NURS 3234 PrepU Exam III
The nurse is caring for a client who is being discharged with total parenteral nutrition (TPN) to be delivered via peripherally inserted central catheter (PICC). When teaching the client about care and management of the PICC line at home, what point(s) will the nurse include? Select all that apply.
"Contact your health care provider if you see yellow or greenish drainage at the PICC site." "If you have a cold or flulike symptoms, wear a mask when you are preparing to give yourself TPN." "Ensure that you have washed your hands thoroughly before handling the PICC line."
A nurse is caring for a client with insomnia. Which teaching will the nurse provide to help the client improve sleep?
"Create a bedtime routine."
The nurse is assessing a client with a history of sleep apnea who is noncompliant regarding wearing the continuous positive airway pressure (CPAP) apparatus. Which statement made by the client indicates understanding of risks related to noncompliance?
"I know if I do not wear the CPAP the oxygen in my blood may drop and damage my heart."
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
A terminally ill client asks the nurse what assisted suicide is. Which response is best for the nurse to provide?
"It is when a lethal combination of drugs is made available to the client wishing to die."
A client in his 40s has asked the nurse how much sleep he should be getting in order to maximize his health and well-being. How should the nurse respond?
"Most adults need between 7 and 9 hours, but everyone is different."
A nurse is caring for a client newly diagnosed with sleep apnea. Which should the nurse teach the client about the most important reason why the continuous positive air pressure (CPAP) device should be used during sleep?
"The CPAP assures you get enough oxygen throughout the night."
A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement?
"There's only an extremely small chance that you will become addicted to this drug."
The nurse is providing instructions to a client who has been prescribed a patient controlled analgesia (PCA) pump postoperatively. The nurse will include which information in the client instructions? Select all that apply.
"You should be the only person pressing the button on this device." "The device is set up to deliver a predetermined dose each time you press the button." "You will be asked to rate your pain frequently to reassess your need for this device." "You will hear a bell sound when the infuser delivers the medication."
A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?
"You won't have to endure any more needlesticks."
A nurse is assessing an adult client with back pain. The client is unable to speak English. Which pain scale is most appropriate for the nurse to use in assessing the client's pain?
0 to 10 numeric rating scale
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
1+
The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr
100 gtt/min
The nurse is monitoring intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the I&O record? Select all that apply.
100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
2,600 mL
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?
42 gtt/min
Which fluid should be administered slowly to prevent circulatory overload?
5% NaCl
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
50 gtt/min
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?
83 mL/hr
A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.
A B AB O
Which example best supports the diagnosis of Sexual Dysfunction: Dyspareunia?
A 50-year-old woman in the process of menopause has pain and burning during intercourse.
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?
A hypotonic solution
During a well-check visit of a toddler, the parent mentions that the child is exhibiting sexual behaviors. Which information on growth and development of a toddler will the nurse discuss with the parent?
Acknowledge that masturbation is normal.
The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?
Acknowledge the pain as the client reports it and administer pain medication as prescribed.
A postoperative client who reported a pain level of 8 was medicated with an IV opioid 20 minutes ago. The client now reports a pain level of 9. Which would be the nurse's best action?
Administer a nonopioid medication
A nurse assesses a client who was administered an opioid analgesic and finds the client unresponsive to shaking and stimulation. Which is the nurse's immediate plan of action?
Administer naloxone
The nurse caring for a client receiving opioid therapy notes that the client's respirations are 7. What is the first action by the nurse?
Administer naloxone.
Which nursing interventions would be anticipated with hospice care? Select all that apply.
Administer prescribed morphine for pain control. Ease respiratory function by providing oxygen via nasal cannula. Administer prescribed antiemetics to control nausea. Insert a Foley catheter to prevent incontinence.
A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?
Administering an oral dose of morphine to treat the client's breakthrough pain
The community health nurse is preparing for a family planning clinic. The nurse identifies which factors that influence contraceptive choices? Select All That Apply
Age Marital status Desire for future pregnancy Religious beliefs Level of education
The nursing instructor is talking with the junior nursing class about male reproductive issues. The instructor tells the students that the causes of erectile dysfunction include which of the following? Select all that apply.
