NUR 313 HESI Practice Questions

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct. Monitoring vital signs Cutting off the clothing Inserting a urinary catheter Removing the client's jewelry Establishing an intravenous line

Monitoring vital signs Cutting off the clothing Inserting a urinary catheter Removing the client's jewelry Establishing an intravenous line

Which client statement indicates that the discharge teaching after a cataract extraction and an intraocular lens implant is effective? "I should call the clinic if my eye begins to hurt." "I am so glad that I can take a shower today." "There will be bright flashes of light for a few days." "My vision should show some improvement by tomorrow."

"I should call the clinic if my eye begins to hurt."

Which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%? Select all that apply. One, some, or all responses may be correct. Level of orientation Arterial blood gases Bilateral lung sounds Complete blood count Pulmonary function test

Arterial blood gases

The client who sustained a burn asks, "What is the difference between my full-thickness and deep partial-thickness burns?" Which information will the nurse share with the client?

Full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis.

Which clinical findings would the nurse expect when assessing a client with chronic kidney failure? Select all that apply. One, some, or all responses may be correct. Polyuria Lethargy Hypotension Muscle twitching Respiratory acidosis

Lethargy Muscle twitching

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. Mold Cold air Pet dander Air pollution Cigarette smoke

Mold Cold air Pet dander Air pollution Cigarette smoke

A client is diagnosed with celiac disease. Which foods would the nurse teach the client to avoid? Select all that apply. One, some, or all responses may be correct. Corn Cheese Oatmeal Rye bread Fruit juice

Oatmeal Rye bread

While caring for a client in traction, which actions could the nurse delegate to a licensed practical nurse (LPN)? Select all that apply. One, some, or all responses may be correct. Padding traction connections Determining correct body alignment Assessing complications associated with immobility Teaching the client about range-of-motion (ROM) exercises Assisting the client with passive and active range-of-motion (ROM) exercises

Padding traction connections Assisting the client with passive and active range-of-motion (ROM) exercises

Which would the nurse do first if an allergic reaction to a blood transfusion occurs? Shut off the infusion. Slow the rate of flow. Administer an antihistamine. Call the health care provider (HCP).

Shut off the infusion.

Which suggestion would the nurse make to a client with rheumatoid arthritis who asks about ways to decrease morning stiffness? Wear loose but warm clothing. Plan a short rest break periodically. Avoid excessive physical stress and fatigue. Take a hot bath or shower in the morning.

Take a hot bath or shower in the morning.

Which clinical manifestations are associated with tuberculosis? Select all that apply. One, some, or all responses may be correct. Fatigue Nausea Weight gain Low-grade fever Increased appetite

Fatigue Nausea Low-grade fever

Which findings for a client who has a cast applied to the lower extremity indicate a complication? Select all that apply. One, some, or all responses may be correct. Warmth Numbness Skin desquamation Generalized discomfort Prolonged capillary refill

Numbness Prolonged capillary refill

Which intervention would the nurse include in the plan of care for a client with Addison disease? Encourage exercise Protect from exertion Restrict fluid intake Monitor for hypokalemia

Protect from exertion

Which parameter monitoring would be the nurse's priority while caring for a client with hypothyroidism? Pulse rate Blood pressure Respiratory rate Body temperature

Respiratory rate

Which information would the nurse include in the discharge teaching plan for a client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis and hemianopsia? Necessity for bed rest at home Use of oxygen (O2) therapy at home Significance of a safe environment Need for decreased protein in the diet

Significance of a safe environment

Which action would the nurse implement when providing care for a client with acquired immunodeficiency syndrome (AIDS)? Use standard precautions. Employ airborne precautions. Plan interventions to limit direct contact. Discourage long visits from family members.

Use standard precautions.

Which statement indicates a client understands transmission of the human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. "I can contract HIV by participating in oral sex." "I can contract HIV by eating from used utensils." "HIV is contracted by using contaminated needles." "I can contract HIV by using the bathroom of a person who is HIV positive." "Babies can contract HIV because of contact with maternal blood during birth."

"I can contract HIV by participating in oral sex." "HIV is contracted by using contaminated needles." "Babies can contract HIV because of contact with maternal blood during birth."

A client who is in skin traction while awaiting surgery for repair of a fractured femur asks the nurse to release the traction because of leg pain. Which response would the nurse make? "I can't do that because the weights are needed to keep the bone aligned." "I will remove half of the weights and notify your primary health care provider." "I'll get your prescribed pain medication increased to help relieve your discomfort." "I follow the primary health care provider's directions, and that is not prescribed."

"I can't do that because the weights are needed to keep the bone aligned."

Which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma? Chest x-ray Pulmonary function tests Serum eosinophil counts Immunoglobulin E levels

Pulmonary function tests

In which order would the nurse complete these steps when administering a blood transfusion?

1.) Check primary health care provider's prescription. 2.) Obtain vital signs and history of transfusions. 3.) Ascertain that intravenous catheter size is 18 or 20 gauge. 4.) Change main line solution to normal saline. 5.) Check client identification before hanging unit of blood.

Arrange the steps of applying negative pressure wound therapy in order of implementation.

1.) Clean the wound. 2.) Cut the foam dressing to the dimensions of the wound. 3.) Apply a large occlusive dressing. 4.) Make a small hole in the occlusive dressing over the foam dressing near the tubing attachment 5.) Connect the tubing to a pump.

According to priority, in which order would the nurse perform care activities for a client with complete partial seizures?

1.) Maintaining airway 2.) Recording the time and duration of seizure 3.)Assessing vital signs 4.) Performing neurological checks Incorrect

Which diagnostic test is most important to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome (ACS)? Chest radiograph Troponin T (cTnT) Creatine kinase MB (CK-MB) 12-lead electrocardiogram (ECG)

12-lead electrocardiogram (ECG)

Which finding would be expected in a client with a history of hypothyroidism? Select all that apply. One, some, or all responses may be correct. Cold intolerance Lethargy and fatigue Hemoglobin 11.2 g/dL 15-pound weight gain Heart rate 59 beats/min

Cold intolerance Lethargy and fatigue Hemoglobin 11.2 g/dL 15-pound weight gain Heart rate 59 beats/min

Which parameter would the nurse assess in a client with right-sided heart failure? Select all that apply. One, some, or all responses may be correct. Fluid volume Lung sounds Mental status Respiratory rate Peripheral pulses

Fluid volume

Which goal would the nurse establish when providing care for a client recovering from a transurethral resection of the prostate (TURP)? Maintain patency of the cystostomy tube. Prevent wound hemorrhage and infection. Maintain patency of the indwelling catheter. Prevent the abdominal dressing from draining.

Maintain patency of the indwelling catheter.

