pupillary light reflex, the nurse should use which technique?a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction.b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction.c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose

Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.

The nurse is performing discharge teaching for a client with Addison's disease. It is MOST important for the nurse to instruct the client about. - Steroid replacement

Steroid replacement

. During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is:a. Decreased in the older adult.b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI.

Stimulated by CNs III, IV, and VI.

The nurse is caring for a patient following an appendectomy. The patient takes a deep breath, coughs, and then winces in pain. Which of the following statements, if made by the nurse to the patient, is BEST? - Take three deep breaths, hold your incision, and then cough

Take three deep breaths, hold your incision, and then cough

A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? a. Educate the client on corneal transplantation. b. Facilitate scheduling the eye surgery. c. Teach about drugs for glaucoma. d. Refer the patient to local Braille classes

Teach about drugs for glaucoma.

The nurse in the outpatient clinic teaches a client with a sprained right ankle to walk with a cane. What behavior, if demonstrated by the client, would indicate that teaching was effective? - The client holds the cane in her left hand

The client holds the cane in her left hand

A 69-year-old client is undergoing his second exchange of intermittent peritoneal dialysis (IPD) . Which of the following would require an intervention by the nurse? - The dialysate outflow is cloudy

The dialysate outflow is cloudy

The nurse is caring for a patient with a pneumothorax resulting from an auto accident three days ago. He has a chest tube connected to a three- chamber water-seal drainage system (Plaur-evac) with 20 cm suction. How would the nurse know if the lung has re-expanded? - The fluid in the water-seal chamber does not fluctuate with respirations

The fluid in the water-seal chamber does not fluctuate with respirations

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true?a. The right side of the brain interprets the vision for the right eye.b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

The image formed on the retina is upside down and reversed from its actual appearance in the outside world.

The parents of child with hemophilia want to know the cause of the disease. Which of the following would be the BEST response by the nurse? - The mother transmits the gene to her son

The mother transmits the gene to her son

15. The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique? - The nurse packs wet gauze into the incision without overlapping it into the skin

The nurse packs wet gauze into the incision without overlapping it into the skin

A 48 year-old woman is seen in the outpatient clinic for complaints of irregular menses. The client's history indicates an onset of menses at age 14, para 2 gravida and regular periods every 28 to 30 days/ the client is divorced and works full time as a bank teller. The nurse knows the MOST probable cause of the client's symptoms is - The onset of menopause

The onset of menopause

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:a. At 30 feet the patient can read the entire chart.b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye.d. The patient can read from 30 feet what a person with normal vision can read from 20 feet

The patient can read at 20 feet what a person with normal vision can read at 30 feet.

The nurse assesses the daily lab reports for a patient with a long history of cirrhosis with acute hepatic encephalopathy. Which of the following findings would indicate to the nurse that the patient is improving. - The patient's ammonia level decreased from 160 to 120 mg/dL

The patient's ammonia level decreased from 160 to 120 mg/dL

A 75-year-old woman undergoes a colonoscopy. During the post procedure period, it is MOST important for the nurse to monitor - The patient's fluid and electrolyte balance

The patient's fluid and electrolyte balance

A client returns from surgery after having a cholecystectomy and there is an order for atiembolism stocking. Which of the following would be appropriate teaching regarding wearing the support stocking? - The stockings should be worn the entire time the client is in the hospital.

The stockings should be worn the entire time the client is in the hospital.

A 36-year-old woman is being treated for rheumatoid arthritis. Which of the following findings should assume the HIGHEST priority for the nurse when planning her care? - The woman has a slight contracture of her right wrist

The woman has a slight contracture of her right wrist

A 55 year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to - Turn the patient every 2 hours

Turn the patient every 2 hours

The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor?a. Large bowel obstructionb. Dyspepsia c. Upper gastrointestinal (GI) bleeding d. Gastric cancer

Upper gastrointestinal (GI) bleeding

The nurse is performing teaching on a client with Bell's palsy. It is MOST important for the nurse to include which of the following instructions? - Use artificial tears 4 times per day

Use artificial tears 4 times per day

A 62-year-old man with peripheral vascular disease (PVD) states that he experiences leg pain frequently when walking and asks the nurse in the clinic what he should do. The nurse should advise him to - Walk until he experiences pain, then rest, and then resume walking

Walk until he experiences pain, then rest, and then resume walking

A 20-year-old woman comes to the outpatient clinic for complaints of vaginal itching. Which of the following recommendations, if given to the client by the nurse is MOST appropriate? - Wear underwear that is lined with a cotton crotch

Wear underwear that is lined with a cotton crotch

After a client has a positive Chlamydia trachomatis culture, she and her husband return for counseling. It would be MOST important for the nurse to ask which of the following questions? - What is your understanding regarding how chlamydia is transmitted?

What is your understanding regarding how chlamydia is transmitted?