Alcoholism Spinal cord trauma Diabetes
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?
An implanted central venous access device (CVAD)
A woman reports pain with intercourse. Which client medications should the nurse check for that contribute to dyspareunia?
Antihistamines
A client is dying and the nurse has developed a strong rapport with the client and spouse. The spouse states to the nurse, "I just don't know how I am going to deal with the process. It makes me nervous to think I can't deal with it." What is the priority concern with the spouse of the client?
Anxiety related to unknown reaction to stages of death
An older adult client experiences the death of a spouse. Which behavior by the client exemplifies the grief stage of reorganization?
Appears sad and reaches out to adult children for support
A nurse is caring for a client who is prescribed continuous positive airway pressure (CPAP) for sleep apnea. Which action will the nurse take?
Apply a CPAP mask while sleeping.
A nurse is changing a client's peripheral IV dressing. Which step is recommended in this procedure?
Apply chlorhexidine to the site in order to disinfect.
The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.
Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.
The nurse is caring for an older client with chronic pain due to osteoarthritis, hypertension, and mild dementia. The client reports blurred vision, and the spouse states, "I'm worried. Today I noticed that there was blood in the stool, and there is more confusion than usual." What is the priority nursing action?
Ask the client and caregiver for a medication history.
The nurse observes the sleep pattern of an obese client with cardiac disease and notes occasional periods of apnea. Which action should the nurse take?
Assess the client's vital signs and pulse oximetry.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?
Banana
A 28-year-old male comes to the clinic for an evaluation. The client complains of a penile discharge. After completing an assessment, the nurse suspects that the client has a chlamydia infection based on which finding? Select all that apply.
Burning on urination Swollen testes Testicular pain
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrhythmias
Which diagnostic test is used to diagnose a chlamydial infection?
Cervical culture
The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?
Change the site every three to four days.
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours.
A client who suffered multiple trauma in a motor vehicle accident is receiving care in an orthopedic trauma unit. The client has a documented history or opioid addiction and the hospital's advanced pain control team has become involved in his pain control plan. Which of the following are aspects of addiction? Select all that apply.
Compulsive use of a particular drug The need to use opioids for purposes other than pain relief
A client is prescribed escitalopram, diuretics, and pseudoephedrine. The client states, "I'm tired all the time." What does the nurse understand may be happening to this client?
Decrease in R.E.M. sleep due to prescribed medications
A nurse working the night shift assesses a client's vital signs at 4 a.m. (0400). What would be the expected findings, based on knowledge of NREM sleep?
Decreased TPR and BP
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?
Diarrhea
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which actions should the nurse perform to avoid further complications and provide relief to the client?
Discontinue the IV promptly.
The nurse is providing care for a confused client who no longer is able to make health care decisions. Which document will the nurse review on the client's medical record to determine the designated person to make decisions on the client's behalf?
Durable power of attorney form
What term is used to describe painful intercourse?
Dyspareunia
The client is actively dying and has a prescription for Do Not Resuscitate. The nonresponsive client is mouth breathing and has noisy respirations. The client is incontinent of urine and feces. The family is at the bedside. What interventions would be appropriate for the nurse to perform to meet the needs of the client and the family? Select all that apply.
Elevate the head of the bed to a semi-Fowler's position. Encourage the family to reminisce about positive, enjoyable events that the client and family shared together. Cleanse the client's mouth every shift and PRN
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?
Elevate the legs
A perimenopausal woman reports insomnia. Which intervention(s) will the nurse suggest to the client? Select all that apply.
Eliminate caffeine and alcohol in the evening because both are associated with disturbances in the normal sleep cycle. Eat a small snack of protein and carbohydrate before bedtime. Discuss the use of a sleep aid with the health care provider.
A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?
Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.
A client has a history of poorly controlled diabetes. Which health concern will the nurse discuss with the client?
Erectile dysfunction
The nurse is assessing an older adult client that reports feeling fatigued and tired throughout the day. What intervention by the nurse will assist with the client's report of fatigue?