Which explanation would the nurse provide a client who asks what a cataract is? An opacity of the lens A thin film over the cornea A crystallization of the pupil An increase in the density of the conjunctiva

An opacity of the lens

Which clinical manifestations are associated with a diagnosis of tuberculosis? Select all that apply. One, some, or all responses may be correct. Diarrhea Anorexia Weight gain Hemoptysis Night sweats

Anorexia Hemoptysis Night sweats

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition? Cyanosis Bradycardia Mental confusion Distended neck veins

Mental confusion

Which findings would support a client's diagnosis of Parkinson disease? Select all that apply. One, some, or all responses may be correct. Nonintentional tremors Frequent bouts of diarrhea Masklike facial expression Hyperextension of the neck Rigidity to passive movement

Nonintentional tremors Masklike facial expression Rigidity to passive movement

When would the client have a tuberculin skin test with purified protein derivative (PPD) read? 1 week Within 12 hours 24 to 48 hours 48 to 72 hours

48 to 72 hours

Which neurological manifestation is associated with hyperthyroidism? Confusion Hearing loss Tremors Slowness of speech

Tremors

Which signs and symptoms will a client admitted to the hospital with a diagnosis of Cushing syndrome exhibit? Hyperkalemia and edema Hypotension and sodium loss Muscle wasting and hypoglycemia Muscle weakness and frequent urination

Muscle weakness and frequent urination

Which term would the nurse use to document observing the characteristic gait associated with Parkinson disease? Ataxic Shuffling Scissoring Asymmetric

Shuffling

After an admission for acute coronary syndrome (ACS), a client is asked to notify the nursing staff before getting out of bed. After finding the client up walking alone in the hallways an hour later, which response by the nurse is best? "Please go get back into your bed immediately." "It must be frustrating to lose your independence." "Sometimes after ACS, people feel dizzy and fall." "The primary health care provider wants you to rest."

"Sometimes after ACS, people feel dizzy and fall."

The health care provider suspects a client has tuberculosis and prescribes a purified protein derivative (PPD) test, chest x-ray, and sputum culture. Prioritize implementation of the ordered interventions.

1.) Institute airborne precautions. 2.Have a chest x-ray performed. 3.Perform a PPD intradermal skin test. 4.Obtain a sputum specimen. 5.Notify the Department of Health.

Which statement is correct regarding negative pressure wound therapy? Select all that apply. One, some, or all responses may be correct. A suction pump is used. Necrotizing infections are treated. Oxygen is administered under high pressure. A low-voltage current is applied to a wound area. Chronic ulcers are reduced by removing fluids from the wound.

A suction pump is used. Chronic ulcers are reduced by removing fluids from the wound.

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do? Ask the client to take several deep breaths. Instruct the client to cough before suctioning. Administer 100% oxygen to the client. Change the suctioning equipment to ensure sterility.

Administer 100% oxygen to the client.

Which wound care is given to a client with severe burn injuries during the acute phase? Assess extent and depth of burns. Provide daily shower and wound care. Remove dead and contaminated tissue. Assess the wound daily and adjust the dressing.

Assess the wound daily and adjust the dressing.

Which action would be the nurse's first priority when receiving a client with major burns? Assessing airway patency Checking the client from head to toe Administering oxygen as needed Elevating the extremities if no fractures are noticed

Assessing airway patency

Which clinical manifestations would the nurse expect a client with hypothyroidism to exhibit? Select all that apply. One, some, or all responses may be correct. Cool skin Photophobia Constipation Periorbital edema Decreased appetite

Cool skin Constipation Periorbital edema Decreased appetite

The nursing team is involved in providing effective pain management. Which task would be performed by the registered nurse (RN) in this case? Hygiene Taking and reporting of vital signs Administering oral pain medications Developing a treatment plan for the client's pain

Developing a treatment plan for the client's pain

Which reported clinical manifestations would the nurse expect from a client with ulcerative colitis? Select all that apply. One, some, or all responses may be correct. Fever Diarrhea Gain in weight Spitting up blood Abdominal cramps

Fever Diarrhea Abdominal cramps

The nurse is caring for a client with deep partial-thickness burns who is receiving an opioid for pain management. Which mode of medication administration is preferred for this client? Oral Rectal Intravenous Intramuscular

Intravenous- quickest onset of action

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning. Employ gentle suctioning as the catheter is being inserted. Loosen the client's secretions before suctioning by instilling saline. Ensure that the cuff of the tracheostomy is inflated during suctioning.

Preoxygenate the client before suctioning.

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation

Respiratory alkalosis

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue? Provide small, frequent meals. Encourage pursed-lip breathing. Schedule nursing activities to allow for rest. Encourage bed rest until energy level improves.

Schedule nursing activities to allow for rest.

A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. Which would the nurse specifically emphasize when planning preoperative teaching for this client? Possible complications Food and fluid restrictions Coughing and deep breathing Isometric exercises of the extremities

Coughing and deep breathing

A client with gastroesophageal reflux disease (GERD) needs to make dietary and lifestyle changes. Which instructions would the nurse include in the client's discharge teaching? Select all that apply. One, some, or all responses may be correct. Encourage the client to quit smoking. Elevate the foot of the bed. Avoid milk and dairy products. Eat three large, evenly spaced Avoid lying down for 2 to 3 hours after eating.

Encourage the client to quit smoking. Avoid lying down for 2 to 3 hours after eating.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) states, "I'm not worried because they have a cure for AIDS." Which response would the nurse use? "Repeated phlebotomies may be able to rid you of the virus." "You may be cured of AIDS after prolonged pharmacological therapy." "Perhaps you should have worn condoms to prevent contracting the virus." "There is no cure for AIDS, but there are medications that can slow down the virus."

"There is no cure for AIDS, but there are medications that can slow down the virus."

A client with tuberculosis asks the nurse about the communicability of the disease. Which response would the nurse use? "Tuberculosis is not communicable at this time." "Untreated active tuberculosis is communicable." "Tuberculosis is communicable during the primary stage." "With the newer long-term therapies, tuberculosis is not communicable."

"Untreated active tuberculosis is communicable."

Which goal would the nurse expect a client receiving treatment for bacterial cystitis to achieve before their discharge from the hospital? Understand the need to drink 4 L of water per day to prevent dehydration. Demonstrate an ability to identify dietary restrictions and plan menus. Achieve relief of clinical symptoms and maintain kidney function. Recognize signs of bleeding as a complication associated with this type of procedure.

Achieve relief of clinical symptoms and maintain kidney function.

How can the nurse describe heart failure to a client? A cardiac condition caused by inadequate circulating blood volume An acute state in which the pulmonary circulation pressure decreases An inability of the heart to pump blood in proportion to metabolic needs A chronic state in which the systolic blood pressure drops below 90 mm Hg

An inability of the heart to pump blood in proportion to metabolic needs

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia? Limit suctioning with catheter to 30 seconds. Apply suction only after the catheter is inserted. Lubricate the catheter with saline before insertion. Use a sterile suction catheter for each suctioning episode.

