RQ 5
2. The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
1.Encouraging fluids The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules.
A client calls the emergency department after experiencing direct contact with poison ivy shrubs. The client tells the nurse that nothing is visible on the skin and asks what to do. The nurse would provide which response?
"Take a shower immediately, lathering and rinsing several times." sap forms an invisible film on the skin. need to wash it off.
10. The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? Select all that apply.
1.Facial edema in the morning 3.Serum calcium level of 12 mg/dL (3.0 mmol/L) 6.Numbness and tingling of the lower extremities
6. A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The nurse would provide which instructions to the client? Select all that apply.
1.Hypoglycemia may be experienced before dinnertime. 3.The insulin should be administered at room temperature.
10. The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.
1.Insomnia 2.Weight loss 5.Mild heat intolerance
1. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?
1. Increased calcium level
20. A client with hiatal hernia chronically experiences heartburn following meals. The nurse would plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
1. Lying recumbent following meals
15. The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply.
1. Maintain NPO (nothing by mouth) status. 2. Encourage coughing and deep breathing. 5. Give hydromorphone intravenously as prescribed for pain.
20. A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the primary health care provider will request which prescriptions? Select all that apply.
1. Radiation 2. Chemotherapy 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone
25. The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?
1. Sweating and pallor
6. The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain needs to include which assessment?
1. The client's pain rating
17. The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function?
1. The passage of flatus
13. A client with severe ulcer disease in the distal stomach undergoes a gastrojejunostomy (Billroth II procedure). Which postoperative prescription would the nurse question and verify?
3. Irrigating the nasogastric tube
7. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication?
3. Iv fluids containing dextrose.
4. A client with chronic pancreatitis has begun medication therapy with pancrelipase. The nurse evaluates that the medication is having the optimal intended benefit if which effect is observed?
3. Reduction of steatorrhea
5. The nurse would plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy?
3. Teach the client and family about the need for hand hygiene.
20. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?
3. a heart rate that is 90 beats per minute and irregular
15. The nurse is monitoring the laboratory results of a client receiving an antineoplastic medication by the intravenous route. The nurse plans to initiate bleeding precautions if which laboratory result is noted?
3. a platelet count of 50,000mm3
24. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client?
3. audible stridor any swelling to the surgical site could cause respiratory distress.
5. An older client with peptic ulcer disease recently has been taking cimetidine. The nurse monitors the client for which most frequent central nervous system side effect of this medication?
3. confusion
12. The nurse is analyzing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy?
3. increased uric acid level increased uric acid level is related specifically to cell destruction.
1. A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription?
3. intravenous infusion of normal saline rehydrate the client to restore fluid volume and to correct electrolyte deficiency.
1. Chemotherapy dosage is frequently based on total body surface area (BSA), so it is important for the nurse to perform which assessment before administering chemotherapy?
3. measure the clients current weight and height
19. The nurse is doing an admission assessment on a client with a history of duodenal ulcer. To determine whether the problem is currently active, the nurse would assess the client for which manifestation of duodenal ulcer?
3. pain relieved by food intake
18. The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is 85 mcg/dL (51 mcmol/L). Which dietary selection does the nurse suggest to the client?
3. pasta with sauce Foods high in protein would be avoided since the client's ammonia level is elevated above the normal range
21. The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency?
3. periorbital edema
22. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL (3.9 mmol/L), temperature of 101° F (38.3° C), pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure of 118/68 mm Hg. Which finding would be the priority concern to the nurse?
3. temperature elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus.
6. A client with severe acne is seen in the clinic, and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would collaborate with the PHCP about the prescription if the client is also taking which medication?
3. vitamin A vitamin A produces a more intense effect of isotretinoin toxicity.
16. The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply.
3."I need to sit up for at least 30 minutes after taking this medication." 4."I need to take this medication first thing in the morning on an empty stomach."
8. A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client?
4. Enlarged lymph nodes Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver.
23. A client with severe Crohn's disease has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
4. Fluid and electrolyte imbalance
3. When caring for a client with cervical cancer who has an internal radiation implant, the nurse would observe which principles? Select all that apply.
2. Keeping pregnant persons out of the client's room. 3. Placing the client in a private room with a private bath. 4. Wearing a lead shield when providing direct client care.
14. The nurse is providing discharge instructions to a client following gastrectomy and would instruct the client to take which measure to assist in preventing dumping syndrome?
2. Limit the fluids taken with meals.
11. A client who has been receiving radiation therapy for bladder cancer states to the nurse, "I feel like I am urinating through my vagina." The nurse interprets that the client may be experiencing which condition?
