RN Adult Medical Surgical Online Practice 2016/2019

A nurse is providing teaching to a client who has AIDS. Which of the following statements by the client indicates an understanding of the teaching?

"I will take my temperature once a day." A client who has AIDS is immunocompromised and is at risk for infection. The client should check their temperature daily to identify a temperature greater than 37.8° C (100° F), which is an early manifestation of an infection.

A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

"I will use my hands rather than a washcloth to clean the radiation area." The client should gently wash the radiation area with their hands using warm water and mild soap to protect the skin from further irritation.

A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make?

"Ginkgo biloba can cause an increased risk for bleeding." Ginkgo biloba increases blood flow and is effective in decreasing the pain associated with peripheral artery disease. The supplement also decreases platelet aggregation, which in turn increases the risk for bleeding. Clients who have been prescribed antiplatelet medications, such as aspirin, should avoid taking ginkgo biloba without first speaking with their provider.

A nurse is providing teaching to an older adult female client who has stress incontinence and a BMI of 32. Which of the following statements by the client indicates an understanding of the teaching?

"I am dieting to lose weight." Excess weight creates increased abdominal pressure that can result in stress incontinence.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal." The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.

A nurse is providing instructions to a client who has type 2 diabetes mellitus and a new prescription for metformin. which of the following statements by the client indicates an understanding of the teaching?

"I should take this medication with a meal." The client should take metformin with or immediately following meals to improve absorption and to minimize gastrointestinal distress.

A nurse is providing teaching to a client who has anemia and a new prescription for an oral iron supplement. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat more high-fiber foods." The client should eat high-fiber foods to help prevent constipation, which is a common adverse effect of oral iron supplements.

A charge nurse is instructing a newly licensed nurse about caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"I will leave assessment equipment in the room to use on this client." When caring for a client who has MRSA, the nurse should follow contact precautions and use dedicated equipment when assessing the client to prevent cross-contamination with other clients.

A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching?

"I will monitor my blood pressure while taking this medication." The client should monitor their blood pressure while taking this medication because hypertension is a common adverse effect and can lead to hypertensive encephalopathy.

A nurse is providing teaching to a client who has type 1 diabetes mellitus and a new prescription for insulin lispro. Which of the following statements by the client indicates an understanding of the teaching?

"I will need to take the lispro in addition to my other prescribed insulin." Insulin lispro is rapid-acting insulin that the client can use in conjunction with intermediate- or long-acting insulins.

A nurse is providing preoperative teaching for a client who is scheduled for a mastectomy. Which of the following statements should the nurse make?

"I will refer you to community resources that can provide support." The nurse should provide the client with support resources, including community programs, to assist the client with acceptance of body image changes.

A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching?

"Ibuprofen can cause gastrointestinal bleeding in older adult clients." A common adverse effect of ibuprofen is gastrointestinal bleeding, and older adult clients have an increased risk for gastrointestinal toxicity and bleeding.

A nurse is caring for a client who has homonymous hemianopsia as a result of a stroke. To reduce the risk of falls while ambulating, the nurse should provide which of the following instructions to the client?

"Scan the environment by turning your head from side to side." Homonymous hemianopsia is the loss of the same visual field in both eyes. Turning their head from side to side helps enlarge a client's visual field. This technique is also useful for the client during mealtimes.

A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client?

"Take insulin even if you are unable to eat your regular diet." The client should continue the prescribed medication regimen when ill to prevent hyperglycemia.

A nurse is providing teaching to a client who is postoperative following a thyroidectomy with removal of the parathyroid glands. The nurse should instruct the client to include which of the following foods that has the greatest amount of calcium?

12 almonds The nurse should determine that almonds are the best source of calcium to recommend because 12 almonds contain 36 mg of calcium. Removal of the parathyroid glands, which regulate calcium in the body, can result in hypocalcemia.

A nurse is preparing to administer 600 mg PO daily to a client. The amount available is oral solution 125 mg/5 mL. How many mL should the nurse administer?

