Pt care Exam 3Practice

A nurse is completing a health history with the daughter of a newly admitted pt who is confused & agitated. The daughter reports that her mother was diagnosed with Alzheimer's disease 1 year ago but became extremely confused last evening & was hallucinating. She was unable to calm her, & her mother thought she was a stranger. On the basis of this history, the nurse suspects that the pt is experiencing: 1. Normal aging. 2. Delirium. 3. Depression. 4. Worsening dementia.

2. Delirium.

To best assist a pt in the grieving process, which factors are most important for the nurse to assess? (SATA) 1. Previous experiences with grief & loss 2. Religious affiliation & denomination 3. Ethnic background & cultural practices 4. Current financial status 5. Current medications

1. Previous experiences with grief & loss 2. Religious affiliation & denomination 3. Ethnic background & cultural practices

During a home health visit a nurse talks with a pt & his family caregiver about the pt's meds. The pt has hypertension & renal disease. Which of the following findings place him at risk for an adverse drug event? (SATA) 1. Taking 2 medications for hypertension 2. Taking a total of eight different medications during the day 3. Having 1 physician who reviews all medications 4. Pt's health history of renal disease 5. Involvement of the caregiver in helping with medication administration

2. Taking a total of eight different medications during the day 4. Pt's health history of renal disease

A nurse is participating in a health & wellness event at the local community center. A woman approaches & relates that she is worried that her widowed father is becoming more functionally impaired & may move in with her. The nurse asks about his ability to complete activities of daily living (ADLs). ADLs include independence with: (SATA) 1. Driving. 2. Toileting. 3. Bathing. 4. Daily exercise. 5. Eating.

2. Toileting. 3. Bathing. 5. Eating.

An assessment of which of the following is most important when a nurse is caring for an adult client experiencing vomiting? A. Electrolyte values B. Bowel function C. Body weight D. Oral mucosa

A. Electrolyte values

Which most common cause of sleep deprivation in the hospital should the nurse consider when planning care? A. Fragmented sleep B. Early awakening C. Restless legs D. Sleep apnea

A. Fragmented sleep

A nurse checks a meal tray for a client on a clear liquid diet. Which item is acceptable on this diet? A. Ginger ale B. Lemon sherbet C. Vanilla ice cream D. Cream of chicken soup

A. Ginger ale

Older adults frequently experience a change in sexual activity. Which best explains this change? 1. The need to touch & be touched is decreased. 2. The sexual preferences of older adults are not as diverse. 3. Medication side effects often impact sexual functioning. 4. Frequency & opportunities for sexual activity may decline.

4. Frequency & opportunities for sexual activity may decline.

A nurse is instructing a client who has narcolepsy about measures that might help with self‑management. Which of the following statements should the nurse identify as an indication that the client understands the instructions? A. "I'll add plenty of carbohydrates to my meals." B. "I'll take a short nap whenever I feel a little sleepy." C. "I'll make sure I stay warm when I am at my desk at work." D. "It's okay to drink alcohol as long as I limit it to one drink per day."

B. "I'll take a short nap whenever I feel a little sleepy."

A nurse is caring for a critically ill client with a urinary retention catheter. Which hourly urine output should first alert the nurse that the primary health-care provider should be notified? A. 20 mL B. 30 mL C. 60 mL D. 120 mL

B. 30 mL

A nurse on a medical‑surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? A. A client who has a new diagnosis of adrenal insufficiency B. A client who has heart failure C. A client who is receiving treatment for diabetic ketoacidosis D. A client who has abdominal ascites

B. A client who has heart failure

A nurse is teaching a client various techniques to promote sleep. Which internal stimulus that most commonly interferes with sleep should the nurse include in the teaching? A. Ringing in the ears B. Bladder fullness C. Hunger D. Thirst

B. Bladder fullness

A nurse is planning care for a client who has dehydration. Which of the following actions should the nurse include? A. Administer antihypertensive on schedule. B. Check the client's weight each morning. C. Notify the provider of a urine output greater than 30 mL/hr. D. Encourage independent ambulation four times a day.