Apply suction only after the catheter is inserted.

When admitting a client with acute coronary syndrome (ACS) to the telemetry unit after cardiac catheterization and percutaneous intervention (PCI), which action would the nurse take first? Attach the cardiac monitor. Auscultate the heart sounds Check the intravenous fluid rate. Assess alertness and orientation.

Attach the cardiac monitor.

Which interventions would the nurse include in the plan of care for a client with gastroesophageal reflux disease (GERD)? Select all that apply. One, some, or all responses may be correct. Encourage client to follow the prescribed treatment regimen. Keep the head of the bed elevated to approximately 30 degrees. Avoid placing the client in the supine position for 2 to 3 hours after a meal. Instruct the client to eat six small meals a day with the last just before bedtime. Instruct the client to take a proton pump inhibitor before the first meal of the day.

Encourage client to follow the prescribed treatment regimen. Keep the head of the bed elevated to approximately 30 degrees. Avoid placing the client in the supine position for 2 to 3 hours after a meal.

The nurse recommends that, when in bed, a client who has osteoarthritis should lie in the supine or prone position. The client states that these positions are uncomfortable for the knees and hips. Which action would the nurse take? Encourage the client to maintain extension for specific periods of time. Urge the client to lie in whatever position is most comfortable. Insert a pillow under the client's knees to relieve discomfort. Place the client in the semi-Fowler position most of the time.

Encourage the client to maintain extension for specific periods of time.

When assessing a client with diabetes insipidus, which signs would the nurse anticipate finding? Select all that apply. One, some, or all responses may be correct. Excessive thirst Increased blood glucose Dry mucous membranes Increased blood pressure Decreased serum osmolarity Decreased urine specific gravity

Excessive thirst Dry mucous membranes Decreased urine specific gravity (Because water is not being reabsorbed, urine is dilute, resulting in a low specific gravity (less than 1.005)

When teaching a client with heart failure about signs and symptoms that indicate a need to contact the primary health care provider, which clinical manifestations would the nurse include? Select all that apply. One, some, or all responses may be correct. Weight loss Extreme fatigue Coughing at night Excessive urination Difficulty breathing

Extreme fatigue Coughing at night Difficulty breathing

Which assessment finding of a client with heart failure would prompt the nurse to contact the health care provider? Select all that apply. One, some, or all responses may be correct. Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain

Fatigue Orthopnea Pitting edema Dry hacking cough 4-pound weight gain

Which factor that contributes to the incidence of hip fractures is a higher risk for older adults? Carelessness Fragility of bone Sedentary existence Rheumatoid diseases

Fragility of bone

The nurse is eliciting a health history from a client with ulcerative colitis. Which factor would the nurse consider to be most likely associated with the client's colitis? Food allergy Infectious agent Dietary components Genetic predisposition

Genetic predisposition

Which task regarding the care of a client with Buck's traction is appropriate to delegate to the unlicensed assistive personnel (UAP)? Check body positioning. Check the distal pulses and capillary refill. Teach the client about potential complications. Help the client with range-of-motion (ROM) exercises.

Help the client with range-of-motion (ROM) exercises.

A client, transferred to the postanesthesia care unit after a transurethral resection of the prostate (TURP), has an intravenous (IV) line and a urinary retention catheter. During the immediate postoperative period, for which potentially critical complication would the nurse monitor? Sepsis Phlebitis Hemorrhage Leakage around urinary catheter

Hemorrhage

Which condition would the nurse question using a negative-pressure wound treatment device? Chronic ulcer Upper thigh wound Hip wound with slight bleeding Treated osteomyelitis within the vicinity of the wound

Hip wound with slight bleeding

The nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joints would the nurse expect the client will report as having been involved first? Select all that apply. One, some, or all responses may be correct. Hips Knees Ankles Shoulders Metacarpals

Hips Knees

A mother diagnosed with acquired immunodeficiency syndrome (AIDS) states she has been caring for her baby even though she has not been feeling well. Which important information would the nurse determine regarding the care provided by the mother? If she has ever kissed the baby and how If the mother is breast-feeding her baby When the baby last received antibiotics How long she has been caring for the baby

If the mother is breast-feeding her baby

The nurse is assessing two clients. One client has ulcerative colitis, and the other client has Crohn disease. Which is more likely to be identified in the client with ulcerative colitis than in the client with Crohn disease? Inclusion of transmural involvement of the small bowel wall Higher occurrence of fistulas and abscesses from changes in the bowel wall Pathology beginning proximally with intermittent plaques found along the colon Involvement starting distally with rectal bleeding that spreads continuously up the colon

Involvement starting distally with rectal bleeding that spreads continuously up the colon

After a transurethral prostatectomy (TURP), a client returns to the postanesthesia care unit with a three-way indwelling catheter and a continuous bladder irrigation. Which nursing action would the nurse monitor during the initial recovery phase? Observe the suprapubic dressing for drainage. Maintain the client in a semi-Fowler position. Monitor for bright red blood in the urinary drainage bag. Encourage fluids by mouth as soon as the gag reflex returns.

Monitor for bright red blood in the urinary drainage bag.

Which actions could the registered nurse (RN) assign to a licensed practical nurse (LPN) caring for the client with a cast or traction? Select all that apply. One, some, or all responses may be correct. Monitoring skin integrity around the cast Marking circumference of any drainage on the cast Teaching the client and caregiver range-of-motion (ROM) exercises Instructing family members on assisting the client with cast care Checking color, temperature, capillary refill, and pulses distal to the cast

Monitoring skin integrity around the cast Marking circumference of any drainage on the cast Checking color, temperature, capillary refill, and pulses distal to the cast

When a nurse needs to administer oxygen at a fraction of inspired oxygen (FiO2) of about 40% to keep a client's oxygen saturation greater than 94%, which method would be best? Face tent Venturi mask Nasal cannula Simple face mask

Nasal cannula

When a client with acute coronary syndrome (ACS) is admitted to the coronary intensive care unit, which topic is a priority to include in teaching? Symptoms of worsening heart failure Use of daily low dose aspirin after discharge Need to report any chest discomfort to the nurses Importance of starting a walking and exercise program

Need to report any chest discomfort to the nurses

A client in a nursing home is diagnosed with urethritis. What would the nurse expect to do before initiating antibiotic therapy prescribed by the primary health care provider? Start a 24-hour urine collection. Prepare for urinary catheterization. Teach the client how to perform perineal care. Obtain a specimen for culture and sensitivity.

Obtain a specimen for culture and sensitivity.

A client with cholelithiasis is scheduled for a lithotripsy. Which would the nurse include in the client's teaching plan? Opioids will be available for postprocedural pain. Fever is a common response after this procedure. Heart palpitations often occur after the procedure. Anesthetics are not necessary during the procedure.

