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.A nurse is reinforcing teaching with a client about how to prevent the onset of manifestations of Raynaud's phenomenon. Which of the following statements should the nurse identify as an indication that the client needs further teaching? 1) "I will keep my house at a cool temperature." 2) "I will try to anticipate and avoid stressful situations." 3) "I will complete the smoking cessation program I started." 4) "I will wear gloves when removing food from the freezer."

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A nurse is caring for a client who has COPD. Which of the following actions should the nurse take? Encourage the client to 1) drink 8 glasses of water a day. 2) Instruct the client to cough every 4 hr. 3) Provide the client with a low protein diet. 4) Advise the client to lie down after eating.

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A nurse is caring for a client who is postoperative open reduction and internal fixation with placement of a wound drain to repair a hip fracture. Which of the following actions should the nurse take? 1) Empty the suction device every 4 hr. 2) Monitor circulation on the affected extremity every 2 hr for the first 12 hr. 3) Position the client's hip so that it is internally rotated .4) Encourage foot exercises every 4 hr.

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A nurse is collecting data from a client who has Cushing's syndrome. Which of the following manifestations should the nurse expect? 1) Bruising 2) Weight loss 3) Hyperpigmentation 4) Double vision

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A nurse is collecting data from a client who was bitten by a tick one week ago. Which of the following client manifestations should the nurse identify as an indication of the development of Lyme disease? 1) An expanding circular rash 2) Swollen, painful joints 3) Decreased level of consciousness 4) Necrosis at the site of the bite

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A nurse is contribution to the plan of care for a client who is 12 hr postoperative following a right radical mastectomy with closed suction drains present. The nurse should expect that the client will be unable to perform which of the following activities with her right arm? 1) Combing her hair 2) Eating her breakfast 3) Buttoning her blouse 4) Tying her shoes

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A nurse is evaluating discharge instructions for a client following a right cataract extraction. Which of the following client statements indicates the teaching is effective? 1) "I will take a stool softener until my eye is healed." 2) "I will expect to have moderately severe pain for 1-2 days." 3) "I will refrain from cooking for 1 week. "4) "I will bend at the waist to tie my shoes."

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A nurse is reinforcing teaching about pernicious anemia with a client following a total gastrectomy. Which of the following dietary supplements should the nurse include in the teaching as the treatment for pernicious anemia? 1) Vitamin B12 2) Vitamin C 3) Iron4) Folate

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A nurse is reinforcing teaching about rifampin with a female client who has active tuberculosis. Which of the following statements should the nurse include in the teaching? 1) "You should wear glasses instead of contacts while taking this medication." 2) "The medication causes amenorrhea if taken along with an oral contraceptive." 3) "A yellow tint to the skin is an expected reaction to the medication." 4) "Lifelong treatment with this medication is necessary."

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A nurse is reinforcing teaching with a client who has iron deficiency anemia and is to start taking ferrous sulfate twice a day. Which of the following statements by the client indicate an understanding of the teaching? 1) "I will take the medication with orange juice." 2) "I should expect to have loose stools while taking this medication." 3) "I will have clay colored stools while taking this medication." 4) "I should take the medication with milk."

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101.A nurse is caring for a client who is experiencing an acute exacerbation of ulcerative colitis. The nurse should recognize that which of the following actions is the priority? 1) Review stress factors that can cause disease exacerbation. 2) Evaluate fluid and electrolyte levels. 3) Provide emotional support. 4) Promote physical mobility.

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A nurse is assisting in the care of a client who is receiving a transfusion of packed red blood cells. The client develops itching and hives. Which of the following actions should the nurse take first? 1) Obtain vital signs. 2) Stop the transfusion. 3) Notify the registered nurse. 4) Administer diphenhydramine.

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A nurse is assisting with the care of a client following a transurethral resection of the prostate (TURP) and has an indwelling urinary catheter. Which of the following actions should the nurse take? 1) Weigh the client weekly. 2) Irrigate the catheter as prescribed. 3) Instruct the client to report an urge to urinate. 4) Instruct the client to bear down as if to have a bowel movement every hour.

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A nurse is reinforcing teaching to a client who is scheduled for an intravenous pyelogram. Which of the following should the nurse include in the teaching? 1) Omit your daily dose of aspirin. 2) Take a laxative evening before the procedure. 3) Expect to be drowsy for 24 hr following the procedure. 4) You will feel cold chills after the dye has been injected.