B. Check the client's weight each morning.

A nurse is collecting data from a client who has hypercalcemia as a result of long‑term use of glucocorticoids. Which of the following findings should the nurse expect? (Select all that apply.) A. Hyperreflexia B. Confusion C. Positive Chvostek's sign D. Bone pain E. Nausea and vomiting

B. Confusion D. Bone pain E. Nausea and vomiting

A client has been in the intensive care unit (ICU) for 3 days. For which common adaptation indicating ICU psychosis associated with sleep deprivation should the nurse assess the client? A. Hypoxia B. Delirium C. Lethargy D. Dementia

B. Delirium

A client is experiencing lack of sleep because of pain. Which is the most appropriate goal for this client? A. The client will be provided with a back massage every evening before bedtime. B. The client will report feeling rested after awakening in the morning. C. The client will request less pain medication during the night. D. The client will experience four hours of uninterrupted sleep.

B. The client will report feeling rested after awakening in the morning.

When a client is under extreme stress, there is an increased production of antidiuretic hormone and aldosterone. The nurse plans to monitor the client routinely because an increase in these hormones will cause a decrease in which of the following? A. Blood pressure B. Urinary output C. Body temperature D. Sweat gland secretions

B. Urinary output

A client has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this client? A. Asking what is an acceptable level of pain B. Providing interventions that do not precipitate pain C. Focusing on pain management intervention before pain is excessive D. Determining the level of function that can be performed without pain

C. Focusing on pain management intervention before pain is excessive

A nurse is caring for a client who has dependent edema. Which pressure has caused the excess fluid in the interstitial compartment? A. Oncotic pressure B. Diffusion pressure C. Hydrostatic pressure D. Intraventricular pressure

C. Hydrostatic pressure

A client is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis; dry, sticky mucous membranes; weakness; disorientation; and a decreasing level of consciousness. Which electrolyte imbalance do these data support? A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia

C. Hypernatremia

A client exhibits an increasing blood pressure and 2-pound weight gain over 2 days. Which additional clinical manifestation can be clustered with these data? A. Decrease in heart rate B. Increase in skin turgor C. Increase in pulse volume D. Decrease in pulse pressure

C. Increase in pulse volume

A nurse is providing education for a client who has severe hypomagnesemia and is prescribed oral magnesium sulfate. Which of the following information should the nurse include in the teaching? A. "Avoid green, leafy vegetables while taking this medication." B. "You should receive a prescription for a thiazide diuretic to take with the magnesium." C. "You should eliminate whole grains from your diet until your magnesium level increases." D. "Report diarrhea while taking this medication."

D. "Report diarrhea while taking this medication."

A nurse is consoling the partner of a client who just died after a long battle with liver cancer. The grieving partner states, "I hate them for leaving me." Which of the following statements should the nurse make to facilitate mourning for the partner? SATA a. "Would you like me to contact the chaplain to come & speak with you?" b. "You will feel better soon. You have been expecting this for a while now." c. "Let's talk about your children & how they are going to react." d. "You know, it is quite normal to feel anger toward your loved one at this time." e. "Tell me more about how you are feeling."

a. "Would you like me to contact the chaplain to come & speak with you?" d. "You know, it is quite normal to feel anger toward your loved one at this time." e. "Tell me more about how you are feeling."

A nurse is talking with an older adult client about improving nutritional status. Which of the following interventions should the nurse recommend? SATA a. Increase protein intake to increase muscle mass. b. Decrease fluid intake to prevent urinary incontinence. c. Increase calcium intake to prevent osteoporosis. d. Limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation.

a. Increase protein intake to increase muscle mass. c. Increase calcium intake to prevent osteoporosis. d. Limit sodium intake to prevent edema. e. Increase fiber intake to prevent constipation.

A nurse is collecting data from an older adult client as part of a comprehensive physical examination. Which of the following findings should the nurse expect as associated with aging? SATA a. Skin thickening b. Decreased height c. Increased saliva production d. Nail thickening e. Decreased bladder capacity

b. Decreased height d. Nail thickening e. Decreased bladder capacity

A nurse is planning a presentation for a group of older adults about health promotion & disease prevention. Which of the following interventions should the nurse plan to recommend? SATA a. Human papilloma virus (HPV) immunization b. Pneumococcal immunization c. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood test

b. Pneumococcal immunization c. Yearly eye examination d. Periodic mental health screening e. Annual fecal occult blood test

A nurse is providing teaching for an older adult client who has lost 4.5 kg (9.9 lb) since the last admission 6 months ago. Which of the following instructions should the nurse include in the teaching? SATA a. "Eat 3 large meals a day." b. "Eat your meals in front of the television." c. "Eat foods that are easy to eat (finger foods)" d. "Invite family to eat meals with you." e. "Exercise every day to increase appetite."

c. "Eat foods that are easy to eat (finger foods)" d. "Invite family to eat meals with you." e. "Exercise every day to increase appetite."