24 mL 125 mg 600 mg 5 mL = X mL

A nurse has received change-of-shift report for a group of clients. Which of the following clients should the nurse assess first?

A client who had a myocardial infarction (MI) 4 days ago and is asking for a PRN sublingual nitroglycerin tablet When using the stable vs. unstable approach to client care, the nurse should assess this client first. A client who had a myocardial infarction 4 days ago and is asking for a PRN sublingual nitroglycerin tablet could be unstable. This client might be experiencing angina or could be having another MI.

A nurse on a medical-surgical unit is receiving change of shift report on four clients which of the following clients should the nurse identify as having the greatest risk for developing an infection

A client who has COPD and is receiving steroid therapy The greatest risk to a client who has COPD is injury from developing an infection due to decreased oxygenation and increased mucus production. Additionally, taking a steroid medication increases the client's risk for infection by suppressing the immune system and masking the presence of an infection. Therefore, the nurse should identify this client as having the greatest risk for developing an infection.

A nurse is admitting a client who has active tuberculosis. Which of the following types of transmission precautions should the nurse initiate?

Airborne Airborne precautions are required for clients who have infections due to micro-organisms that can remain suspended in air for lengthy periods of time, such as tuberculosis, measles, varicella, and disseminated varicella zoster.

A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following nonpharmacological interventions should the nurse suggest to the client to reduce pain?

Alternate application of heat and cold to the affected joints. The nurse should instruct the client to alternate heat and cold applications to decrease joint inflammation and pain. The application of cold can relieve joint swelling and the application of heat can decrease joint stiffness and pain.

A nurse is planning care for a client who has extensive burn injuries and is immunocompromised. Which of the following precautions should the nurse include in the plan of care to prevent a Pseudomonal aeruginosa infection?

Avoid placing plants or flowers in the client's room. Live plants can harbor P. aeruginosa, and this bacterium can infect burn wounds and cause life-threatening complications. The nurse should ensure no one brings live plants or flowers into the client's room.

A nurse on a medical-surgical unit is reviewing the medical record of an older client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires re-evaluation of the IV therapy prescription? Graphic RecordTemperature 37.1° C (98.8° F)Heart rate 88/minRespiratory rate 18/minBlood pressure 118/68 mm HgO2 saturation 96%Pain rating (0 to 10) 0 Medication Administration Record​​Propranolol 40 mg PO BIDMetformin 500 mg PO BIDAlendronate sodium 10 mg PO daily Laboratory Results​Hgb 15.1 g/dLHct 54.2%BUN 29 mg/dLSodium 145 mEq/LPotassium 4.7 mEq/L

BUN The client's Hct and BUN levels indicate dehydration and require an increase in the IV fluid infusion rate.

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following laboratory findings should the nurse expect?

BUN 32 mg/dL DKA results in osmotic diuresis and subsequent dehydration. The nurse should expect a client who has DKA to have elevated BUN, creatinine, and specific gravity levels resulting from the excess glucose present in the urine.

A nurse is reviewing the laboratory test results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication?

BUN 34 mg/dL Amphotericin B is nephrotoxic. Therefore, an elevated BUN or creatinine level can indicate renal impairment. The nurse should notify the provider of this result.

A nurse is caring for a client who has a positive culture for methicillin-resistant staphylococcus aureus (MRSA). Which of the following actions should the nurse take?

Bathe the client using chlorhexidine solution. The nurse should bathe the client using chlorhexidine solution because it reduces the risk of transmission of MRSA to other areas of the body.

A nurse is caring for a client who has a new diagnosis of hyperthyroidism. Which of the following is the priority assessment finding that the nurse should report to the provider?

Blood pressure 170/80 mm Hg Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a systolic blood pressure of 170 mm Hg, which indicates that the client is at risk for thyroid storm.

A nurse is assessing a client who has Grave's disease. What is an indication of exophthalmos?

Bulging eyes The nurse should identify an outward protrusion of the eyes as exophthalmos, a common finding of Graves' disease. An overproduction of the thyroid hormone causes edema of the extraocular muscle and increases fatty tissue behind the eye, which results in the eyes protruding outward. Exophthalmos can cause the client to experience problems with vision, including focusing on objects, as well as pressure on the optic nerve. (O O) u (---)

A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range?