Opioids will be available for postprocedural pain.

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy? Oxygen flow rate is set to 8 L/min. There is bubbling present in the humidifier. Pressure areas of tubing along the ears are padded. Smoking and open flame prohibited signs are clearly posted.

Oxygen flow rate is set to 8 L/min.

Which action would be included in the plan of care for a client with a history of parkinsonism who has recently developed rigidity, tremors, and signs of pneumonia? Gait training in the physical therapy department daily Isometric exercises every 2 hours while awake Active range-of-motion exercises at least every 4 hours Passive range-of-motion exercises at least every 8 hours

Passive range-of-motion exercises at least every 8 hours

A regimen of rest, exercise, and physical therapy is prescribed for a client with rheumatoid arthritis. Which purpose of the regimen would the nurse teach to the client? Treating the arthritic pain Halting the inflammatory process Preventing additional joint damage Providing for the return of lost joint motion

Preventing additional joint damage

A client with myasthenia gravis experiences generalized weakness. Which nursing intervention would the nurse integrate into the client's plan of care? Maintain strict bed rest for this client. Provide the client frequent rest periods. Reassure the client there are many other tasks awaiting him or her. Arrange for a relative to be present with the client.

Provide the client frequent rest periods.

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Assist the client in assuming a position of comfort and perform postural drainage.

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula.

Which symptoms would the nurse include when teaching a client to recognize symptoms of hypoglycemia? Select all that apply. One, some, or all responses may be correct. Rapid heartbeat Emotional changes Abdominal cramping Nausea and vomiting Weakness and fatigue Numbness of fingers, toes, or mouth

Rapid heartbeat Emotional changes Numbness of fingers, toes, or mouth

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, high-protein diet and intravenous (IV) fluids with vitamins have been prescribed. When implementing these prescriptions, which goal is the nurse trying to achieve? Reduce gastric acidity Reduce colonic irritation Reduce intestinal absorption Reduce bowel infection rate

Reduce colonic irritation

The provider prescribes one unit of packed red blood cells to be administered to a client. To ensure the client's safety, which action will the nurse take during administration of blood products? Stay with client during first 15 minutes of infusion. Flush packed red blood cells with 5% dextrose and 0.45% normal saline. Remove the intravenous catheter if a blood transfusion reaction occurs. Administer the red blood cells through a percutaneously inserted central catheter line with a 20-gauge needle.

Stay with client during first 15 minutes of infusion.

Which nursing intervention is the priority when the nurse notices that the client has a blood pressure of 90/70 mm Hg and a heart rate of 50 beats per minute while the nurse is performing nasotracheal suctioning? Administer intravenous fluids to the client. Report to the primary health care provider. Stop the suctioning procedure immediately. Administer 100% oxygen manually to the client

Stop the suctioning procedure immediately.

The nurse is educating a client with hypothyroidism about the use of levothyroxine. Which information would the nurse provide? Select all that apply. One, some, or all responses may be correct. Take dose same time each day. Refrain from switching brands. Have regular bloodwork drawn. Hold medication for pulse >60 beats per minute. Report weight loss more than 3 pounds.

Take dose same time each day. Refrain from switching brands. Have regular bloodwork drawn.

Which instruction would the nurse include when teaching a client with asthma how to use a peak flow meter? Sit up straight in a firm chair. Check peak flow early in the morning. Take the deepest breath you can, then blow out hard and fast. Calculate the average of 3 readings to obtain your peak flow.

Take the deepest breath you can, then blow out hard and fast.

A client who had a cerebrovascular accident (CVA, also known as a "brain attack") begins to eat lunch. Which client behavior indicates the client may be experiencing left hemianopsia? The client asks to have food moved to the left side of the tray. The client drops the coffee cup when trying to use the right hand. The client ignores the food on the left side of the tray when eating. The client reports not being able to use the right arm to help eat meals.

The client ignores the food on the left side of the tray when eating.

The nurse identifies 12 mm of induration at the site of a client's tuberculin purified protein derivative (PPD) test. Which rational would the nurse use to explain this test? The test result is negative and would not require any follow-up. The result indicates a need for further tests and a chest x-ray. The skin test is a screening method and you now need a Tine test. This skin test is inconclusive and requires repeat testing in 6 weeks.

The result indicates a need for further tests and a chest x-ray.

The nurse reviews the assessment findings of four clients with burns. Which client's findings are consistent with chemical burns? Cardiac arrest Minimal to absent pain Paralysis Hoarseness

Paralysis

Which statement by a client is consistent with a diagnosis of heart failure? "I see spots before my eyes." "I am tired at the end of the day." "I feel bloated when I eat a large meal." "I have trouble breathing when I climb a flight of stairs."

"I have trouble breathing when I climb a flight of stairs."

A client develops bacterial meningitis. Which action is the priority nursing care? Monitoring for signs of intracranial pressure Adding pads to the side of the bed Administering prescribed antibiotics Administering glucocorticoids

Administering prescribed antibiotics

When teaching a client with hypertension about a 2-gram sodium diet, which foods would the nurse instruct the client to avoid? Select all that apply. One, some, or all responses may be correct. Canned chili Ground beef Fresh salmon Luncheon meat Cooked broccoli

Canned chili Luncheon meat

A client is admitted via the emergency department with a tentative diagnosis of diverticulitis. The nurse anticipates that which test will be prescribed? Computed tomography (CT) scan Gastroscopy Colonoscopy Barium enema

Computed tomography (CT) scan

A client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess? Select all that apply. One, some, or all responses may be correct. Skin rash Dehydration Hypovolemia Hyperkalemia Metabolic acidosis

Dehydration Hypovolemia

Which statement by a client with a new non-weight-bearing long leg cast indicates the need for additional discharge teaching? "The cast can be wrapped in plastic when I take a shower." "I called my office to let them know I will be back at work next week." "The physical therapist is going to teach me how to walk with crutches." "I am going to give myself a pedicure with red nail polish when I get home."

"I am going to give myself a pedicure with red nail polish when I get home."

Which classic sign will a nurse find in a client with Addison disease? Ecchymosis Hyperreflexia Exophthalmos Hyperpigmentation

Hyperpigmentation

The primary health care provider for a client with chronic kidney disease prescribed immediate hemodialysis for the first time. Which clinical manifestation indicates the need for immediate hemodialysis in this client? Ascites Acidosis Hypertension Hyperkalemia

Hyperkalemia

A client is diagnosed with Cushing syndrome. The nurse would monitor the client for which cardiovascular complication? Chest pain Tachycardia Hypertension Atrial fibrillation

Hypertension

The nurse identifies silvery scales on a client's elbows and knees. Which finding in the client's history will help the nurse identify the origin of this rash?

Stress in recent months?