2. The development of a vesicovaginal fistula The fistula is an abnormal opening between these two body parts; if this occurs, the client may experience drainage of urine through the vagina.
12. The nurse would tell the client who is taking levothyroxine to notify the primary health care provider (PHCP) if which problem occurs?
2. Tremors signs and symptoms of hyperthyroidism.
2. The health education nurse plans to provide instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions would the nurse provide? Select all that apply.
2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 5. Examine your body monthly for any lesions that may be suspicious.
9. A client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication?
2. calcium level
3. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply.
2. comatose state 3. deep rapid breathing 5. elevated blood glucose level
5. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety?
2. convey empathy, trust, and respect toward the client.
9. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem?
2. inadequate fluid volume cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration.
13. The nurse is providing medication instructions to a client with breast cancer who is receiving cyclophosphamide. The nurse would tell the client to take which action?
2. increase fluid intake to 2000-3000ml daily.
21. The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings would alert the nurse to the presence of a possible postoperative complication? Select all that apply.
2. leukocytosis 4. urinary output of 800ml/hr 5. clear drainage on nasal dripper pad
13. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?
2. maintain patent airway
3. Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply.
2. red meats 3.Whole-grain cereals 5.Carbonated beverages
4. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose needs to be taken if which symptoms develop? Select all that apply.
2. shakiness 3. palpitations 5. light headedness
11. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse would take which initial action?
2. test the drainage for glucose. which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid.
5. Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed?
2. triglyceride level
3. A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication?
2. uric acid level Busulfan can cause an increase in the uric acid level.
14. The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.
2."I need to decrease my oral fluids when I start this medication." 5."I need to report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."
5. A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse would make which statement to the client?
3. "You need to consult with the primary health care provider (PHCP) before receiving immunizations." Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the PHCP's approval.
2. A client with gastroenteritis has an as-needed prescription for loperamide hydrochloride. For which condition would the nurse administer this medication?
3. An episode of diarrhea manage acute and chronic diarrhea in conditions such as inflammatory bowel disease.
17. The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How would the nurse assess for its presence?
3. Ask the client to extend the arms. Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched
14. A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse would take which most appropriate action?
3. Continue to monitor the drainage. drainage from the nasogastric tube is normally bloody for 24 hours postoperatively
15. A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and would instruct the client that which time is best to take this medication?
3. Early morning before 9 a.m. Administration at this time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning.
7. When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply.
a pearly papule with a central crater and a waxy border. location in the bald spot atop the head that is exposed to outdoor sunlight.
8. A client arriving at the emergency department has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the client's hand?
a white color to the skin, which is insensitive to touch
2. A client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed?
4. pulmonary function studies Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis.
10. Megestrol acetate, an antineoplastic medication, is prescribed for a client with metastatic endometrial carcinoma. The nurse reviews the client's history and would contact the primary health care provider if which diagnosis is documented in the client's history?
4. venous thromboembolism
3. Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse?
4. white blood cell count of 3,000mm3 leukopenia is an adverse effect of this medication.
3. A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg. During the admission assessment, the nurse expects to note which finding?
A skin infection of the dermis and underlying hypodermis
18. The nurse is reviewing the history of a client with bladder cancer. The nurse expects to note documentation of which most common sign or symptom of this type of cancer?
2. Hematuria
7. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? Select all that apply.
1. Coffee 2. Chocolate 3. Peppermint 5. Fried chicken
22. The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer and tells the staff that which is a late sign or symptom of this oncological emergency?
4. Electrocardiographic changes
19. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.
1. tremors 3. irritability 4. nervousness
3. The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.
1. Fever 3. Complaints of indigestion upper quadrant 5. Pain in the upper right quadrant after a fatty meal
8. The nurse is teaching the client about prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?
1. "I can take aspirin or my antihistamine if I need it."
16. The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?
1. "I need to increase the fiber in my diet."
24. The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?
1. "I need to limit my intake of dietary fiber."
6. A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.
1. Administer stool softeners as prescribed. 3. Encourage a high-fiber diet to promote bowel movements without straining. 4. Apply cold packs to the anal-rectal area over the dressing until the packing is removed.
15. The nurse is teaching a client about the risk factors associated with colorectal cancer. The nurse determines that further teaching is necessary related to colorectal cancer if the client identifies which item as an associated risk factor?
1. Age younger than 50 years
27. The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis who is at risk for vitamin B12 deficiency. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.