Calcium A client who has pancreatitis is expected to have decreased calcium and magnesium levels due to fat necrosis.

A nurse is caring for a client who is undergoing hemodialysis to treat end-stage kidney disease. The client reports muscle cramps and a tingling sensation in their hands. Which of the following medications should the nurse plan to administer?

Calcium carbonate Hypocalcemia is a manifestation of ESKD and an adverse effect of dialysis. Often occurring late in the dialysis session, hypocalcemia can cause the client to experience muscle cramping and tingling to extremities. The nurse should plan to administer a calcium supplement, such as calcium carbonate, as a calcium replacement.

A home health nurse is providing teaching to a client who has a stage 1 pressure injury on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching?

Change position every hour. Changing position every 1 to 2 hr decreases pressure on bony prominences. The nurse should also instruct the client to limit the angle of the hips when in a lateral position to no more than 30°. This positioning prevents direct pressure on the trochanter.

A nurse is preparing to administer a blood transfusion to a client who has anemia. Which of the following actions should the nurse take first?

Check for the type and number of units of blood to administer. According to evidence-based practice, the nurse should first confirm that the type and number of units of blood to administer matches what is indicated in the client's medication administration record.

A nurse is providing teaching to a female client who has a history of UTIs. What information should the nurse include in the teaching?

Clean the perineum from front to back. The client should wipe her perineum from the front to the back after voiding or defecating to avoid introducing bacteria to the urethra.

A nurse is planning care for a client who is postoperative following a laparotomy and has a closed-suction drain. Which of the following actions should the nurse take to manage the drain?

Compress the drain reservoir after emptying. Compressing the reservoir creates a vacuum that draws fluid out of the wound, through the drain, and into the reservoir.

A nurse is caring for a client who has hypothyroidism. Which of the following manifestations should the nurse expect?

Constipation A client who has hypothyroidism can experience constipation due to the decrease in the client's metabolism, resulting in slow motility of the gastrointestinal tract. The nurse should instruct the client to increase fiber and fluid intake to reduce the risk for constipation.

A nurse is caring for a client who is receiving total parenteral nutrition and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take?

Contact the provider to clarify the prescription. Mealtimes do not pertain to this client due to the NPO status. The nurse should monitor the client's glucose levels on a set schedule, either every 6 hr or per facility protocol. Thus, the prescription requires clarification.

A nurse is providing preoperative teaching for a client who is scheduled for an open cholecystectomy. Which of the following actions should the nurse take?

Demonstrate ways to deep breathe and cough. The nurse should demonstrate deep breathing and coughing exercises and explain the importance of splinting the incision to reduce the risk for respiratory complications.

A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion?

Digoxin Cardiac glycosides, such as digoxin, are withheld prior to cardioversion. These medications can increase ventricular irritability and put the client at risk for ventricular fibrillation after the synchronized countershock of cardioversion.

A nurse is assessing a client's hydration status. Which of the following findings indicates fluid volume overload?

Distended neck veins The nurse should identify distended neck and hand veins as indicators of fluid volume overload.

A nurse is checking the ECG rhythm strip for a client who has a temporary pacemaker. The nurse notes a pacemaker artifact followed by a QRS complex. Which of the following should the nurse take?

Document that depolarization has occurred. When a pacing stimulus is delivered to the ventricle, a pacemaker artifact appears as a spike on the ECG rhythm strip. The spike should be followed by a QRS complex, which indicates pacemaker capture or depolarization.

A nurse is providing teaching to a client who has a new prescription for psyllium. Which of the following information should the nurse include in the teaching?

Drink 240 mL (8 oz) of water after administration. The client should follow each dose of psyllium with an additional 240 mL (8 oz) of liquid.

A nurse is assessing a client who has had a suspected stroke. The nurse should place their priority on which of the following findings?

Dysphagia Dysphagia indicates that this client is at greatest risk for aspiration due to impaired sensation and function within the oral cavity. Therefore, the nurse should place priority on this finding.

