PN Adult Medical Surgical Online Practice 2020 B

A nurse is caring for a client who is postoperative and has a portable wound bulb suction device. Which of the following actions should the nurse take?

Compress the bulb reservoir and then close the drainage valve Fully compress the bulb reservoir and then replace the valve plug using aseptic technique to establish suction after emptying or activating a portable wound bulb suction device. Portable wound bulb suction device provides closed suction to evacuate drainage from a wound area. The nurse should not instill irrigation fluid into the drain because it can increase the risk for infection. In place for 3 to 5 days following surgery to remove excess fluid and exudate from the surgical incision. Apply a drain sponge around the tubing insertion site of the portable wound bulb suction device. Cutting a slit in a gauze sponge allows fibers to become enmeshed in the wound, which can lead to infection or abscess.

A nurse is caring for a client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes Macular degeneration results in a distortion and blurring of central vision. The client might completely lose central vision and view a dark spot in the center. Narrow angle glaucoma: halos around lights Retinal detachment: colored spots before visual fields. Uveitis: spontaneous tearing of eyes.

A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?

Encourage reminiscence of past experiences to reduce client's confusion.

A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?

Escharotomy Relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible, and the client's oxygenation should improve. Fasciotomy is used to treat compartment syndrome for clients following traumatic musculoskeletal injury. Skin grafting is used to promote wound healing for clients who have large wounds. Hyperbaric oxygen therapy involves high pressure oxygen therapy and is part of treatment for life-threatening wound infections.

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend including in the pamphlet?

Females have a higher risk for contracting STIs than males. Oral contraceptive use, prolonged contact with male secretions, and increased cervical permeability during hormone fluctuations increase a female's risk for acquiring STIs.

A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?

Frequent colds Corticosteroids can increase susceptibility to infection by suppressing the immune response. Hyperglycemia Decreased urination + edema Hypertension resulting from water + sodium retention.

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosemide Increase excretion of potassium -> hypokalemia. Levothyroxine decrease digoxin absorption, lower lvl.

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months. Expected range: 4% - 5.9% 7% effective diabetic control. Dx diabetes: glucose tolerance test + fasting blood glucose test.

A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?

Household family members should be tested for TB.

A nurse is reviewing the plan of care for a client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow between the client's legs. Have the client perform incentive spirometry every 2 hr as well as deep breathing and coughing every 2 hr to prevent atelectasis. Check the neurovascular status on the extremity every 2 to 4 hr.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens o of the affected areas. Use bed cradle

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults. Neutropenia: immunocompromised. Thrombocytopenia: monitor platelet count daily.

A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow.

Lower the client to the floor. Place a pad beneath the client's head. Loosen the clothing around the client's neck. Time the length of the client's seizure. Reorient and reassure the client.

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Maintain hip flexion at 90° or less when sitting. Do not lean forward to change sitting positions.

A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?

Obtain the client's blood pressure. The greatest risk to the client is postural hypotension due to decreased blood volume following surgery. Dangle their legs at the bedside to prevent vertigo. Place the client in Fowler's position, which raises the client's head to prevent vertigo and facilitate movement out of bed

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime. Do not offer hot chocolate because it contains caffeine.

A nurse is contributing to the plan of care for a client who had a stroke. For which of the following interprofessional team members should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist

A nurse in a telemetry unit is collecting data from a client who has a newly-inserted permanent pacemaker. Which of the following findings should the nurse report to the provider?

The client experiences hiccups when sitting. Indicate that the pacemaker wires are displaced or that the pacemaker is not firing properly. Pulse rate of a client who has a newly-inserted permanent pacemaker should not fall below 5/min slower than the preset rate because this could indicate that the pacemaker is not functioning properly Presence of a pacing spike before the P-wave on the ECG rhythm strip is an indication that the pacemaker is firing correctly and that the atria is contracting as intended.

A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?