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? SATA a. Remove the dentures from the body. b. Make sure body is lying completely flat. c. Apply fresh linens & provide clean gown d. Remove all equipment from bedside. e. Dim the lights in the room.

c. Apply fresh linens & provide clean gown d. Remove all equipment from bedside. e. Dim the lights in the room.

A nurse is caring for a client who has stage IV lung cancer & is 3 days postoperative following a wedge resection. The client states, "I told myself that I would go through with the surgery & quit smoking, if I could just live long enough to attend my child's wedding." Based on the Kübler‑Ross model, which stage of grief is the client experiencing? a. Anger b. Denial c. Bargaining d. Acceptance

c. Bargaining

A nurse identifies that an older adult client may have a problem with excess fluid volume. Which characteristics of the client's skin support this conclusion? A. Dry and scaly B. Taut and shiny C. Red and irritated D. Thin and inelastic

B. Taut and shiny

A nurse is obtaining a health history from a newly admitted client. Which client statement about alcohol intake is based on a common physiological response? A. "After I go drinking, I have to urinate during the night." B. "When I drink, I get hungry in the middle of the night." C. "Falling asleep is hard, but once asleep I sleep great." D. "If I drink too much, I oversleep in the morning."

A. "After I go drinking, I have to urinate during the night."

A nurse conducted an assessment of a new pt who came to the medical clinic. The pt is 82 years old & has had osteoarthritis for 10 years & diabetes mellitus for 20 years. He is alert but becomes easily distracted during the assessment. He recently moved to a new apartment, & his pet beagle died just 2 months ago. He is most likely experiencing: 1. Dementia. 2. Depression. 3. Delirium. 4. Anxiety.

2. Depression.

Which concept should the nurse consider when assessing a client's pain? A. The expression of pain is not always congruent with the pain experienced. B. Pain medication can significantly increase a client's pain tolerance. C. The majority of cultures value the concept of suffering in silence. D. Most people experience approximately the same pain tolerance.

A. The expression of pain is not always congruent with the pain experienced.

A nurse is assessing a client experiencing acute pain. Which characteristic is more common with acute pain than with chronic pain? A. Self-focusing B. Sleep disturbances C. Guarding behaviors D. Variations in vital signs

D. Variations in vital signs

Which is important for a nurse to consider when a client reports the presence of pain? Select all that apply. A. The extent of pain is directly related to the amount of tissue damage. B. Fatigue decreases the intensity of pain experienced by the client. C. Behavioral adaptations are congruent with statements about pain. D. Giving opioids to a client in pain will lead to an addiction. E. The person feeling the pain is the authority on the pain.

E. The person feeling the pain is the authority on the pain.

A nurse is caring for a client who has terminal lung cancer. The nurse observes the client's family assisting with all ADLs. Which of the following rationales for self‑care should the nurse communicate to the family? a. Allowing the client to function independently will strengthen muscles & promote healing. b. The client needs privacy at times for self‑reflecting & organizing life. c. The client's sense of loss can be lessened through retaining control of some areas of life. d. Performing ADLs is a requirement prior to discharge from an acute care facility.

c. The client's sense of loss can be lessened through retaining control of some areas of life.

When the nurse is assessing a client, the client states, "The pain moves from my chest down my left arm." Which characteristic of pain is associated with this statement? A. Pattern B. Duration C. Location D. Constancy

C. Location

A nurse is caring for clients receiving a variety of interventions for pain management. Which pain relief method has the shortest duration of action? A. Client-controlled analgesia B. Intramuscular sedatives C. Intravenous narcotics D. Regional anesthesia

C. Intravenous narcotics

A 71-year-old pt enters the emergency department after falling down stairs at church. The nurse is conducting a fall history with the pt & his wife. They live in a one-level ranch home. He's had diabetes for over 15 years & experiences some numbness in his feet. He wears bifocal glasses. His BP is stable at 130/70. The pt doesn't exercise regularly & states that he experiences weakness in his legs when climbing stairs. He is alert, oriented, & able to answer questions clearly. What are the fall risk factors for this pt? (SATA) 1. Impaired vision 2. Residence design 3. Blood pressure 4. Leg weakness 5. Exercise history

1. Impaired vision 4. Leg weakness 5. Exercise history

A nurse sees a 76-year-old woman in the outpatient clinic. She states that she recently started to notice a glare in the lights at home. Her vision is blurred, & she is unable to play cards with her friends, read, or do her needlework. Which of the following nursing interventions are appropriate? (SATA) 1. Refer her to an ophthalmologist. 2. Suggest large-print books & playing cards. 3. Reassure her that this is part of normal aging. 4. Suggest lower-wattage light bulbs to decrease glare. 5. Assess her home environment for safety.