Which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis? "Shower twice a day with mild soap and warm water." "Soak the affected areas in hot water on a daily basis." "Apply an alcohol free, moisturizing lotion several times a day." "Cover affected areas when in contact with others."

"Apply an alcohol free, moisturizing lotion several times a day."

Which dietary changes would the nurse suggest to the client with diarrhea associated with human immunodeficiency virus (HIV)? Select all that apply. One, some, or all responses may be correct. "Eat more fatty food." "Eat much less roughage." "Drink two cups of coffee daily." "Eat more spicy and sweet food." "Drink plenty of fluids between meals."

"Drink plenty of fluids between meals." "Eat much less roughage."

Which instructions would the nurse give to a client with renal calculi? Select all that apply. One, some, or all responses may be correct. "Drink plenty of water." "Have spinach soup every day." "Substitute lemon juice for tea." "Include high amounts of protein in the diet." "Consume foods rich in omega-3 fatty acids."

"Drink plenty of water." "Substitute lemon juice for tea."

A client is receiving hemodialysis for chronic kidney disease. For which complication would the nurse monitor the client? Peritonitis Hepatitis B Renal calculi Bladder infection

Hepatitis B

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will elicit information consistent with this diagnosis? "Have you experienced an infection recently?" "Is there a history of this disorder in your family?" "Did you receive a head injury during the past year?" "What medications have you taken in the past several months?"

"Have you experienced an infection recently?"

Which nursing intervention indicates misinformation when providing care for clients with the human immunodeficiency virus (HIV) infection? "I will ask the client to avoid exposure to new infectious agents." "I will ask the client about intake of supplemental vitamins and micronutrients." "I will ask the client to avoid involvement in community activities." "I will ask the client if he or she is up to date with recommended vaccines."

"I will ask the client to avoid involvement in community activities."

The nurse is teaching a client about gastroesophageal reflux disease (GERD). Which statement made by the client indicates correct understanding of GERD management? "Three meals per day is the best regimen to avoid GERD symptoms." "I can reduce my GERD symptoms through a high-carbohydrate, low-fat diet." "A snack at bedtime will help reduce the acidity of my stomach during the night." "I will place a 6-inch (15-cm) block under the head of my bed to help with digestion."

"I will place a 6-inch (15-cm) block under the head of my bed to help with digestion."

After the nurse has taught a client with asthma about use of a peak flow meter, which client statements indicate that the teaching has been effective? Select all that apply. One, some, or all responses may be correct. "Readings in the green zone mean that my asthma is under control." "If I get a reading in the yellow zone, I need to stop what I'm doing and rest for a while." "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." "I should check the peak flow readings at least twice a day until my baseline is established." "I don't need to check my peak flow readings if I use the quick relief medication."

"Readings in the green zone mean that my asthma is under control." "If I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital." "I should check the peak flow readings at least twice a day until my baseline is established."

Which instruction would the nurse include when teaching a client with human immunodeficiency virus (HIV) about self-management? "Limit your daily fluid intake to 2 liters daily." "Eat more roughage daily with your meals." "Rinse your mouth with normal saline after every meal." "Maintain a 4- to 5-hour gap between each meal."

"Rinse your mouth with normal saline after every meal."

Which client is at risk for developing type 2 diabetes mellitus (DM)? Select all that apply. One, some, or all responses may be correct. 15-year-old male who plays video games 6 hours per day 36-year-old female with a history of gestational diabetes 47-year-old male who weighs 250 pounds and is 5' 9" tall 28-year-old female with polycystic ovarian syndrome (POS) 60-year-old male of Native American descent who abuses alcohol

15-year-old male who plays video games 6 hours per day 36-year-old female with a history of gestational diabetes 47-year-old male who weighs 250 pounds and is 5' 9" tall 28-year-old female with polycystic ovarian syndrome (POS) 60-year-old male of Native American descent who abuses alcohol

Which of these clients seen at a health fair will be most at risk for hypertension? 23-year-old white man 44-year-old white woman 50-year-old Mexican-American woman 62-year-old African American man

62-year-old African American man

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about the anticipated disease process would the nurse incorporate when responding to the client's question? There is a high cure rate with proper treatment for this disease. This disease has a slow, progressive course, without remissions. The disease is a chronic illness with exacerbations and remissions. Myasthenia gravis has a poor prognosis, with death occurring in a few months.

The disease is a chronic illness with exacerbations and remissions.

A health care provider prescribed a diagnostic workup for a client who may have myasthenia gravis. Which initial objective would the nurse establish with the client? "The client will adhere to the teaching plan." "The client will achieve psychologic adjustment." "The client will maintain present muscle strength." "The client will prepare for a possible myasthenic crisis."

"The client will maintain present muscle strength."

The registered nurse is teaching a student nurse about the use of a suction pump in negative-pressure wound therapy. Which statement by the student nurse indicates the need for further teaching? "The wound site should be monitored at least every 2 hours." "This treatment is used mostly for areas of skin cancer." "The foam dressing should be changed every 48 to 72 hours." "A continuous low-negative pressure should be maintained."

"This treatment is used mostly for areas of skin cancer."

Which client statement indicates the need for further teaching about the traction device after a major fracture? "Traction must be applied continuously to be effective." "Weights of 5 to 45 pounds are used to apply the counterweight." "The risks of skeletal traction include infection at the pin insertion site." "Traction pushes the fractured ends together to prevent them from pulling apart."

"Traction pushes the fractured ends together to prevent them from pulling apart."

Which clinical manifestations would the nurse expect the client to report when experiencing renal calculi? Select all that apply. One, some, or all responses may be correct. Blood in the urine Irritability and twitching Dry, itchy skin and pyuria Frequency and urgency of urination Pain radiating from the kidney to a shoulder

Blood in the urine Frequency and urgency of urination

After a client has had bronchoscopy, which finding indicates that the client's gag reflex has returned? Alert and oriented Able to swallow saliva Speaks without difficulty Denies sore throat

Able to swallow saliva

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), which would the nurse do? Initiate pulmonary hygiene to clear air passages of trapped mucus. Instruct to deep-breathe slowly with inhalation longer than exhalation. Encourage continuous rapid panting to promote respiratory exchange. Administer oxygen at a low concentration to maintain respiratory drive.

Administer oxygen at a low concentration to maintain respiratory drive.

The nurse assists a client on a rehabilitation unit after a cerebrovascular accident (CVA, also known as a "brain attack") with residual hemiparesis to walk with the use of a cane. To help achieve the goal of safe walking with a cane, which method would the nurse teach the client? Shorten the stride of the unaffected extremity. Advance the cane and the affected extremity simultaneously. Lean the body toward the side with the cane when ambulating. Hold the cane on the same side as the affected extremity and increase the base of support.

Advance the cane and the affected extremity simultaneously.