Truncal obesity Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". Ecchymosis, muscle wasting, facial edema, flushing of cheeks, and thinning of the skin are expected findings of Cushing's syndrome. Addison's disease: bronzing of the skin of the knuckles, knees, and elbows. Lordosis: increase in the curvature of the lumbar spine, which is common for clients who have poor posture Grave's disease: exophthalmos

A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?

Upright, leaning forward to facilitate breathing. Peritonitis: semi-fowler Shock: supine position with lower extremities elevated, or modified Trendelenburg position, to increase the venous return to the heart. Side-lying position with knees bent to assist in decreasing the pain related to a unilateral or sensory motor deficit on one side of the body.

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client. Change the client's position slowly to prevent sudden increases in ICP. The use of a turn sheet to reposition the client provides the nurse with the ability to better control the client's movement and alignment. The nurse should instruct the client to exhale during the position change to prevent an increase in ICP. Monitor the client's temperature every 1 to 2 hr to detect hyperthermia, which can occur following a head injury. Hyperthermia increases the body's blood pressure and blood flow to the brain, which increases ICP. The nurse should also avoid obtaining rectal temperatures because this can trigger the Valsalva maneuver, resulting in an increase of ICP. Avoid coughing because it increases ICP. The nurse should gently reposition the client every 2 hr to prevent pooling of respiratory secretions and can obtain a prescription to suction the client if needed for periods of less than 10 seconds.

A nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure." Antibiotic therapy can be initiated to reduce the risk for endocardial infection. Avoid aspirin + other NSAIDs -> risk for bleeding. Client w/ mechanical mitral valve replacement requires long term anticoagulant therapy. Use soft bristled brush to decrease risk of bleeding. Weigh daily for fluid overload. Report 24 hr wt gain of 1-2 kg.

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet." Low-fiber, low-residue diet to help control pain + inflammation of small intestine + reduce diarrhea. Take antidiarrheal meds to relieve abdominal cramping + loose stools. Decrease dietary fat. Weigh daily.

A nurse is providing information regarding transmission-based precautions for a client who has Clostridium dicile to an assistive personnel (AP). Which of the following instructions should the nurse include?

"Provide the client with disposable utensils and dishes for meals." "Leave blood pressure equipment in the client's room." "Clean contaminated surfaces with a bleach solution."

A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify that which of the following client statements indicates an understanding of the teaching?

"Pursed-lip breathing works best for activities like walking up stairs." Performing pursed-lip breathing during times of activity, such as walking up stairs, helps increase airway pressure and reduce the amount of trapped air in the lungs. This breathing technique helps eliminate excess carbon dioxide that clients who have COPD might retain.

A nurse is reinforcing teaching with a client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

"Take calcium supplements with meals." Perform low-impact aerobic or weight-bearing exercises. Supplement with vit D for calcium absorption. Avoid throw rugs as it increase risk for falling.

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning." Take for rest of life. Do not take w/in 4 hr of taking antacids, iron, calcium supplements.

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include?

"The virus can be transmitted without lesions being present." Genital herpes lesions have a vesicular appearance and occur in clusters. Incurable and recurring viral disease.

A home health nurse is caring for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?

"Use a bronchodilator 30 minutes before your meal." Consume high protein for lung tissue repair. Drink beverages at end of meal + prevent early satiety. Avoid laying down for an hour after meal to promote digestion + air exchange.

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide." Avoid paprika because it is made from raw plants and can contain bacteria. Wash their hands and bodies with antimicrobial soaps.

A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching? (Select all that apply.)

"Your knee is flexed and extended as prescribed by your provider." "The machine is padded with sheep skin." Head of bed can elevate up to 20*. Exert force on CPM, but allow machine to perform PROM. Avoid placing machine on floor to prevent contamination.

A nurse is preparing to assist with the insertion of a double-lumen gastric sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images depicts the tube that the nurse should select?