1. Refer her to an ophthalmologist. 2. Suggest large-print books & playing cards. 5. Assess her home environment for safety.

A 63-year-old pt is retiring from his job at an accounting firm where he was in a management role for the past 20 years. He has been with the same company for 42 years & was a dedicated employee. His wife is a homemaker. She raised their 5 children, babysits for her grandchildren as needed, & belongs to numerous church committees. What are the major concerns for this pt? (SATA) 1. The loss of his work role 2. The risk of social isolation 3. A determination on whether the wife will need to start working 4. How the wife expects household tasks to be divided in the home in retirement 5. The age the pt chose to retire

1. The loss of his work role 4. How the wife expects household tasks to be divided in the home in retirement

A pt's family member is considering having her mother placed in a nursing center. The nurse has talked with the family before & knows that this is a difficult decision. Which of the following criteria does the nurse recommend in choosing a nursing center? (SATA) 1. The center needs to be clean, & rooms should look like a hospital room. 2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 4. The center provides 3 meals daily with a set menu & serving schedule. 5. Staff encourage family involvement in care planning & assisting with physical care.

2. Adequate staffing is available on all shifts. 3. Social activities are available for all residents. 5. Staff encourage family involvement in care planning & assisting with physical care.

A nurse is assessing an older adult brought to the emergency department following a fall & wrist fracture. The pt is very thin & unkempt, has a stage 3 pressure injury on her coccyx, & has old bruising to the extremities in addition to her new bruises from the fall. She defers all of the questions to her caregiver son, who accompanied her to the hospital. What is the nurse's next step? 1. Call social services to begin nursing home placement. 2. Ask the son to step out of the room so that she can complete her assessment. 3. Call adult protective services b/c you suspect elder mistreatment. 4. Assess the pt's cognitive status.

2. Ask the son to step out of the room so that she can complete her assessment.

A nurse in a provider's office is caring for a client who states that, for the past week, "I have felt tired during the day & cannot sleep at night." Which of the following responses should the nurse ask when collecting data about the client's difficulty sleeping? SATA A. "Have your working hours changed recently?" B. "Do you feel confused in the late afternoon?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing."

A. "Have your working hours changed recently?" C. "Do you drink coffee, tea, or other caffeinated drinks? If so, how many cups per day?" D. "Has anyone ever told you that you seem to stop breathing for a few seconds while you are asleep?" E. "Tell me about any personal stress you are experiencing."

A nurse on a medical‑surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? A. A client who has nasogastric suctioning B. A client who has chronic constipation C. A client who has syndrome of inappropriate antidiuretic hormone D. A client who took an toxic dose of sodium bicarbonate antacids

A. A client who has nasogastric suctioning

A 2-g sodium diet is prescribed for a client with hypertension. Which food should the nurse teach the client to avoid? Select all that apply. A. American cheese B. Canned tuna fish C. Shredded wheat D. Potatoes E. Cashews

A. American cheese B. Canned tuna fish

A nurse is helping a client who is experiencing mild pain to get ready for bed. Which nursing action is most effective to help limit pain? A. Assisting with relaxing imagery B. Obtaining a prescription for an opioid C. Encouraging the client to take a warm shower D. Recommending that the client be more active during the day

A. Assisting with relaxing imagery

A nurse is caring for a client who is experiencing pain. For which common psychological response to pain should the nurse assess the client? A. Concerned about loss of control and independence B. Withdrawing from social interactions with others C. Asking for medication to provide for relief D. Experiencing nausea and vomiting

A. Concerned about loss of control and independence

A nurse is reviewing the medical record of a client who has hypocalcemia. The nurse should identify which of the following findings as a risk factor for the development of this electrolyte imbalance? A. Crohn's disease B. Postoperative following appendectomy C. History of bone cancer D. Hyperthyroidism