Have the client further evaluated for depression
A 13-year-old female client comes in for a sports physical for school. During the exam, the client mentions she has a great boyfriend. Which question should the nurse prioritize with this client?
Have you received a human papillomavirus (HPV) vaccination?
A 54-year-old man is recovering from an outbreak of Herpes zoster on his left chest. He tells the nurse that even his shirt touching him causes a horrible pain on the left side of the chest. What term would best describe the client's pain?
Hyperalgesia
A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?
Hyperphosphatemia
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?
Hypertonic
A nurse is caring for a client who is sleeping for abnormally long periods of time. This condition may be caused by injury to which body structure?
Hypothalamus
An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?
Include more bananas in the diet.
Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance?
Infant
After the death of a terminally ill spouse, a client reports frequent headaches and loss of appetite. The client states, "How am I going to live without him?" What type of grief is the client experiencing?
Inhibited grief
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.
Intravenous therapy Electrolyte management Nutrition management
The hospice nurse is educating a client's family on the physical signs of approaching death. The nurse identifies that the education has been effective when the family says they will know that death is imminent when they see which related symptoms? Select all that apply.
Irregular respiratory rate Restlessness Bowel incontinence Cyanosis of dependent areas
A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the physician to prescribe which type of solution?
Isotonic
A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client?
Magnesium
The clinic nurse sees the client today and asks about his chief concern. The client describes to the nurse his inability to attain an erection. Which would be a priority for the nurse to assess? Select all that apply.
Medications that the client is taking Specifics about the erectile problem If there is a history of diabetes
A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L (19 mmol/L) PaO2: 95 mm Hg Which imbalance would the nurse suspect?
Metabolic acidosis
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?
Metabolic alkalosis
A postoperative client who has been receiving morphine for pain management is exhibiting a depressed respiratory rate and is not responsive to stimuli. Which drug has the potential to reverse the respiratory-depressant effect of an opioid?
Naloxone
The nurse is caring for new parents. During her education session, the nurse instructs the parents on a newborn's sleep patterns. Which statement is accurate about a newborn's sleep patterns?
Newborns sleep 16 to 17 hours per day.
The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.
Offer the client fluids in small containers. Provide a moisturizer for the lips and mouth. Remove the water pitcher from the client's bedside.
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?
Offer the client sugar-free candy to help combat thirst.
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order?
Packed cells
The nurse is caring for a client suspected of being infected with human papillomavirus (HPV). Which clinical manifestation observed by the nurse would correlate with this suspicion?
Pale, soft, papillary lesions on the genitalia and perianal area
What is the rationale for using CPAP to treat sleep apnea?
Positive air pressure holds the airway open.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
The nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?
Preventing constipation
A nurse is caring for a client who has been diagnosed with a disturbed sleep pattern. Which measures should the nurse implement to promote sleep? Select all that apply.
Promoting daytime exercises Providing a back massage Assisting with progressive relaxation
A nurse educates a young couple on putting their newborn on his back to sleep. What is the rationale for this information?
Prone position increases the risk for sudden infant death syndrome.
The nurse is caring for a client receiving epidural opioids . What side effects of the medication should the nurse assess for? Select all that apply.
Pruritis Urinary retention Nausea Infection
Which statement accurately describes the process known as grief reaction?
Reactions to grief may differ from client to family.
The nurse is caring for a client that is at the end of life. After the client is pronounced dead, what actions by the nurse are essential components of care? Select all that apply.
Removing all tubes according to agency policy, unless an autopsy is to be performed Placing identification tags on the client's dentures or other prostheses Arranging for family members to view the body before it is discharged to the mortician
A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?
Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
Sacral area
A specially trained nurse has inserted a PICC line. What would be done next?
Send the client to the radiology department.
Which of the following statements best describes the relationship between biologic sex and gender identity?
Sex is chromosomally determined, while gender is a psychosocial construct.
A client's partner expresses concern to the nurse about the client's snoring. Which assessment parameters will the nurse teach the couple to observe for the possibility of sleep apnea?
Snoring with periods of irregular silence
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?
Stop the transfusion and notify the health care provider.
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately.