Which roles could the nurse assign to unlicensed assistive personnel (UAP) in caring for a client with a cast? Select all that apply. One, some, or all responses may be correct. Applying ice to the cast Positioning the casted extremity above heart level Marking the circumference of any drainage on the cast Looking for clinical manifestations of compartment syndrome Teaching range-of-motion exercises to the client and caregiver

Applying ice to the cast Positioning the casted extremity above heart level

The nurse is taking care of a client with cirrhosis of the liver. Which clinical manifestations would the nurse assess in the client? Select all that apply. One, some, or all responses may be correct. Ascites Hunger Pruritus Jaundice Headache

Ascites Pruritus Jaundice

When an older client with heart failure is transferred from the emergency department to the medical service, which would the nurse on the unit do first? Interview the client for a health history. Assess the client's heart and lung sounds. Monitor the client's peripheral pulse quality. Obtain the client's blood specimen for electrolytes.

Assess the client's heart and lung sounds.

Which action by a client taking immunosuppressant medication for rheumatoid arthritis indicates to the nurse the need for additional teaching? Has bloodwork for complete blood cell count (CBC) obtained Performs frequent hand washing Attends crowded sporting events Implements a home exercise program

Attends crowded sporting events

When assisting a client with Parkinson disease to ambulate, which instruction would the nurse provide the client? Avoid leaning forward. Hesitate between steps. Rest when tremors are experienced. Keep arms close to the center of gravity.

Avoid leaning forward.

While providing care for four clients with human immunodeficiency virus (HIV) infections, the nurse notes newly developed clinical manifestations. Which client's condition would the nurse be able to delay reporting to the primary health care provider until unit rounds are made within the next 24 hours? Burning, itching, and discharge from the eyes Blood in the urine Yellow discoloration of the skin N,V, accompanied by abdominal pain

Burning, itching, and discharge from the eyes

Which action would the clinic nurse take when a client with chronic obstructive pulmonary disease (COPD) has a 10-mm area of induration after Mantoux testing? Document the result as a negative finding. Teach the client about need for a chest x-ray. Discuss latent tuberculosis with client. Notify the local public health department.

Document the result as a negative finding.

A client with acute kidney injury states, "Why am I experiencing twitching and tingling of my fingers and toes?" Which process would the nurse consider when formulating a response to this client? Acidosis Calcium depletion Potassium retention Sodium chloride depletion

Calcium depletion

Which action will the nurse include in the plan for care for a client after a bronchoscopy examination? Check for the gag reflex. Send the client for a chest x-ray examination. Assess breathing every 30 minutes. Have the client avoid the Valsalva maneuver.

Check for the gag reflex.

A client who has been hospitalized with celiac disease is making dietary choices for upcoming meals. Which foods are appropriate for the client? Breaded veal cutlet with cheese Roast beef sandwich with pickles Chicken noodle soup with crackers Cheese omelet with chopped spinach

Cheese omelet with chopped spinach

Which characteristic of urine changes in the presence of a urinary tract infection (UTI)? Clarity Viscosity Glucose level Specific gravity

Clarity

The nurse is reviewing laboratory results from several clients. Based on the given data, which client is most likely to have a diagnosis of hyperthyroidism documented in the medical record?

Client B- 35 y/o, T4= 13 mcg/dL, FT4= 2.8 ng/dL, T3= 250 ng/dL

When developing the plan of care for a client with rheumatoid arthritis, which client consideration would the nurse include? Surgery Comfort Education Motivation

Comfort

The nurse is caring for a client with Addison disease. Which dietary modification should the nurse include in the client's teaching plan? Increase potassium intake to replace renal losses. Increase protein intake to heal the adrenal tissue and thus cure the disease. Take supplemental vitamins to supply energy and assist in regaining the weight that was lost. Consume extra salt to replace the amount being lost due to a lack of sufficient aldosterone needed to conserve sodium.

Consume extra salt to replace the amount being lost due to a lack of sufficient aldosterone needed to conserve sodium.

A health care provider prescribes dietary and medication therapy for a client with a diagnosis of gastroesophageal reflux disease (GERD). What is appropriate for the nurse to teach the client about meal management? Consume a snack each evening. Divide food into four to six meals a day. Eat the last of three daily meals by 8:00 PM. Suck on a peppermint candy after each meal.

Divide food into four to six meals a day.

A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client reports persistent pain 1 week later. Which statement indicates the cause of the posttherapeutic neuralgia? Damage to the nerves Untreated major depression Scarring in the area of the rash Continued presence of the skin rash

Damage to the nerves

Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing? Decrease air trapping Prevent bronchial dilation Strengthen intercostal muscles Reduce diaphragmatic excursion

Decrease air trapping

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? Prevents bronchial spasm Decreases air trapping in lung Improves alveolar surface area Strengthens diaphragmatic contraction

Decreases air trapping in lung

When a client is diagnosed with left-sided congestive heart failure, which assessment findings would the nurse expect? Select all that apply. One, some, or all responses may be correct. Dyspnea Crackles Frequent cough Peripheral edema Jugular distention

Dyspnea Crackles Frequent cough

Which client has findings consistent with rheumatoid arthritis? Uric acid 8.5 mg/dL C-reactive protein (CRP) 800 mcg/dL Anti-deoxyribonucleic acid (DNA) antibody 90 IU/mL ESR 65 mm/hour

ESR 65 mm/hour- ESR index of inflammation, normal value less than 30 mm/hr

The nurse uses the rule of nines to estimate the percentage of the burn surface area (BSA) on a client who has burns covering the entire surface of both arms, the posterior trunk, the genitals, and the entire left leg. What is the percentage of burn injury for this client? Record your answer as a whole number. ________%

Each arm accounts for 9%; the posterior torso is 18% and the entire left leg is 18%. The genitals account for 1%. 9 + 9 + 18 + 18 + 1 = 55%.

The nurse assisted a client with myasthenia gravis to bathe. The nurse identified the client's arms had progressively become weaker with sustained movement. Which intervention would the nurse implement with this client? Encourage the client to rest for short periods. Continue the bath while supporting the client's arms. Gradually increase the client's activity level each day. Administer a dose of pyridostigmine bromide.

Encourage the client to rest for short periods.

Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? Ensuring patent airway Administering intravenous (IV) fluids Monitoring level of consciousness Protecting the client from injury during seizures

Ensuring patent airway

Which medications used for the treatment of plaque psoriasis will the nurse administer subcutaneously? Select all that apply. One, some, or all responses may be correct. Alefacept Infliximab Etanercept Adalimumab Ustekinumab

Etanercept Adalimumab Ustekinumab

A client with active tuberculosis is walking down the hall to obtain a glass of juice from the kitchen, even after having received education regarding airborne precautions. Which nursing intervention would the nurse implement at this time? Ensure regular visits by staff members to meet the client needs. Explore what the airborne precautions mean to the client. Report the situation to the infection control nurse immediately. Reteach the concepts of airborne precautions to the client.