A. Crohn's disease

A client is having difficulty sleeping and may be experiencing shortened non-rapid-eye-movement (NREM) sleep. Which client assessment supports this conclusion? Select all that apply. A. Decreased pain tolerance B. Inability to concentrate C. Excessive sleepiness D. Irritability E. Confusion

A. Decreased pain tolerance C. Excessive sleepiness

A nurse is assessing a client experiencing chronic pain. Which characteristic is more common with chronic pain than with acute pain? Select all that apply. A. Gradual onset B. Long duration C. Anticipated end D. Psychologically depleting E. Responds to conventional interventions

A. Gradual onset B. Long duration D. Psychologically depleting

A nurse is reviewing the laboratory test results for a client who has an elevated temperature. The nurse should identify which of the following findings is a manifestation of dehydration? (Select all that apply.) A. Hct 55% B. Blood osmolarity 260 mOsm/kg C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035 E. Blood creatinine 0.6 mg/dL

A. Hct 55% C. Blood sodium 150 mEq/L D. Urine specific gravity 1.035

A client receiving an enteral feeding develops diarrhea. Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea? A. Hypertonic B. Hypotonic C. Isotoinc D. Icteric

A. Hypertonic

A nurse is documenting a client's I&O. Which should be recorded at approximately half its volume? A. Ice chips given by mouth B. A continuous bladder irrigation C. Solution used to maintain patency of a tube. D. A tube feeding of half formula and half water

A. Ice chips given by mouth

A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse include in the plan of care? A. Infuse hypotonic IV fluids. B. Implement a fluid restriction. C. Increase sodium intake. D. Administer sodium polystyrene sulfonate.

A. Infuse hypotonic IV fluids.

A nurse is assessing a client's fluid status. Which of the following assessments indicate that the client has a deficient fluid volume? Select all that apply. A. Negative balance of intake and output B. Increased body temperature C. Decreased blood pressure D. Flat neck veins E. Weight loss

A. Negative balance of intake and output B. Increased body temperature C. Decreased blood pressure D. Flat neck veins E. Weight loss

A nurse is talking with a client about ways to help sleep & rest. Which following recommendations should the nurse give to the client to promote sleep & rest? SATA A. Practice muscle relaxation techniques. B. Exercise each morning. C. Take an afternoon nap. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.

A. Practice muscle relaxation techniques. B. Exercise each morning. D. Alter the sleep environment for comfort. E. Limit fluid intake at least 2 hr before bedtime.

A nurse at a clinic is collecting data about pain from of a client who reports severe abdominal pain. The nurse asks the client if there has been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine? A. Presence of associated manifestations B. Location of the pain C. Pain quality D. Aggravating and relieving factors

A. Presence of associated manifestations

A nurse is preparing a presentation at a local community center about sleep hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? SATA A. REM sleep provides cognitive restoration. B. REM sleep lasts about 90 min. C. It is difficult to awaken a person in REM sleep. D. Sleepwalking occurs during REM sleep. E. Vivid dreams are common during REM sleep.

A. REM sleep provides cognitive restoration. C. It is difficult to awaken a person in REM sleep. E. Vivid dreams are common during REM sleep.

A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult? A. Serum laboratory values B. Intake and output results C. Condition of the skin D. Presence of tenting

A. Serum laboratory values

A client's diet is progressed from clear liquid to full liquid. Which can the nurse include on the full-liquid diet that is not included on the clear-liquid diet? Select all that apply. A. Vanilla ice cream B. Cream of Wheat C. Cranberry juice D. Sport drinks E. Custard F. Milk

A. Vanilla ice cream B. Cream of Wheat E. Custard F. Milk

When assessing clients who have difficulty sleeping, the nurse assess for which common physiological response to insomnia? Select all that apply. A. Vertigo B. Fatigue C. Irritability D. Headache E. Frustration

A. Vertigo B. Fatigue D. Headache

A primary health-care provider prescribes a client's IV fluids to be discontinued. Which is an essential nursing intervention when discontinuing the client's intravenous infusion? A. Withdraw the intravenous catheter along the same angle of its insertion. B. Use an alcohol swab to scrub the insertion site. C. Flush the line with normal saline. D. Don sterile gloves.