A maternity nurse is instructing new parents on the proper sleeping position for their newborn child. In what position does the nurse instruct the parents to place the infant?
Supine position
A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply.
Swelling Pallor Coolness
What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply.
Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site.
The nurse is teaching a client with terminal cancer who is interested in hospice care. Which home hospice benefits will the nurse explain? Select all that apply.
The nurse and physician are on call 24 hours, every day of the week. Counseling services are available. Pain will be managed with medication, if needed. Homemaker services can be included.
A patient calls the clinic and tells the nurse they have a foamy, greenish, and itchy vaginal discharge. The patient asks the nurse what the significance of this discharge is. What is the best response by the nurse?
The patient may have trichomoniasis.
A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?
The student should drink large amounts of water on practice days.
A 5-year-old client reports abdominal pain. Which action(s) will the nurse take to assess the pain? Select all that apply.
Use the Wong-Baker FACES pain rating scale. Observe the client. Ask the client to describe the pain.
A male client comes to the clinic because he thinks that he has syphilis. Which test would the nurse expect the client to have done?
VDRL
The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?
Verify the prescription for type of solution and amount of infusion.
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?
Weigh the client's wet linen or dressing.
A new mother is discussing her 6-month-old infant's sleep habits and expresses concern about the infant obtaining too much sleep. The mother reports the infant's circadian cycle as listed above. The best statement by the nurse is:
Your infant is obtaining the average hours of sleep per day for an infant."
Which clients would the nurse identify that are at risk for the development or presence of sexual dysfunction? Select all that apply.
a 52-year-old male with a history of hypertension a postmenopausal female client a 30-year-old female experiencing PMS
The nurse is caring for a client who reports throbbing pain at the site of a recent laceration from a pocketknife. How will the nurse document this type of pain? Select all that apply.
acute cutaneous
A client with dehydration will have an increase in:
aldosterone
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
cardiac irregularities
What name is given to the rhythmic biologic clock that exists in humans?
circadian rhythm
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.
crackles in the lungs distended neck veins
A client reports throbbing pain caused by a laceration that occurred to the finger while cutting vegetables. Which terminology should the nurse use to document this pain? Select all that apply.
cutaneous acute
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights
The nurse is performing an intake assessment of a 60-year-old client who admits to having a nightcap of 4 to 6 ounces of scotch whisky each night. What effect might this alcohol be having on the client's sleep?
decreased REM sleep
During an orientation class for new RN graduates, the nurse educator identifies which conditions as potential risks for clients to experience sleep pattern disturbance? Select all that apply.
depression substance use constipation stroke
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes.
The nurse identifies that a client is in stage 3 sleep. What assessment finding by the nurse is indicative of this stage?
enuresis
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
febrile reaction
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
fluid volume excess and acidosis
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
fluid volume excess.
Which medication would the nurse most likely see on the medication administration record (MAR) of a client with diabetic neuropathy?
gabapentin
What independent nursing action can be used to facilitate sleep in hospitalized clients who are on bed rest?
giving a back massage
The action of ibuprofen is to:
have an antiprostaglandin effect on the CNS.
A nurse reads a client's chart and sees that she may have dyspareunia. Which of the following would be priority assessments? Select all that apply.
history of hormonal imbalance client's ability to use vaginal lubricants during sexual act physical assessment of internal and external genitalia
A critical care nurse is aware of the legislation that surrounds organ donation. When caring for a potential organ donor, the nurse is aware that:
hospitals are mandated to notify transplantation programs of potential donors.