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escription for lorazepam preoperatively. Which of the following statements by the client should indicate to the nurse that the medication has been effective? 1) "My mouth is very dry." 2) "I feel very sleepy." 3) "I am not hungry any longer." 4) "My leg feels numb."

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A nurse is caring for a client who was admitted with major burns to the head, neck, and chest. Which of the following complications should the nurse identify as the greatest risk to the client? 1) Hypothermia 2) Hyponatremia 3) Fluid imbalance 4) Airway obstruction

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A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times? 1) On the same day every month 2) Prior to the beginning of menses 3) Three to seven days after menses stops 4) On the second day of menstruation

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A nurse is collecting data from a client who has right-sided heart failure. Which of the following findings should the nurse expect? 1) Frothy sputum 2) Dyspnea 3) Orthopnea 4) Peripheral edema

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A nurse is reinforcing teaching about cyclosporine for a client who is postoperative following a renal transplant. Which of the following statements by the client indicates an understanding of the teaching? 1) "I will take this medication until my BUN returns to normal." 2) "This medication will help my new kidney make adequate urine." 3) "I will need to take this medication for the rest of my life. "4) "This medication will boost my immune system.

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A nurse is caring for a client who is receiving chemotherapy for treatment of ovarian cancer and experiencing nausea. Which of the following actions should the nurse take? 1) Advise the client to lie down after meals 2) Instruct the client to restrict food intake prior to treatment 3) Provide the client with an antiemetic 2 hr prior to the chemotherapy 4) Encourage the client to drink a carbonated beverage 1 hr before meals.

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A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? 1) Inspiratory stridor 2) Expiratory wheeze 3) Absence of breath sounds 4) Coarse crackles

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A nurse is caring for a client who has Parkinson's disease and is taking selegiline 5 mg by mouth twice daily. Which of the following therapeutic outcomes should the nurse monitor for with a client who is taking this medication? 1) Improved speech patterns 2) Increased bladder function. 3) Decreased tremors 4) Diminished drooling

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A nurse is caring for a client who has second- and third-degree burns and a prescription for a high-calorie, high-protein diet. Which of the following menu choices should the nurse recommend? 1) 1⁄2 cup whole-grain pasta with tomato sauce and pears 2) Turkey and cheese sandwich with scalloped potatoes 3) 1⁄2 cup black beans with a brownie 4) Roast beef with romaine lettuce salad

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A nurse is caring for a client who is postoperative and requesting something to drink. The nurse reads the client's postoperative prescriptions, which include, "Clear liquids, advance diet as tolerated." Which of the following actions should the nurse take first? 1) Offer the client apple juice. 2) Elevate the client's head of bed. 3) Auscultate the client's abdomen. 4) Order a lunch tray for the client.

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A nurse is collecting data from a client who has AIDS. When checking the client's mouth, the nurse notes a white, creamy covering on the tongue and buccal membranes. The nurse should recognize this is a manifestation of which of the following conditions? 1) Xerostomia 2) Gingivitis 3) Candidiasis 4) Halitosis

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A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? 1) Decreased pedal pulses 2) Hypertension 3) Peripheral edema 4) Diarrhea

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A nurse is contributing to the plan of care for a client who has a terminal illness. Which of the following interventions should the nurse identify as the priority? 1) Promote the client's expression of feelings about loss of self-care ability. 2) Encourage the client to recall positive life events. 3) Schedule pain medication on a routine basis. 4) Suggest ways the client can continue interacting with social contacts

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A nurse is reinforcing teaching with a client who has been newly diagnosed with chronic open angle glaucoma. Which of the following statements by the client indicates an understanding of the teaching? 1) "When my vision improves, I will be able to stop taking the eye drops." 2) "If I forget to take my eye drops, I should wait until the next time they are due." 3) "I should call the clinic before taking any over-the-counter medications." 4) "Every two years I will need to have my vision checked by an eye doctor."

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A nurse is collecting data on a client who has a surgical wound healing by secondary intention. Which of the following findings should the nurse report to the charge nurse? 1) The wound is tender to touch. 2) The wound has pink, shiny tissue with a granular appearance. 3) The wound has serosanguineous drainage .4) The wound has a halo of erythema on the surrounding skin.

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