A. Withdraw the intravenous catheter along the same angle of its insertion.

A client has continuous bladder irrigation. Which should the nurse do with the irrigant on the I&O sheet when calculating the fluid balance for this client? A. Add it to the oral intake column. B. Deduct it from the total urine output. C. Subtract it from the intravenous flow sheet as output. D. Document the intake hourly in the urine output column.

B. Deduct it from the total urine output.

A nurse evaluates a client's fluid balance by monitoring the client's intake and output. Which must the nurse understand about the ratio of the client's fluid intake to output? A. Intake should be much higher than the fluid output. B. Intake should be slightly more than the output. C. Intake should be lower than the urine output. D. Intake should be equal to the urine output.

B. Intake should be slightly more than the output.

A nurse assesses a client for the clinical manifestations of electrolyte imbalances. Which of the following indicates that the client may have a potassium deficiency? Select all that apply. A. Increased blood pressure B. Irregular pulse rhythm C. Muscle tension D. Chest pain E. Dry hair

B. Irregular pulse rhythm

Which is the most important nursing intervention that supports a client's ability to sleep in the hospital setting? A. Providing an extra blanket B. Limiting unnecessary noise on the unit C. Shutting off lights in the client's room D. Pulling curtains around the client's bed at night

B. Limiting unnecessary noise on the unit

A nurse is caring for a client who is having difficulty sleeping. Which client response indicates that the client is not obtaining adequate rapid-eye-movement (REM) sleep? Select all that apply. A. Hyporesponsiveness B. Immunosuppression C. Irritability D. Confusion E. Vertigo

C. Irritability D. Confusion

An older female adult explains to the nurse that she has insomnia. The nurse interviews the client and her husband and reviews the client's medication reconciliation form. Which of the following does the nurse conclude is associated with the client's insomnia? Select all that apply. Client's Clinical Record Interview with Client - Client reports having difficulty falling asleep, waking frequently during the night, and having difficulty falling back to sleep. Client states, "I never feel rested in the morning." Interview with Client's Husband - "My wife's problem with sleeping has been going on for several months. She is so tired during the day that she takes several naps during the day. I encourage her to have a drink of whiskey to knock her out when she goes to bed." Medication Reconciliation Form - Diphenhydramine 50 mg PO at hour of sleep - Metformin 100 mg PO twice a day A. Metformin B. Older adult C. Fe

B. Older adult C. Female gender D. Alcohol intake E. Diphenhydramine

Hydrochlorothiazide, a diuretic, is prescribed for a client who is retaining fluid. The nurse should encourage the client to ingest nutrients that contain which electrolyte? A. Magnesium B. Potassium C. Calcium D. Sodium

B. Potassium

When a nurse evaluates the effectiveness of client teaching, which food selection by a client indicates understanding regarding an abundant source of calcium? Select all that apply. A. Bread B. Yogurt C. Spinach D. Green beans E. Peanut butter

B. Yogurt C. Spinach

A nurse is caring for a client who is receiving morphine via a patient‑controlled analgesia (PCA) infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device? A. "I'll wait to use the device until it's absolutely necessary." B. "I'll be careful about pushing the button too much so I don't get an overdose." C. "I should tell the nurse if the pain doesn't stop while I am using this device." D. "I will ask my adult child to push the dose button when I am sleeping."

C. "I should tell the nurse if the pain doesn't stop while I am using this device."

Which statement by a client indicates a precipitating factor associated with pain? Select all that apply. A. "I usually feel a little dizzy and think I'm going to vomit when I have pain." B. "My pain usually comes and goes throughout the night." C. "I usually have pain after I get dressed in the morning." D. "My pain feels like a knife cutting right through me." E. "My abdominal incision hurts when I cough."

C. "I usually have pain after I get dressed in the morning." E. "My abdominal incision hurts when I cough."

During which time frame do people tend to be the sleepiest? A. 12 noon and 2 p.m. B. 6 a.m. and 8 a.m. C. 2 a.m. and 4 a.m. D. 6 p.m. and 8 p.m.

C. 2 a.m. and 4 a.m.

A nurse is caring for a client who has been following the facility's routine & bathing in the morning. However, at home, the client always takes a warm bath just before bedtime. Now the client is having difficulty sleeping at night. Which of the following actions should the nurse take first? A. Rub the client's back for 15 min before bedtime. B. Offer the client warm milk & crackers at 2100. C. Allow the client to take a bath in the evening. D. Ask the provider for a sleeping medication.