(Clear tube ending with blue tube) When using a double-lumen gastric sump tube, the clear portion of the tube allows for aspiration of stomach contents. The blue portion of the tube, or the "pigtail", vents the tube to the atmosphere, which prevents the tube from becoming lodged against the wall of the stomach and protects the stomach from damage. Percutaneous endoscopic gastrostomy (PEG) feeding tube. A provider inserts a PEG feeding tube surgically through the abdomen and into the stomach to allow for long-term medication administration and tube feedings. Single-lumen NG tube, which is used to facilitate gastric decompression and removal of gastric contents. Multiple-lumen gastrointestinal tube, which is inserted through the nasal cavity or mouth to place pressure on bleeding esophageal varices for a client who has cirrhosis.

A nurse is reinforcing dietary teaching with a client about increasing the intake of foods containing vitamin C to enhance absorption of oral iron supplements. Which of the following food choices should the nurse include in the teaching?

1 cup of boiled broccoli Brown rice is phytate: can impair iron absorption when consuming iron supplement at the same time. Cottage cheese is calcium: can impair iron absorption when consuming iron supplement at the same time.

A nurse is reinforcing teaching with a client who has coronary artery disease. Which of the following instructions should the nurse include in the teaching?

"Add oily fish to your diet twice weekly." Food rich in omega-3 fatty acids. Exercise to improve blood lipid lvl, wt loss, reduce bp Avoid whole milk (high in saturated fat), consume non fat dairy. Maintain fat intake < 35% of total daily calories

A nurse is reinforcing instructions with a client who has a new hearing aid. Which of the following instructions should the nurse include?

"Adjust the volume to a level where you can hear others speak at a distance of 3 feet." Whistling sound indicates incorrect insertion, improper fit, or wax build up. Do not submerge the hearing aid in water.

A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make?

"Hospice care will provide support for you and your loved ones during the dying process."

A nurse in a health clinic is reinforcing teaching with a client about tuberculosis (TB). Which of the following client statements indicates an understanding of the teaching?

"I can develop TB by breathing in the infection." Airborne transmission. Can develop TB 3-10 weeks Positive reaction: immune response, not actively infected.

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water." Avoid exposure to bacteria

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?

"I had a low fever this morning."

A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?

Decrease in exertional dyspnea Adventitious lung sounds are a manifestation of the presence of secretions or atelectasis.

A nurse is caring for a client who is undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?

Muscle spasticity Parkinson's disease: tremors at rest Myasthenia gravis: ptosis Guillain-Barre syndrome: ascending paralysis

A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching which can lead to hypocalcemia (twitching, paresthesia of fingers, toes, mouth)

A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take?

Notify the charge nurse of the client's BUN level. Expected range: 10 - 20 mg/dL

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

"Calcitonin will slow the breakdown of bone in your body." Calcitonin inhibits osteoclast activity, therefore minimizing bone loss. Adrenocorticotropic hormone increases the secretion of cortisol. Parathyroid hormones decrease urinary excretion of calcium. Epinephrine and norepinephrine increase blood flow to skeletal muscles, help the body withstand stress, and prevent hypoglycemia.

A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response to the medication?

"I have gained 3 pounds since my last appointment." Hyperthyroidism can cause weight loss.

A nurse is reinforcing teaching with a client prior to the removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter."

A nurse is reinforcing teaching with a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will limit my coffee intake." Can excrete calcium through diuretic effects.

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

"I will limit my daily intake of protein to slow progression of kidney failure." Maintain adequate carbs. Restrict fluids + phosphorus. Avoid potassium -> kidney causes hyperkalemia. Avoid salt subs (high in K)

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as an expected change associated with aging?

"My food tastes bland even after I add seasoning." Due to tongue atrophy. Constipation common. Usually retain long term memory better than short term. Perspiration decreases.

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

"Perform testicular self-examination after taking a warm shower." Causes relaxation of the scrotal skin, which allows for better palpation of the testes.