1. Meat 3. Liver
1. The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
1. Notify the surgeon. the nurse would suspect peritonitis
7. The nurse is caring for a client who is postoperative following a pelvic exenteration, and the surgeon changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse would check which priority item before administering the diet?
1.Bowel sounds
22. A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?
1. This is a normal, expected event.
1. Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication?
1. Tinnitus absorbed readily through the skin. causes tinnitus.
1. The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?
1. Withdraws the NPH insulin first
5. The primary health care provider (PHCP) prescribes semaglutide for a client with type 1 diabetes mellitus who takes insulin. The nurse would plan to take which most appropriate intervention?
1. Withhold the medication and call the PHCP, questioning the prescription for the client. semaglutide is a glucagon-like peptide-1 agonist used for type 2 diabetes mellitus only. It is not recommended for clients with type 1 diabetes
7. The nurse is applying a topical corticosteroid to a client with eczema. The nurse understands that it is safe to apply the medication to which body areas? Select all that apply.
1. back. 4. soles of the feet. 5. palms of the hands. avoid areas of higher absorption to prevent systemic absorption.
25. A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply.
1. fever 2. nausea 4. tremors 5. confusion
4. A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred?
1. hyperventilation suppresses renal excretion of acid and causing acidosis. hyperventilation is a sign of acid base imbalance.
18. A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply.
1. hypotension 3. hyperkalemia
10. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching?
1. i need to stop my insulin
12. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions would the nurse anticipate receiving? Select all that apply.
1. initiate an infusion of 3% NaCl 3. restrict fluids to 800ml over 24 hours 5. administer a vasopressin antagonist as prescribed
8. The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid to treat acne. The nurse determines that which client complaint may be associated with the use of this medication?
1. itching.
5. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?
1. malaise
7. The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse contacts the primary health care provider before administering the medication if which disorder is documented in the client's history?
1. pancreatitis the medication impairs pancreatic function
16. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply.
1. polyuria 3. bone pain
8. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed?
1. polyuria hyperglycemia causes this.
11. The nurse is monitoring the intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. On inspection of the site, the nurse notes redness and swelling and that the infusion of the medication has slowed in rate. The nurse suspects extravasation and would take which actions? Select all that apply.
1. stop the infusion 2. prepare to apply ice or heat to the site 4. notify the primary health provider (PHCP) 5. prepare to administer a prescribed antidote into the site.
17. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching?
1."I should consume less than 1 liter of fluid per day."
11. The nurse determines that the client needs further instruction on cimetidine if which statements were made? Select all that apply.
1."I will take the cimetidine with my meals." 2. "I'll know the medication is working if my diarrhea stops." 4."Taking the cimetidine with an antacid will increase its effectiveness."
9. A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply.
1.Administer methimazole with food. 3.Assess the client for unexplained bruising or bleeding. 4.Instruct the client to report side and adverse effects such as sore throat, fever, or headaches.
7. The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse would provide which instructions to the client? Select all that apply.
1.Diarrhea may occur secondary to the metformin. 2.The repaglinide is not taken if a meal is skipped. 3.The repaglinide is taken 30 minutes before eating. 4.A simple sugar food item is carried and used to treat mild hypoglycemia episodes.
13. The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings would the nurse expect to note? Select all that apply.
1.Pathological fracture 2.Urinalysis positive for Bence Jones protein 5.Serum creatinine level of 2.0 mg/dL (176.6 mcmol/L)
4. A client diagnosed with viral hepatitis is complaining of "no appetite" and "losing my taste for food." What instruction would the nurse give the client to provide adequate nutrition?
2. Increase intake of fluids, including juices.
15. A client with type 1 diabetes mellitus who takes NPH daily in the morning calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?
2. "The best time for me to exercise is after breakfast." hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10- to 15-g carbohydrate snack
26. The nurse is caring for a client after a mastectomy. Which nursing intervention would assist in preventing lymphedema of the affected arm?
2.Elevating the affected arm on a pillow above heart level
10. The primary health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
2. "I ate shellfish about 2 weeks ago at a local restaurant." transmitted by the fecal-oral route via contaminated water or food (improperly cooked shellfish), or infected food handlers.
13. The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction would the nurse include in the discharge teaching?
2. "Take your prescribed pills 1 hour before or 2 hours after the injection." Because pramlintide delays gastric emptying
8. A client with peptic ulcer disease has been taking omeprazole for 4 weeks. The ambulatory care nurse evaluates that the client is receiving the optimal intended effect of the medication if the client reports the absence of which symptom?