C. Allow the client to take a bath in the evening.

A nurse strains a back muscle when moving a client up in bed. Which can the nurse do at home that utilizes the gate-control theory of pain relief to minimize the discomfort? A. Use guided imagery. B. Perform progressive muscle relaxation. C. Apply a cold compress to the site for 20 minutes. D. Take a nonsteroidal anti-inflammatory medication every 6 hours.

C. Apply a cold compress to the site for 20 minutes.

A nurse is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the nurse identify as an adverse effect of opioids? (Select all that apply.) A. Urinary incontinence B. Diarrhea C. Bradypnea D. Orthostatic hypotension E. Nausea

C. Bradypnea D. Orthostatic hypotension E. Nausea

A client receiving a diuretic is encouraged to increase the intake of potassium. Which food selected by the client indicates that the teaching is understood? Select all that apply. A. Pears B. Cabbage C. Cantaloupe D. Fresh salmon E. Chicken liver

C. Cantaloupe D. Fresh salmon

Which is most important for nurses to understand when caring for clients in pain? A. Clients who are in pain will request pain medication. B. Clients usually are able to describe the characteristics of their pain. C. Clients need to know that the nurse believes what they say about their pain. D. Clients will demonstrate vital signs that are congruent with the intensity of their pain.

C. Clients need to know that the nurse believes what they say about their pain.

A nurse is caring for two clients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these clients? A. Diarrhea B. Cachexia C. Deficient fluid volume D. Impaired skin integrity

C. Deficient fluid volume

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has a fluid overload? A. Chills, fever, and generalized discomfort B. Blood in the tubing close to the insertion site C. Dyspnea, headache, and increased blood pressure D. Pallor, swelling, and discomfort at the insertion site

C. Dyspnea, headache, and increased blood pressure

A nurse is assessing a client in pain. Which word might the nurse use when documenting the pattern of a client's pain? A. Tenderness B. Moderate C. Episodic D. Phantom

C. Episodic

Which concept associated with sleep should the nurse consider to plan nursing care for a hospitalized client? A. People require eight hours of uninterrupted sleep to meet energy needs. B. Frequency of awakenings during sleep decreases as people age. C. Fear can interfere with the ability to relax and sleep. D. Bedrest decreases the need for sleep.

C. Fear can interfere with the ability to relax and sleep.

A nurse receives a laboratory report for a client indicating a potassium level of 5.2 mEq/L. When notifying the provider, the nurse should expect which of the following actions? A. Starting an IV infusion of 0.9% sodium chloride B. Consulting with dietitian to increase intake of potassium C. Initiating continuous cardiac monitoring D. Preparing the client for gastric lavage

C. Initiating continuous cardiac monitoring

A client in the hospital emergency department tells the nurse, "I feel lousy, and I've had diarrhea for several days. I have nausea, and I don't feel like eating or drinking." The nurse obtains the client's vital signs, performs a focused physical assessment, and reviews the results of laboratory studies. Which should the nurse conclude is the client's human response based on this information? Client's Clinical Record Vital Signs - Temperature: 101.2F, oral - Pulse: 92 beats per minute, regular, thready - Respirations: 26 breaths per minute, deep - Blood pressure: 100/60 mm Hg Focused Physical Assessment - Weight loss of 4 pounds in 3 days - Tenting of the skin Laboratory Values - Urine specific gravity: 1.036 - Serum potassium: 5.3 mEq/L - Arterial blood gases: pH: 7.30 PaCO2: 24 mEq/L HCO3: 18 mEq/L A. Hypokalemia B. Hypervolemia C. Metabolic acidosis D. Respiratory alkalosis

C. Metabolic acidosis

A nurse is collecting data from a client who is reporting pain despite taking analgesia. Which of the following actions should the nurse take to determine the intensity of the client's pain? A. Ask the client what precipitates the pain. B. Question the client about the location of the pain. C. Offer the client a pain scale to measure their pain. D. Use open‑ended questions to identify the client's pain sensations.

C. Offer the client a pain scale to measure their pain.

Which should a nurse do to encourage a confused client to drink more fluid? A. Serve fluid at a tepid temperature. B. Explain the reason for the desired intake. C. Offer the client something to drink every hour. D. Leave a pitcher of water at the client's bedside.