A nurse is assessing a client who has advanced lung caner and is receiving palliative care. The client has just undergone thoracentesis. The nurse should expect a reduction in which of the following common manifestations of advanced cancer?

Dyspnea Thoracentesis, the removal of pleural fluid, can temporarily relieve hypoxia and thus ease the client's breathing and improve comfort.

A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory values should the nurse expect?

Elevated bilirubin level Bilirubin levels reflect the liver's ability to conjugate and excrete bilirubin, a byproduct of the hemolysis of red blood cells. Bilirubin levels rise with liver disease and clinically reflect the client's degree of jaundice.

A nurse in an acute care facility is caring for a client who is at risk for seizures. Which of the following precautions should the nurse implement?

Ensure that the client has a patent IV. The nurse should ensure the client has IV access in the event that the client requires medication to stop seizure activity.

A nurse is preparing to present a program about prevention of atherosclerosis at a health fair. Which of the following recommendations should the nurse plan to include? (select all that apply)

Follow a smoking cessation program Maintain an appropriate weight Eat a low-fat diet Smoking cessation is an important lifestyle modification to prevent atherosclerosis. Preventing obesity through diet and exercise can help to prevent atherosclerosis. Eating a low-fat diet decreases LDL cholesterol and can prevent atherosclerosis.

A nurse is assessing a client who is at risk for the development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia?

Glossitis, a smooth red tongue, is a manifestation of deficiencies in vitamin B6, zinc, niacin, or folic acid. Glossitis also indicates pernicious anemia.

A nurse is caring for a client who has DKA. Which of the following findings should indicate to the nurse that the client's condition is improving?

Glucose 272 mg/dL A glucose reading less than 300 mg/dL indicates improvement in the client's status.

A nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Hair loss on the lower legs The nurse should expect a client who has peripheral arterial disease to have hair loss on the lower legs as a result of impaired arterial circulation affecting follicular growth.

A PACU nurse is assessing a client who is postoperative following a right nephrectomy. The client's initial vital signs were heart rate of 80/min. BP 130/70. Respiratory rate of 16/min. Temperature 36C/ 96.8F. Which of the following vital sign changes should alert the nurse that the patient might be hemorrhaging?

Heart rate 110/min One of the first signs of hemorrhage is an increase in the heart rate from the client's baseline, which occurs to compensate for blood loss.

A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)?

Heart rate 52/min A client who is experiencing AD will exhibit multiple manifestations, including bradycardia, severe headache, and flushing.

A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which of the following laboratory values should the nurse report to the provider?

Hgb 8 g/dL The nurse should report an Hgb level of 8 g/dL, which is below the expected reference range and is an indicator of postoperative hemorrhage or anemia.

A nurse is providing teaching to a client who has asthma about the use if a metered-dose inhaler. The nurse should identify that which of the following client actions indicates an understanding of the teaching?

Holding breath for 10 seconds after inhaling The client should hold their breath for 10 seconds after inhaling so the medication can move deep into the airways.

A nurse is planning a health promotional presentation for a group of African American clients at a community center. Which of the following disorders presents the greatest risk to this group of patients?

Hypertension When using the safety/risk reduction approach to client care, the nurse should determine that the disorder with the greatest risk for this group of clients is hypertension. The prevalence of hypertension is highest among African American clients, followed by Caucasian clients, and then Hispanic clients.

A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect?

Hypoactive bowel sounds Hypokalemia decreases smooth muscle contraction in the gastrointestinal tract leading to decreased peristalsis.

A nurse is caring for a client who recently had a stroke of the right hemisphere. Which of the following manifestations should the nurse expect?

Impulsive behavior The nurse should expect a client who has had a right-hemispheric stroke to manifest impulsive behavior.

A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide?

Increase fluid intake. Increasing fluid intake will help to prevent constipation. Therefore, the nurse should instruct the client to increase fluid intake to facilitate the elimination of the barium used during the test.

A nurse is providing education to a client who has tuberculosis and their family. Which of the following information should the nurse include in the teaching?