A nurse is caring for a client who has prostate cancer. The client asks the nurse why they are having difficulty with urination. Which of the following responses should the nurse make?

"The tumor causes obstruction of urine from the urethra." Increase protein-specific antigen.

A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who is dehydrated, has mental confusion, and has tried to get out of bed several times during the night. Dehydration -> risk for falls.

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans

A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr?

864

A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?

Assist the client to change positions at least every 2 hr to promote return of respiratory function following anesthesia and prevent atelectasis and pneumonia. Have the client use the incentive spirometer once per hour while awake during the first 24 hr postoperative to prevent respiratory complications. Never massage the extremities because doing so could dislodge a blood clot, causing a pulmonary embolus.

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen as it is a nonopioid analgesic that is a good choice for a client who has osteoarthritis because its adverse effects are less toxic than many other analgesics. However, clients should be advised that acetaminophen toxicity can cause liver damage. Methotrexate, etanercept: rheumatoid arthritis. Gabapentin: neuropathic pain.

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?

Allow the weights to hang freely. Refrain from bumping into weights. AP should ensure ropes run across pulleys w/in pulleys' grooves + that any knots are not touching pulley system.

A nurse is monitoring a client who has a cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the cast using a blow dryer on a cool setting. Pregabalin is used to relieve nerve pain Have the provider bivalve a cast to relieve pressure caused by impaired blood flow. The cast is split down both sides and held together with hook and loop fastener straps to maintain immobilization.

A nurse in a dermatology clinic is reviewing the medical records of a group of clients. Which of the following prescriptions for a client who has psoriasis should the nurse clarify with the provider?

Dermabrasion Dermabrasion: treatment for acne that could trigger further irritation in a client who has psoriasis. Topical steroid cream, coal tar ointment, UV radiation are treatments for psoriasis.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube.

A nurse is caring for a client who is 2 hr postoperative following the amputation of a foot. Which of the following actions should the nurse take first?

Check the incisional dressing for excessive bleeding (hemorrhaging)

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?

Cleanse the client's skin prior to electrode placement to improve electrode conduction. Electrodes are prelubed to adhere to skin + provide clear signal transmission. Electrodes on chest + limbs. Supine position.

A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take?

Cleanse the drainage plug with alcohol swabs. Secure the drainage tube to the client's gown to allow for ambulation. Pinning the gown to the client's bedding can result in dislodgement of the drain.

A nurse is caring for a client who is postoperative following an above-the-knee amputation of the right leg and reports pain in the absent portion of the limb. The client received an opioid analgesic 1 hr prior. Which of the following actions should the nurse take?

Collaborate with the physical therapist to initiate alternative pain therapies. Phantom limb pain is a type of neuropathic pain. Antiepileptic and antispasmodic medications can be more effective than opioid medications with neuropathic pain.

A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease? Rheumatoid arthritis Diabetes mellitus Myasthenia gravis Crohn's disease

Diabetes mellitus Risk for developing cardiovascular and peripheral vascular disease because of the changes in the microvasculature resulting from elevated levels of glucose. Rheumatoid arthritis: risk for iron deficiency anemia. Myasthenia gravis: risk for pneumonia due to aspiration resulting from muscle weakness. Crohn's disease: risk for malabsorption, malnutrition, and eventually colon cancer resulting from repeated damage to the intestinal mucosa.

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough ACE inhibitor -> dry, nonproductive cough. Beta blocker meds: decrease HR, alter glucose lvls. Enalapril: vertigo

A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?

Decreased blood pressure Indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath sounds Might indicate a pneumothorax or laryngeal edema

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Adverse effects: nasal + throat discomfort, muscle pain + stiffness

A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?

Elevated serum amylase level due to injury of pancreatic cells. Hypotension, tachycardia, + increased leukocyte count.

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?