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?
hypertonic
The nurse anticipates a dying client to exhibit which signs of impending death? Select all that apply.
incontinence restlessness loss of sensation Cheyne-Stokes respirations
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?
increased respiratory rate
A student is learning how to administer intravenous fluids, including accessing a vein. What is the most potentially harmful risk posed for the client when accessing the vein?
infection
A nurse at the health care facility is caring for an older adult client who complains of sleeplessness. Which condition is a manifestation of depression in an older client?
insomnia
The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain? Select all that apply.
neuropathic acute
A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?
oral hygiene
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
A nurse is developing a plan of care for a dying client. Which physiologic basic human need should be addressed?
personal hygiene
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?
plasma
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
A client reports awakening during the night and does not feel as though restful sleep is achieved. The nurse reviews the medications the client is prescribed and identifies one of the medication that the client may take that may have an effect on sleep patterns. Which medication will the nurse discuss with the client?
prednisone
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure
A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?
replace fluid and electrolytes
The parents of a boy 10 years of age are worried about his sleepwalking (somnambulism). What topic should the nurse discuss with the parents?
safety
The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess?
sternum
A client that is post-menopausal reports painful intercourse for the last two months. When performing an assessment of the client, what data should the nurse obtain?
the use of antihistamines, tranquilizers, or alcohol
An 82-year-old client is newly admitted to an assisted living facility. Which intervention promotes safety at night for the client?
using a night light in the bathroom
A male client presents to the clinic with reports of erectile dysfunction. Which statement by the nurse will assist in identifying the potential cause of the erectile dysfunction?
"Do you take any medications such as antihypertensives, antidepressants, or illicit drugs?"
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
A 16-year-old girl tells the nurse that her friend has genital warts and asks the nurse how to make sure that she does not get them. Which of the following should the nurse recommend?
"Get the human papillomavirus vaccine."
The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client?
"Have you been experiencing muscle weakness or leg cramps?"
While conducting a sexual history, the nurse asks a client about protection from sexually transmitted infections (STIs). Which question would be most appropriate for the nurse to ask?
"Have you had any sexually transmitted infections and if so, which ones?"
While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?
"How much do you typically urinate during the day?"
which statement made by a client with terminal illness indicates acceptance of the diagnosis?
"I do not feel like watching football tonight. I just want to be alone."
Which statement by the client indicates acceptance of dying?
"I have finalized all my financial arrangements for my family."
A nurse is collecting a sexual health history from an older adult woman who is postmenopausal. Which client statement requires further education by the nurse?
"I have noticed I have less lubrication with sexual intercourse."
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?
"Let me refer you to the blood bank so they can provide you with information."
The nurse is conducting an assessment on a newly admitted 18-year-old client. When questioned about sexual preference, the client appears slightly confused and confesses to not being sure. Which is an appropriate response(s) from the nurse? Select all that apply
"What has happened to cause you to question yourself?" "Have you discussed this with your family?" "What have you done to help you try to determine this?"
The nurse assessing an adolescent's need for further information regarding sexual health should ask which question?
"What questions or concerns do you have about your sexual health?"
The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:
0100 During REM sleep, the client's temperature, pulse, blood pressure, and respirations increase. The client may experience small muscle twitching, such as facial muscles twitching, and irregular pulse rate and respirations. During non-eye movement sleep, the client will exhibit a decrease in body temperature, pulse, blood pressure, and respirations.
The client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.
167
The nurse is caring for four clients. Which client does the nurse identify as the most likely to have undertreated pain? Select all that apply.
29-year-old who has a speech impediment 34-year-old with schizophrenia 41-year-old who is from a different country 60-year-old with early onset dementia
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3,000
The client experiences intractable chronic pain from cancer. The nurse is developing a care plan to provide the client adequate pain relief. What principle(s) will guide the treatment plan? Select all that apply.
Administer pain medications around the clock. Give oral medications for pain relief. Assess the client's pain experience at every visit. Contact the health care provider if the client reports unrelieved pain.
A client has been in the hospital for the past 10 days following the development of an infection at her surgical incision site. Each morning, the client reports overwhelming fatigue and has told the nurse, "I just can't manage to get any sleep around here." How should the nurse first respond to this client's statement?
Assess the factors that the client believes contribute to the problem.
A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
The nurse has entered the room of a newly admitted client and observed a continuous positive airway pressure (CPAP) on the client's bedside table. Which action(s) will the nurse take to assess the client's use of the CPAP machine? Select all that apply.
Discuss the client's habit of using the CPAP. Examine the fit of the mask.
The nurse is developing a discharge teaching plan for clients taking opioid pain medication. Which of the following should the nurse include? Select all that apply.