Family members in the household should undergo TB testing. Family members who live in the same household with the client have been exposed to TB. Therefore, the nurse should recommend TB screening to foster early detection and treatment of TB.

A nurse in an emergency department is caring for a client who is experiencing a thyroid storm. Which of the following manifestations should the nurse expect? (select all that apply)

Fever The nurse should expect the client to have a fever because of the excessive thyroid hormone release. Hypertension The nurse should expect one of the early manifestations of thyroid storm to include systolic hypertension because of the excessive thyroid hormone release. Tachycardia The nurse should expect the client to have tachycardia because of the excessive thyroid hormone release.

A nurse is providing postoperative teaching for a client who had a total knee arthroplasty. Which of the following instructions should the nurse take?

Flex the foot every hour when awake. The nurse should instruct the client to flex the foot every hour to reduce the risk for thromboembolism and promote venous return.

A nurse is caring for a client who had a nephrostomy tube inserted 12 hr ago. Which of the following findings should the nurse report to the provider?

The client reports back pain. The nurse should notify the provider if the client reports back pain, which can indicate that the nephrostomy tube is dislodged or clogged.

A nurse is caring for a client who has anorexia, low-grade fever, night sweats, and a productive cough. Which of the following actions should the nurse take first?

Initiate airborne precautions. This client is exhibiting manifestations of tuberculosis. The greatest risk in this client situation is for other people in the facility to acquire an airborne disease from this client. Therefore, the first action the nurse should take is to initiate airborne precautions.

A nurse is planning care for a client who is having a modified radical mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain is removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is planning care for a client who is having a modified radial mastectomy of the right breast. Which of the following interventions should the nurse include in the plan of care?

Instruct the client that the drain will be removed when there is 25 mL of output or less over a 24-hr period. The nurse should instruct the client that the drain will remain in place for 1 to 3 weeks after surgery and will be removed when there is 25 mL of output or less in a 24-hr period.

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and notes clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take?

Irrigate the indwelling urinary catheter. The nurse should irrigate the client's catheter per facility protocol to remove clots obstructing the urine flow.

A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care?

Keep a lead-lined container in the client's room. The nurse should keep a lead-lined container and forceps in the client's room in case of accidental dislodgement of the implant.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Low urine specific gravity An expected finding for a client who has diabetes insipidus is a urine specific gravity between 1.001 and 1.005. Decreased water reabsorption by the renal tubules is caused by an alteration in antidiuretic hormone release or the kidneys' responsiveness to the hormone.

Identify the sequence the client should follow when demonstrating crutch use.

The client should first place his body weight on the crutches. Next, he should advance the unaffected leg onto the stair. Third, he should shift his weight from the crutches to the unaffected leg. Last, he should bring the crutches and the affected leg up to the stair.

A nurse in a provider's office is assessing a client who has migraine headaches and is taking feverfew to prevent headaches. The nurse should identify that which of the following client medications interact with feverfew?

Naproxen Both naproxen and feverfew impair platelet aggregation and place the client at risk for bleeding.

A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% - 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen?

Nonrebreather mask The nurse should initiate a nonrebreather mask to deliver between 80% to 95% oxygen to the client. A client who has an unstable respiratory status should receive oxygen via a nonrebreather mask.

A nurse is caring for a client who has a prescription for enalapril. The nurse should identify which of the following findings as being an adverse effect of the medication?

Orthostatic hypotension The nurse should identify that dilation of arteries and veins causes orthostatic hypotension, which is an adverse effect of enalapril.

A nurse is reviewing the ABG results of a client who has advanced COPD. Which of the following results should the nurse expect?

PaCO2 56 mm Hg A client who has COPD retains PaCO2 due to the weakening and the collapse of the alveolar sacs, which decreases the area in the lungs for gas exchange and causes the PaCO2 to increase above the expected reference range.

A nurse is teaching a client who has end-stage kidney disease about organ donation. What information should the nurse include in the teaching?