Elevated troponin Troponin is used specifically to detect cardiac muscle injury. Creatinine: kidney fx ESR: infection/inflammation of body. Lipase: pancreatic disease

A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heart rate 120/min

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain?

Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully. Injury to the parietal lobe results in alterations to higher-level activities, such as writing, and processing sensory information, such as proprioception, pain, temperature, touch, and pressure. Injury to the occipital lobe results in alterations in visual perception and the ability to track movement of an object. Injuries to this area can result in an inability to recognize objects, faces, or the written word. Injury to the temporal lobe results in alterations in the ability to understand the spoken language and impaired short-term memory.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride to clear the tubing of any blood clots or tissue pieces and allow for a better flow. Slowing the bladder irrigation flow rate will increase the risk for clotting in the tubing and disrupt the irrigation output. Applying a clamp to the urethral catheter will prevent drainage from the bladder and increase the risk for bladder trauma.

A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light. Opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight. Discard insulin if it becomes discolored.

A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?

Oxygen saturation of 88%

A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?

Place the client in a negative-pressure airflow room.

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals to decrease rapid gastric emptying. Do not consume fluids with meals because it increases the rate of gastric emptying. Offer 6 small meals throughout the day to prevent gastric distention and episodes of dumping syndrome.

A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking their medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?

Prednisone Prednisone is administered to replace glucocorticoids, which are deficient in adrenocortical insufficiency. Abrupt withdrawal of the medication can lead to an adrenal crisis. Furosemide is a high-ceiling loop diuretic used to treat heart failure. Methimazole is an antithyroid hormone used to treat hyperthyroidism. Metoprolol is a beta-adrenergic antagonist used to treat hypertension.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client. When the client's body is out of alignment with the traction, muscle spasms develop, causing increased pain. Therefore, the nurse should reposition the client, ensuring there is a straight line from the client's hip to the traction rope and pulley, evaluate the client's response, and provide other interventions as needed. Do not massage area. Do not remove weights unless ordered. Do not loosen ropes.

A nurse is repositioning a client who has low back pain. Which of the following positions is should the nurse place the client in?

Semi-Fowler's with knees flexed Sitting in semi-Fowler's position with the head of bed elevated 15° to 45° and flexing the knees will help relax the lumbar area of the client's back and relieve pressure on the nerves. Clients in the orthopneic position sit forward and lean on an overbed table, which does not relax the lumbar area or relieve pressure on the nerves. Clients in the dorsal recumbent position lie flat in bed with pillows for support, which does not relax the lumbar area or relieve pressure on the nerves. Clients in the prone position lie flat on the abdomen, which does not relax the lumbar area or relieve pressure on the nerves.

A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress. Sit in a firm, straight-back chair to help maintain upper body alignment. Apply heat to painful joints to relieve muscle spasms + reduce pain.

A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?

Urine output is 50 mL/hr. Monitor the client's lung sounds because pneumonia is a complication of burns. Clear lung sounds only indicate that the client has not had excessive fluid replacement, not whether fluid resuscitation was adequate.

A nurse is preparing a client for a cardiac catheterization. Which of the following actions should the nurse take rst?

Verify the client has given informed consent.

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3 indicates infection. Report a urine output of less than 30 mL/hr as an indication of hypovolemia or kidney impairment This urine output is within the expected reference range of at least 30 mL/hr.

A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following? (Click on the audio button to listen to the clip.)

Wheezes Pleural friction rub: dry, grating sound during respirations, client with pleurisy. Vesicular: soft, low-pitched blowing sounds that occur as air passes through the smaller airways, auscultate periphery of lung field of client w/o pulmonary illness. Crackles: crackling or bubbling sounds heard during inspiration, auscultate lungs of client with fluid overload. Crackles can be termed fine, medium, or coarse and are an indication of air passing through fluid or mucus. Crackles do not tend to clear with coughing.

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin. This will protect the regular insulin from contamination with the NPH insulin.

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

Withhold the dose. Digoxin slows HR.