Do not drive while taking pain medication. Do not smoke without someone else present. Avoid alcohol.
A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action?
Document the client's allodynia.
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?
Examine the effectiveness of the current pain regimen
A middle-age adult man has just started an exercise program. What would the nurse teach him about timing of exercise and sleep?
Exercising within 2 hours of bedtime can hinder ability to sleep.
Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?
Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea
The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.)
FLACC Scale Wong-Baker Faces Scale COMFORT scale
A nurse implements a back massage as an intervention to relieve pain. What theory is the motivation for this intervention?
Gate-control theory
A client reports periodic difficulty falling asleep. Which teaching will the nurse provide? Select all that apply.
Go on a daily walk. Adhere to a regular schedule for waking and going to sleep. Decrease caffeine intake.
A 62-year-old client informs the nurse that the parent has been anxious and disoriented in the morning. The client also informs the nurse that the parent gets up frequently to use the bathroom. Which nursing intervention can decrease the disruption of sleep?
Have your parent take diuretic medicine in the morning.
A nurse is explaining premenstrual syndrome to a female client. The client demonstrates understands when stating what may occur in the premenstrual phase?
Headache
The nurse prepares to assess a client who is presenting to the infertility clinic for her first appointment. What should the nurse include when obtaining data from the client?
History of an untreated sexually transmitted infection (STI)
A man 68 years of age comes to the clinic complaining that he is having difficulty obtaining an erection. When reviewing the client's history, what might the nurse note that contributes to impotence?
History of hypertension
A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?
Hypothalamus
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis
The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition?
Metabolic alkalosis
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.
Metabolic alkalosis Hypokalemia
A factory worker has a work schedule involving rotating work hours between days, evenings, and nights. The client tells the nurse about being a "morning person" and not sleeping well when working the night shift. Which information will the nurse teach the client about sleep hygiene?
Modify the sleep environment to simulate quiet and darkness.
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
The clinic nurse is explaining the action of sildenafil (Viagra) to a client. The nurse should assess his medication regimen to determine if he is taking medications that are contraindicated with Viagra. Which of the following medications is contraindicated with Viagra?
Nitrates
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload.
The nurse is admitting a client that has obesity and is diagnosed with obstructive sleep apnea (OSA). The client states, "I just wake up a lot and don't feel rested but it's not a big deal." What education should the nurse provide about the complications related to OSA?
OSA contributes to hypertension and heart disease.
A client is alert but nonverbal after a motor vehicle accident. Which action(s) will the nurse include in the assessment of pain for this client? Select all that apply.
Observing for grimacing and other signs of pain Using the Wong Baker FACES pain rating scale Checking for loss of function of the extremities Communicating with the client in writing Performing vital signs
The client is to receive two units of packed red blood cells (PRBC) for anemia following surgery. The nurse is preparing to administer the first unit. What interventions would the nurse take to administer the PRBC safely? Select all that apply.
Obtain baseline vital signs prior to beginning the transfusion. Verify client identification and blood product information with a second nurse. Wear clean gloves when spiking the blood container with the administration set. Check that informed consent has been obtained from the client.
The emergency room nurse is caring for a client who will need a lumbar puncture. The health care provider prescribes lidocaine 2.5% and prilocaine 2.5% cream (EMLA) to decrease the pain associated with the procedure. When should the nurse administer the cream?
One hour prior to the procedure
The nurse is working in the emergency department when a male client states, "I have been exposed to gonorrhea from a sexual partner and I think I have it." What symptoms should the nurse assess in this client that correlate with the client's suspicions of infection? Select all that apply.
Purulent penile discharge Difficulty urinating Increased frequency of urination
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV.
The nurse is conducting an assessment on a 42-year-old female client. The client admits to having unprotected sex with multiple individuals over the years. Based on the data collected during the assessment, which disorder should the nurse suspect this client has?
Syphilis
A client taking a diuretic twice daily for treatment of hypertension reports being awakened often by a full bladder. What teaching regarding the diuretic will the nurse provide?
Take it before 6:00 p.m. at night.
The nurse is assessing a client who was hospitalized due to a fall with brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply.