Explore what the airborne precautions mean to the client

Which symptom might the nurse identify when assessing a client with hyperthyroidism? Fatigue Dry skin Anorexia Bradycardia

Fatigue

A client admitted with a burn injury has erythema and mild swelling. Which type of burn would the nurse suspect?

First-degree burn

The nurse is evaluating a client who has been receiving medical intervention for a diagnosis of Crohn disease. Which expected outcome is most important for this client? Performs skin care Tolerates oral fluids Experiences less abdominal cramping Gains a half pound (0.2 kilograms) per week

Gains a half pound (0.2 kilograms) per week

The nurse is assessing a client with a moon-shaped face and thin arms and legs. The nurse expects which other assessment findings? Select all that apply. One, some, or all responses may be correct. Weight loss Gastric ulcer Pain in bones Poor appetite Muscle weakness

Gastric ulcer Pain in bones Muscle weakness

The nurse is interviewing a client with a tentative diagnosis of Parkinson disease. Which description would the nurse give to the client about the onset of symptoms? Suddenly Gradually Overnight Irregularly

Gradually

Which food selections by a client with celiac disease indicate the nurse's dietary teaching was successful? Select all that apply. One, some, or all responses may be correct. Green beans Baked potato Noodle pudding Turkey sandwich Whole-wheat cereal

Green beans Baked potato

Which finding for a client who has just returned to the nursing unit after bronchoscopy and lung biopsy would be most important to report to the health care provider? Client arousable, but lethargic Cough productive of bloody mucus Heart rate 126 beats per minute Client report of dry and sore throat

Heart rate 126 beats per minute

Which interventions regarding preventing future infections are taught to a sexually active female client with a urinary tract infection? Select all that apply. One, some, or all responses may be correct. Increase fluid intake. Wear snug nylon underwear. Use douche and scented lubricants. Clean the perineum wiping front to back. Empty the bladder before and after sexual intercourse.

Increase fluid intake. Clean the perineum wiping front to back. Empty the bladder before and after sexual intercourse.

Which finding from cerebral spinal fluid would lead the nurse to associate with a diagnosis of bacterial meningitis? Increased protein Increased glucose Decreased specific gravity Decreased white blood cell count

Increased protein

The nurse presents discharge instructions to a client for self-care after application of a cast to their fractured right ulna and radius. Which clinical manifestation would the nurse instruct the client to immediately report to their primary health care provider? Slight stiffness of the fingers Increasing pain at the injury site Small amount of dark, bloody drainage on the cast Bounding radial pulse in the affected extremity

Increasing pain at the injury site

A client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors? Men are more likely to be affected than women. Young people are affected more frequently than older people. Individuals who are obese are more prone to this condition than those who are thin. People who are physically active are more apt to develop this condition than those who are sedentary.

Individuals who are obese are more prone to this condition than those who are thin.

A client with a long history of alcohol abuse is admitted to the hospital with ascites and jaundice. A diagnosis of hepatic cirrhosis is made. Which is a nursing priority? Institute fall prevention and safety measures. Evaluate coping skills. Measure abdominal girth daily. Test stool specimens for blood

Institute fall prevention and safety measures

A client manifests right-sided hemianopsia as a result of a cerebrovascular accident (CVA, also known as a "brain attack"). Which goal would the nurse include in the client's plan of care? Correct the client's misuse of equipment. Instruct the client to scan surroundings. Teach the client to look at the position of the left extremities. Provide the client with tactile stimulation to the affected extremities.

Instruct the client to scan surroundings.

When caring for a client who has had a bronchoscopy in the ambulatory surgery unit, which action would the nurse take? Offer ice chips to decrease throat pain. Avoid turning the head from side to side. Keep the client in the semi-Fowler position Suggest medicated lozenges for sore throat.

Keep the client in the semi-Fowler position

Which symptom would the nurse expect a client diagnosed with Cushing syndrome to exhibit? Lability of mood Postural hypotension Increased skin thickness Ectomorphism with a moon face

Lability of mood

A client admitted with urinary retention has an indwelling urinary catheter prescribed. Which action would the nurse implement to prevent the client from developing a urinary tract infection? Assess urine specific gravity. Collect a weekly urine specimen. Maintain the prescribed hydration. Empty the drainage bag once a day.

Maintain the prescribed hydration.

Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? Report of chest tightness Heart rate of 112 beats per minute Expiratory wheezes in both lungs Markedly decreased breath sounds

Markedly decreased breath sounds

A client is admitted to the hospital with a diagnosis of Crohn disease. Which is important for the nurse to include in the teaching plan for the client? Controlling constipation Meeting nutritional needs Preventing increased weakness Anticipating a sexual alteration

Meeting nutritional needs

Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? Face tent Venturi mask Nasal cannula Nonrebreather mask

Nonrebreather mask

Which assessment findings would the nurse expect in the client hospitalized with a diagnosis of severe chronic kidney disease? Select all that apply. One, some, or all responses may be correct. Polyuria Paresthesias Hypertension Metabolic alkalosis Widening pulse pressure

Paresthesias Hypertension

The nurse assesses a client admitted with suspected Guillain-Barré syndrome who reports numbness, which began in the hands and feet and now involves the arms, legs, and lower trunk. For which related clinical manifestations would the nurse assess in this client? Ptosis and dysphagia Paresthesias and paralysis Atrophy and fasciculations Muscle weakness and drooling

Paresthesias and paralysis

A client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. Which action would the nurse plan to take? Perform a neurovascular assessment of the extremity. Reassure the client that these injuries are not that serious. Gather equipment needed for the application of skeletal traction. Prepare the client for a surgical reduction of the injured extremity.

Perform a neurovascular assessment of the extremity.

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barré syndrome? Physical therapy Speech exercises Fitting with a vertebral brace Follow-up on cataract progression

Physical therapy

Which is a secondary cause of adrenal insufficiency? Hemorrhage Tuberculosis Pituitary tumors Metastatic cancer

Pituitary tumors

When a client with a history of hypertension that is usually successfully treated with medications has a blood pressure of 160/100 mm Hg during a clinic appointment, which action would the nurse take next? Teach the client about the need for a low sodium diet. Ask the client when blood pressure medications were taken last. Question the client about symptoms such as headache or chest pain. Call for an ambulance to transport the client to the emergency department.

Question the client about symptoms such as headache or chest pain.