C. Offer the client something to drink every hour.

Which of the following statements associated with rest and sleep must the nurse consider when planning nursing care? Select all that apply. A. Energy demands increase with age. B. Metabolic rate increases during rest. C. Sleep requirements increase during stress. D. Catabolic hormones increase during sleep. E. Lack of awareness of the environment increases with sleep.

C. Sleep requirements increase during stress. E. Lack of awareness of the environment increases with sleep.

A nurse is performing an admission assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply.) A. Distended neck veins B. Hyperthermia C. Tachycardia D. Syncope E. Decreased skin turgor

C. Tachycardia D. Syncope E. Decreased skin turgor

A nurse is performing an admitting interview. Which client statement about pain should cause the most concern for the nurse? A. "I try to pretend that it is not part of me, but it takes a lot of effort." B. "My pain medication works, but I'm afraid of becoming addicted." C. "At home, I take something for the pain before it gets too bad." D. "They say my pain may get worse, and I can't stand it now."

D. "They say my pain may get worse, and I can't stand it now."

A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain? A. A client who has a broken femur and reports hip pain. B. A client who has incisional pain 72 hr following pacemaker insertion. C. A client who has food poisoning and reports abdominal cramping. D. A client who has episodic back pain following a fall 2 years ago.

D. A client who has episodic back pain following a fall 2 years ago.

A client with a diagnosis of cancer of the ovary had her uterus and both ovaries and fallopian tubes removed (hysterectomy with bilateral salpingo-oophorectomy) and a surgical debulking via an abdominal incision 2 days ago. The client reports abdominal pain at level 5 on a 0-to-10 pain scale. After assessing the pain further, which should the nurse do first? A. Reposition the client. B. Offer a relaxing back rub. C. Use distraction techniques. D. Administer the prescribed analgesic.

D. Administer the prescribed analgesic.

A client requests pain medication for severe pain. Which should the nurse do first when responding to this client's request? A. Use distraction to minimize the client's perception of pain. B. Place the client in the most comfortable position possible. C. Administer pain medication to the client quickly. D. Assess the various aspects of the client's pain.

D. Assess the various aspects of the client's pain.

A nurse is teaching a community health education class about rest and sleep. Which concept related to sleep should the nurse include? A. Total time sleeping in bed decreases as one ages. B. Sleep needs remain consistent throughout the life span. C. Alcohol intake interferes with one's ability to fall asleep. D. Bedtime routines are associated with an expectation of sleep

D. Bedtime routines are associated with an expectation of sleep

At which time does a nurse medicate a client for pain for it to be considered preemptive analgesia? A. Before a client goes to sleep B. At equally distant times around the clock C. As soon as a client reports the occurrence of pain D. Before doing a dressing change that has been painful in the past

D. Before doing a dressing change that has been painful in the past

Several clients are taking supplemental calcium daily. The nurse teaches them to maintain their fluid intake at a minimum of 2,500 mL. The nurse explain that this intervention is designed to prevent which complication? A. Mobilization of calcium from bone B. Irritation of the bladder mucosa C. Occurrence of muscle cramps D. Formation of kidney stones

D. Formation of kidney stones

Which is the best choice for an appetizer when teaching a client about a 2-g sodium diet? A. Pigs in a blanket B. Stuffed mushrooms C. Cheese and crackers D. Fresh vegetable sticks

D. Fresh vegetable sticks

A nurse is assessing several clients for fluid and electrolyte imbalances. Which of the following is common to both excess fluid volume and deficient fluid volume? Select all that apply. A. Increased pulse amplitude B. Decreased blood pressure C. Difficulty breathing D. Mental confusion E. Muscle weakness

D. Mental confusion E. Muscle weakness

A nurse is counseling an older adult who describes having difficulty dealing with several issues. Which of the following problems verbalized by the client should the nurse identify as the priority? a. "I spent my whole life dreaming about retirement, & now I wish I had my job back." b. "It's been so stressful for me to have to depend on my child to help around the house." c. "I just heard my friend Al died. That's the 3rd one in 3 months." d. "I keep forgetting which medications I have taken during the day."

d. "I keep forgetting which medications I have taken during the day."

A nurse is caring for a client who has a terminal illness. Death is expected within 24 hr. The client's family is at the bedside & asks the nurse what to expect at this time. Which of the following findings should the nurse include? a. Regular breathing patterns b. Warm extremities c. Increased urine output d. Decreased muscle tone

d. Decreased muscle tone