The client who receives a kidney from a live donor has a lower rate of transplant rejection. A client who receives a kidney from a live donor has a lower rate of transplant rejection because the donor is often more medically compatible than a donor who is deceased.

A nurse is caring for a client who is experiencing supraventricular tachycardia. Upon assessing the client, the nurse observes the following findings: heart rate 200/min. , bp 78/40 mm Hg. , and resp. 30/min. Which of the following actions should the nurse take?

Perform synchronized cardioversion. The nurse should perform synchronized cardioversion for a client who has supraventricular tachycardia.

A nurse is caring for a client who is 12 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

Place a pillow between the client's legs. The nurse should place a pillow between the client's legs to prevent hip dislocation.

A nurse is caring for a client who has an arterial line. Which of the following actions should the nurse take?

Place a pressure bag around the flush solution. The nurse should place a pressure bag around the flush solution of 0.9% sodium chloride because the pressure from an artery is greater than that of the line.

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?

Place personal items, such as pictures, at the client's bedside. The nurse should plan to have the family bring personal items such as pictures to place at the client's bedside for cognitive support.

A nurse is caring for a client who has bilateral pneumonia and an SaO2 of 85%. The client has dyspnea with a productive cough and is using accessory muscles to breathe. Which of the following actions should the nurse take first?

Place the client in high-Fowler's position. The greatest risk to this client is injury from airway obstruction. Therefore, the priority intervention the nurse should take is to move the client into high-Fowler's position. High-Fowler's position facilitates lung expansion and improves ventilation and gas exchange.

A nurse is teaching a client about osteoporosis prevention. The nurse should instruct the client that which of the following medications can increase their risk for developing osteoporosis?

Prednisone The nurse should instruct the client that prednisone can increase the risk for developing osteoporosis due to suppression of bone formation, and an increase in bone resorption by osteoclasts. Prednisone can also reduce intestinal absorption of calcium.

A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication?

Report of a night cough The nurse should recognize that a night cough is an early indication of heart failure and report this adverse reaction to the provider.

A nurse is updating the plan of care for a client who is receiving chemotherapy. Which of the following findings should the nurse identify as the priority?

Report of sore throat When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a report of a sore throat, which could be a manifestation of an infection. The client is at risk for neutropenia due to myelosuppression; therefore, an infection could lead to sepsis.

A nurse is assessing a client following the completion of hemodialysis. Which of the following findings is the nurse's priority to report to the provider?

Restlessness Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding to report to the provider is restlessness, which can be an indication the client is experiencing disequilibrium syndrome. Disequilibrium syndrome is caused by the rapid removal of electrolytes from the client's blood and can lead to dysrhythmias or seizures. Other manifestations include nausea, vomiting, fatigue, and headache.

A nurse is caring for a client who is 8hr postoperative following a total hip arthroplasty. The client is unable to void on the bedpan. Which of the following actions should the nurse take first?

Scan the bladder with a portable ultrasound. The first action the nurse should take using the nursing process is to assess the client. Scanning the bladder with a portable ultrasound device will determine the amount of urine in the bladder.

A nurse is providing follow-up care for a client who sustained a compound fracture 3 weeks ago. The nurse should recognize that an unexpected finding for which of the following lab values is a manifestation of osteomyelitis and should be reported to the provider?

Sedimentation rate An increased sedimentation rate occurs when a client has any type of inflammatory process, such as osteomyelitis.

A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased intracranial pressure? (select all that apply)

Sleepiness exhibited by the client Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressure A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturing Both decerebrate and decorticate posturing indicate increased ICP.

A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking?

Slow the infusion rate. Dyspnea, restlessness, and the onset of crackles during a blood transfusion are manifestations of circulatory overload. The nurse should slow or stop the infusion to improve the client's ability to breathe, place the client in an upright position, and notify the provider. The provider might prescribe a diuretic to alleviate the fluid overload.

A nurse is providing discharge instructions to a client who has active tuberculosis. Which of the following information should the nurse include in the instructions?

Sputum specimens are necessary every 2 to 4 weeks until there are three negative cultures. After three negative sputum cultures, the client is no longer considered infectious.