The client has dark-colored urine with a noticeable odor. The client reports dizziness when standing up from a chair. The client has been working outside in warm temperatures.
A nurse is working with an older adult client who has been diagnosed with onset insomnia and informs the nurse about waking at least once during the night. What actions by the nurse can help promote adequate sleep? Select all that apply.
The nurse advises the client to exercise no closer than 6 hours to bedtime. The nurse encourages the client to remove the television from the bedroom. The nurse encourages the client to minimize caffeine intake several hours prior to bedtime. The nurse helps the client come up with a bedtime routine that can be implemented each night
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
A client visits a community clinic reporting a foul-smelling vaginal discharge that is thin, foamy, and green in color; itching of vulva and vagina; and burning on urination. Which STI would the nurse suspect?
Trichomonas vaginalis
Which sexually transmitted infection has the following characteristics: thin, foamy, greenish vaginal discharge that causes itching of the vulva and vagina?
Trichomoniasis
Which client likely faces a risk for the nursing diagnosis of Disturbed Sleep Pattern: Difficulty Remaining Asleep?
a client who receives IV antibiotics every 3 hours
A nurse is reviewing the medication administration record. Which order does the nurse question?
a diuretic administered twice daily at 9 a.m. and 9 p.m.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
he client is scheduled for a polysomnography to determine if the client has obstructive sleep apnea (OSA). The nurse instructs the client to:
anticipate sleeping overnight at a health care center.
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply.
blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
Cross-matching of blood is ordered for a client before major surgery. What does this process do?
determines compatibility between blood specimens
The nurse learns during the assessment of a client that the client has difficulty falling asleep, wakes up early, and does not feel refreshed in the morning. This client is most likely experiencing:
disturbed sleep pattern.
The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply.
elevated respiratory rate decreased blood pressure
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
hypertonic
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic solution
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L)
hypokalemia
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:
hypokalemia.
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:
hyponatremia
A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client reports coldness around the infusion site. What IV complication does this describe?
infiltration
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
A hospice nurse is assessing a client with end-stage chronic obstructive pulmonary disease (COPD). Which assessment findings would suggest that the client is dying? Select all that apply.
jaundiced skin Cheyne-Stokes respirations decreased urine output
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:
low calcium.
Based on the circadian cycle, the body prepares for sleep at night by decreasing the body temperature and releasing which chemical?
melatonin
Which natural chemical does the body produce at night to decrease wakefulness and promote sleep?
melatonin
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?
muscle cramping and tetany
A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?
phlebitis
A client with renal disease requires IV fluids. It is important for the nurse to:
place the fluids on an electronic device.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:
replacement of fluids for those lost from vomiting and diarrhea.
A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.
respiratory muscle weakness confusion ventricular dysrhythmia
The nurse is preparing to provide education to a group of high school students on sexually transmitted infection (STI) prevention. The nurse knows that this age group often uses oral-genital stimulation as a way to prevent pregnancy. Which concept should the nurse make sure to convey to the group?
skin-to-skin contact can spread herpes and genital warts
A client has voiced concerns about her inability to fall asleep. When reviewing her history, what information would the nurse expect to find? Select all that apply.
smokes 1 pack of cigarettes daily drinks coffee with all meals history of hyperthyroidism
A client with a sleep disorder experiences cataplexy. Which is a feature of this condition?
sudden loss of motor tone that may cause the person to fall asleep; usually experienced during a period of strong emotion
The nurse is performing an assessment for a client related to pain. In order to determine the need for pain medication, what should the nurse base the decision on?
temporal pattern.
A couple have presented to the healthcare provider for a follow up visit following the husband's uncomplicated myocardial infarction (MI) one week ago. The nurse determines that education on resuming intimate sexual contact should be discussed. What timeline regarding sexual intercourse should the nurse be sure is included in the discussion?
three months if no symptoms of chest pain
A client tells the nurse that she is experiencing stabbing pain in her mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of:
trigeminal neuralgia.
A client is diagnosed with narcolepsy. What is a characteristic of this disorder?
uncontrollable desire to sleep