The nurse is creating a dietary plan for a client with cholecystitis who has been placed on a modified diet. Which is appropriate to include in the client's dietary plan? Soft-textured foods to reduce the digestive burden Low-cholesterol foods to avoid further formation of gallstones Increased protein to promote tissue healing and improve energy reserves Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

Reduced fat intake to avoid stimulation of the cholecystokinin mechanism for bile release

Which dietary modifications help improve the nutritional status of a client with acquired immunodeficiency syndrome (AIDS)? Refraining from consuming fatty foods Refraining from consuming frequent meals Refraining from consuming high-calorie foods Refraining from consuming high-protein foods

Refraining from consuming fatty foods

Which assessment findings are associated with Cushing disease? Select all that apply. One, some, or all responses may be correct. Round face Dependent edema in the feet and ankles Increased fatty deposition in the extremities Thin, translucent skin with bruising Increased fatty deposition in the neck and back

Round face Dependent edema in the feet and ankles Thin, translucent skin with bruising Increased fatty deposition in the neck and back

To determine whether a client is experiencing acute coronary syndrome (ACS), which component of the electrocardiogram would the nurse analyze? P wave PR interval QRS complex ST segment

ST segment

Which dietary choice reflects the recommendations of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply. One, some, or all responses may be correct. Salami Pickles Salmon French fries Canned soup

Salmon

Which clinical findings would the nurse expect to observe in a client with a diagnosis of psoriasis? Select all that apply. One, some, or all responses may be correct. Scaly lesions Pruritic pustules Reddened papules Multiple petechiae Erythematous macules

Scaly lesions Reddened papules

Which individual's activities increase the risk of developing carpal tunnel syndrome? Housekeeper Software engineer Health care worker Professional athlete

Software engineer

An older client experiences a cerebrovascular accident (CVA) with right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities would the nurse explain will be affected? Speaking preferences aloud Recognizing familiar objects Comprehending written words Understanding verbal communication

Speaking preferences aloud

Which action would the nurse take first when a client who is receiving a blood transfusion develops fever, chills, and low back pain? Stop the blood transfusion and infuse saline. Administer the prescribed antipyretic. Obtain a prescription for an antihistamine. Notify the blood bank about the symptoms.

Stop the blood transfusion and infuse saline.

Which nursing intervention is the priority when the nurse notices that the client receiving a blood transfusion is having an acute hemolytic reaction? Stop the blood transfusion immediately. Report to the primary health care provider. Recheck identifying tags and numbers on the client. Maintain a patent intravenous (IV) line with saline solution.

Stop the blood transfusion immediately.

The nurse determined a client's arterial blood gases reflected a compensated respiratory acidosis. The pH was 7.34; which additional laboratory value did the nurse consider? The partial pressure of oxygen (PO2) value is 80 mm Hg. The partial pressure of carbon dioxide (PCO2) value is 60 mm Hg. The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L). Serum potassium value is 4 mEq/L (4 mmol/L).

The bicarbonate (HCO3) value is 50 mEq/L (50 mmol/L) *Bicarb elevated range= 22-26 *PCo2 range= 35-45, so 60= abnormal=acidosis= BUT COMPENSATED, so looking at the bicarb- metabolic value

A client had an annual tuberculin purified protein derivative (PPD) test, and the area of induration was 10 mm within 48 hours after planting. Which conclusion would the nurse make about the client's response to this diagnostic? The client has contracted clinical tuberculosis. The client has passive immunity to tuberculosis. The client has been exposed to the tubercle bacillus. The client has developed a resistance to the tubercle bacillus.

The client has been exposed to the tubercle bacillus.

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. The nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record your answer as a whole number. ________%

The entire right lower extremity is 18%; the anterior portion of the right upper extremity is 4.5%. 18 + 4.5 = 22.5

Which diagnostic test result indicates if a client will develop acquired immunodeficiency syndrome (AIDS) from the human immunodeficiency virus (HIV)? Level of immunoglobulin M (IgM) in the client's blood The number of CD4+ T cells available Presence of antigen-antibody complexes Speed with which the virus invades the ribonucleic acid (RNA)

The number of CD4+ T cells available

Which laboratory value will be most important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome (ACS)? Troponin T (cTnT) C-reactive protein (CRP) Low-density lipoprotein (LDL) B-type natriuretic protein (BNP)

Troponin T (cTnT)

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? Hypoxemia Hypocapnia Compensated metabolic acidosis Uncompensated respiratory acidosis

Uncompensated respiratory acidosis

For which clinical manifestations will the nurse monitor when caring for a client admitted with heart failure? Select all that apply. One, some, or all responses may be correct. Weight loss Unusual fatigue Dependent edema Nocturnal dyspnea Increased urinary output

Unusual fatigue Dependent edema Nocturnal dyspnea

Which modifiable risk factor would the nurse include in a community presentation on cardiovascular risk factors? Select all that apply. One, some, or all responses may be correct. Weight Inactivity Cholesterol Tobacco use Homocysteine

Weight Inactivity Cholesterol Tobacco use Homocysteine

The nurse is evaluating the actions of a caregiver for a client with a lower extremity cast. Which action of the caregiver indicates the nurse needs to provide additional instruction? Using a towel to blot dry the cast Moving joints above and below the cast regularly Elevating the injured part above heart level for 48 hours Wrapping the client's cast with a plastic cover for 36 hours

Wrapping the client's cast with a plastic cover for 36 hours

Which client has second-degree burns? Waxy white, dark-brown appearance Redness, pain, minimal edema Moist blebs, blisters, severe pain Dry, leather eschar, absence of pain

Moist blebs, blisters, severe pain

Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response would the nurse provide? "Your urine will be pink and free of clots." "You will have an abdominal incision and a dressing." "There will be an incision between your scrotum and rectum." "There will be a urinary catheter and a continuous bladder irrigation."

"There will be a urinary catheter and a continuous bladder irrigation."

The nurse is caring for a client with type 2 diabetes mellitus and renal insufficiency. The client is scheduled for a computerized tomography (CT) scan with contrast. Which medication would the nurse withhold to prevent lactic acidosis? Pioglitazone Insulin Glyburide Metformin

Metformin

Which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident (CVA, also known as a "brain attack")? Glaucoma Hypothyroidism Continuous nervousness, stress Transient ischemic attacks (TIAs)

Transient ischemic attacks (TIAs)

Which action by a client with asthma indicates that the client teaching about use of a peak flow meter has been effective? Calls the health care provider when peak flows are in the green zone Does deep breathing and relaxation exercises when peak flow is in the red zone Uses a quick relief inhaled medication when peak flow is in the yellow zone Stops taking the daily inhaled corticosteroid when peak flow is in the yellow zone

Uses a quick relief inhaled medication when peak flow is in the yellow zone

To avoid complications in a client who has developed severe bone marrow depression after receiving chemotherapy for cancer, which actions by the nurse are appropriate? Select all that apply. One, some, or all responses may be correct. Monitor for signs of alopecia. Encourage an increase in fluids. Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately. Teach the client to avoid eating raw fruits or vegetables.

Wash hands before entering the client's room. Advise use of a soft toothbrush for oral hygiene. Report an elevation in temperature immediately.