A nurse is caring for a client who is receiving mechanical ventilation via a tracheostomy tube. The nurse should expect which of the following complications?

Stress ulcers Stress ulcers in clients who are receiving long-term mechanical ventilation are caused by elevated levels of hydrochloric acid in the stomach. Stress ulcers increase the risk for systemic infection and require pharmacological treatment.

A nurse is caring for a client following extubation of her endotracheal tube 10 minutes ago. Which of the following findings should the nurse report to the provider immediately?

Stridor Using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is stridor. Stridor can indicate a narrowing airway or possible obstruction caused by edema or laryngeal spasms. The nurse should report the finding immediately and implement an intervention.

A nurse is providing teaching to a client who has a gastric ulcer and a new prescription for omeprazole. The nurse should instruct the client that the medication provides relief by which of the following actions?

Suppressing gastric acid production Omeprazole is a proton pump inhibitor. It relieves manifestations of gastric ulcers by suppressing gastric acid production.

A nurse is assessing a client who is postoperative following a thyroidectomy. Which of the following findings is the nurse's priority?

Temperature 38.9° C (102° F) When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is an elevated temperature. An elevated temperature is a manifestation of excessive thyroid hormone release, or thyroid storm, due to an increase in metabolic rate. The nurse should report this finding immediately to the provider because it can lead to seizures and coma.

A nurse is providing discharge teaching to a client who has heart failure and a new prescription for a potassium-sparing diuretic. Which of the following information should the nurse include in the teaching?

Try to walk at least three times per week for exercise. The development of a regular exercise routine can improve outcomes in clients who have heart failure.

A nurse is caring for a client who is having a seizure. Which of the following interventions is the nurse's priority?

Turn the client to the side. The greatest risk to this client is hypoxia from an impaired airway. Therefore, the priority intervention the nurse should take is to place the client in a side-lying position to prevent aspiration.

An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration?

Urine specific gravity 1.045 A urine specific gravity greater than 1.030 indicates a decrease in urine volume and an increase in osmolarity, which is a manifestation of hypertonic dehydration.

A nurse is planning discharge teaching for a client who has an external fixation device for a fracture of the lower extremity. Which of the following instructions should the nurse include in the plan of care?

Use crutches with rubber tips. Using crutches with rubber tips prevents the client from slipping and decreases the risk of falls.

A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric stroke. Which of the following neurological deficits should the nurse expect to find when assessing the client? (select all that apply)

Visual spatial deficits Visual spatial deficits and loss of depth perception occur secondary to a right-hemispheric stroke. Left hemianopsia Left hemianopsia, or blindness in the left half of the visual field, occurs secondary to a right-hemispheric stroke. One-sided neglect One-sided neglect, or an unawareness of the affected side, occurs secondary to a right-hemispheric stroke.

A nurse is reviewing the laboratory results of a client who has aplastic anemia. Which of the following findings indicate a potential complication?

WBC count 2,000/mm3 A WBC count of 2,000/mm3 is below the expected reference range and indicates a risk for severe immunosuppression.

A nurse is obtaining a medication history from a client who is scheduled to undergo cataract surgery. The nurse should recognize that which of the following client medications is a contraindication for the surgery and notify the provider?

Warfarin Warfarin is an anticoagulant, which increases the client's risk for bleeding, and is contraindicated for a client scheduled for eye or central nervous system surgery.

A nurse and an assistive personnel are caring for a client who has bacterial meningitis. The nurse should give the AP which of the following instructions?

Wear a mask. Bacterial meningitis requires droplet precautions; therefore, the AP and the nurse should wear a mask when coming within 0.9 m (3 ft) of the client until 24 hr after the client has begun receiving antibiotic therapy.

A nurse is providing discharge instructions to a client who has a partial-thickness burn on the hand. Which of the following instructions should the nurse include?

Wrap fingers with individual dressings. The nurse should instruct the client to wrap the fingers individually to allow for functional use of the hand while healing occurs. The nurse should also instruct the client to perform range-of-motion exercises to each finger every hour while awake to promote function of the injured hand.