The nurse is caring for a young adult admitted to the hospital with a severe head injury. The nurse should position the patient - With his neck in a midline position and the head of the bed elevated 30

With his neck in a midline position and the head of the bed elevated 30

15. The nurse observes a client with late-stage Alzheimer disease eat breakfast. Afterward the client states, "I am hungry and want breakfast." What is the nurse's best response?a. "I see you are still hungry. I will get you some toast."b. "You ate your breakfast 30 minutes ago." c. "It appears you are confused this morning."d. "Your family will be here soon. Let's get you dressed."

a. "I see you are still hungry. I will get you some toast."

5. Which statement would the nurse include when teaching the assistive personnel (AP) about how to care for a client with cranial nerve II impairment? a. "Tell the client where food items are on the breakfast tray." b. "Place the client in a high-Fowler position for all meals." c. "Make sure the client's food is visually appetizing." d. "Assist the client by placing the fork in the left hand.

a. "Tell the client where food items are on the breakfast tray.

. The nurse recalls that the risk factors for acute gastritis include which of the following? (Select all that apply.a. Alcoholb. Caffeine c. Corticosteroids d. Fruit juice e. Nonsteroidal anti-inVammatory drugs (NSAIDs)

a. Alcoholb. Caffeine c. Corticosteroids e. Nonsteroidal anti-inVammatory drugs (NSAIDs)

A client is admitted with a diagnosis of cerebellar stroke. What intervention is most appropriate to include on the client's plan of care?a. Ambulate only with a gait belt.b. Encourage double swallowing. c. Monitor lung sounds after eating. d. Perform post void residuals

a. Ambulate only with a gait belt.

13. Which risk factor(s) places a client at risk for leukemia? (Select all that apply.) a. Chemical exposure b. Genetically modifed foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

a. Chemical exposure c. Ionizing radiation exposure e. Viral infections

8. A nurse assesses a client with a brain tumor. Which newly identified assessment findings would alert the nurse to urgently communicate with the primary health care provider? (Select all that apply.) a. Glasgow Coma Scale score of 8 b. Decerebrate posturing c. Reactive pupils d. Uninhibited speech e. Decreasing level of consciousness

a. Glasgow Coma Scale score of 8 b. Decerebrate posturing e. Decreasing level of consciousness

The nurse is assessing a client with long-term rheumatoid arthritis (RA) who has been taking prednisone for 10 years. For which complications of chronic drug therapy would the nurse assess? (Select all that apply.)a. Osteoporosis b. Diabetes mellitus c. Glaucomad. Hypertensione. Hypokalemia f. Decreased immunity

a. Osteoporosis b. Diabetes mellitus c. Glaucomad. Hypertensione. Hypokalemia f. Decreased immunity

14. Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.)a. Tachycardiab. Fever c. Bronchospasm d. Tachypneae. Urticariaf. Hypotension

a. Tachycardiab. Fever c. Bronchospasm d. Tachypneae. Urticariaf. Hypotension

The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk?a. Excess cerumenb. Swimming c. Sinus congestion d. Meniere disease

b. Swimming

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. After Raising the head of the bed, what action would the nurse take next? a. Initiate oxygen via a nasal cannula. b. Recheck the client's blood pressure. c. Palpate the bladder for distention.d. Administer a prescribed beta blocker.

c. Palpate the bladder for distention

1. The nurse assesses a client's recent memory. Which statement by the client confirms that recent memory is intact? a. "A young girl wrapped in a shroud fell asleep on a bed of clouds." b. "I was born on April 3, 1967, in Johnstown Community Hospital." c. "Apple, chair, and pencil are the words you just stated." d. "I ate oatmeal with wheat toast and orange juice for breakfast

d. "I ate oatmeal with wheat toast and orange juice for breakfast

11. Assistive personnel are caring for a client with leukemia and ask why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct? a. "If the WBCs are high, there already is an infection present." b. "The client is in a blast crisis and has too many WBCs." c. "There must be a mistake; the WBCs should be very low." d. "Those WBCs are abnormal and don't provide protection.

d. "Those WBCs are abnormal and don't provide protection

2. A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary healthcare provider? a. Mild temporal headache b. Pupils equal and react to light c. Alert and oriented 3 d. Decreasing level of consciousness

d. Decreasing level of consciousness

16. The nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How would the nurse document this type of seizure?a. Atonicb. Myoclonicc. Absenced. Tonic-clonicd.

d. Tonic-clonic

Which of the following forms of focus-related disorders is caused by an inelasticity of the lens?a. myopiab. astigmatism c. cataracts d. presbyopia

d. presbyopia

The nurse in the outpatient clinic plans to care for a 65-year-old woman with left-sided weakness due to a cerebral vascular accident (CVA). The client has a history of hypertension and osteoporosis. It is MOST important for the nurse to encourage the client to - Increase her activities that involve weight- bearing.

increase her activities that involve weight- bearing.

Exactly in the center of the posterior part of the retina, corresponding to the axis of the eye and at a point where the sense of vision is the most accurate is an oval yellowish spot called the __________.a. retina b. macula c. optic nerve d. choroid

macula

. A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate being prescribed for this client?a. Phenytoinb. Lorazepam c. Mannitol d. Morphine

mannitol