2. Heartburn
16. The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing action is most appropriate?
2. Change the dressing as prescribed. immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected.
1. A client with Crohn's disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment?
2. Checking the frequency and consistency of bowel movements reduces the degree of inflammation in the colon, thereby reducing the diarrhea.
25. A client is diagnosed as having a intestinal tumor. The nurse would monitor the client for which complications of this type of tumor? Select all that apply.
2. Peritonitis 3. Hemorrhage 4. Fistula formation 5. Bowel perforation
21. The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?
2. Purple discoloration of the stoma
2. The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse would tell the client to take which action?
2. Refrigerate the insulin
7. A client with gastritis who uses nonsteroidal antiinflammatory drugs (NSAIDs) has been taking misoprostol. The nurse determines that the misoprostol is having the intended therapeutic effect if which finding is noted?
2. Relief of epigastric pain
12. The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse would provide the client with which information about the procedure?
2. That the best time for the examination is after a shower
28. The nurse is instructing a client with iron-deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction would the nurse tell the client?
2.Administer the iron through a straw. needs to be administered through a straw or medicine dropper placed at the back of the mouth, because the iron stains the teeth.
17. A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10 to 11.1 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?
2.Prednisone
8. Tamoxifen citrate is prescribed for a client with metastatic breast carcinoma. The client asks the nurse if a family member with bladder cancer can also take this medication. The nurse most appropriately responds by making which statement?
3. "This medication can be taken to prevent and treat clients with breast cancer."
12. The nurse has given instructions to a client with biliary disease who has just been prescribed cholestyramine. Which statement by the client indicates a need for further instruction?
3. "This medication would only be taken with water."
19. The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?
3. "I empty the urinary collection bag when it is two-thirds full." needs to be changed when it is one-third full to prevent pulling of the appliance and leakage.
4. The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching?
3. "I need to constantly watch for signs of low blood sugar." Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia.
9. The nurse has taught the client with suspected gallbladder disease about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?
3. "I'm glad I don't have to lie still for this procedure."
23. As part of chemotherapy education, the nurse teaches a client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse understands that further teaching is needed if the client makes which statement?
3. "I'm going to take aspirin for my headache as soon as I get home."
9. A client with a peptic ulcer is diagnosed with a Helicobacter pylori infection. The nurse is teaching the client about the medications prescribed, including clarithromycin, esomeprazole, and amoxicillin. Which statement by the client indicates the best understanding of the medication regimen?
3. "The medications will kill the bacteria and stop the acid production."
23. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply.
3.Feeling cold 4.Loss of body hair 5.Persistent lethargy 6.Puffiness of the face
11. The nurse provides instructions to a client who is taking levothyroxine. The nurse would tell the client to take the medication in which way?
3.On an empty stomach to enhance absorption.
6. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus about measures to take if feeling sick to prevent diabetic ketoacidosis (DKA). The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement?
4. "I will notify my primary health care provider (PHCP) if my blood glucose level is higher than 250 mg/dL (13.9 mmol/L)."
9. Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments?
4. "The medication is likely to cause stinging every time it is applied."
12. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?
4. A rigid, boardlike abdomen
8. A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place highest priority on which item as part of the client's care plan?
4. Assessing for the return of the gag reflex This assessment addresses the client's airway.
10. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times?
4. At least 30 minutes before exposure to the sun so they can penetrate the skin.
3. A client with gastroenteritis has an as-needed prescription for ondansetron. For which condition(s) would the nurse administer this medication?
4. Nausea and vomiting
6. A client with a gastric ulcer has a prescription for sucralfate 1 gram by mouth 4 times daily. The nurse would schedule the medication for which times?
4. One hour before meals and at bedtime
4. While giving care to a client with cervical cancer who has an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse would take which initial action?
4. Pick up the implant with long-handled forceps and place it in a lead container.
29. Laboratory studies are performed for a client suspected to have iron-deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?
4. Red blood cells that are microcytic and hypochromic
10. A client with gastroesophageal reflux disease has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition?
4. Vomiting following cancer chemotherapy gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation.
14. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention?
4. administer short duration insulin IV. Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration
14. A client with non-Hodgkin's lymphoma is receiving daunorubicin. Which finding would indicate to the nurse that the client is experiencing an adverse effect related to the medication?
4. crackles on auscultation of the lungs heart failure (lung crackles) is an adverse effect of daunorubicin
11. The nurse is assessing a client 24 hours after a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
4. document the findings
2. An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump?
4. it administers a small continuous dose of short duration insulin subcutaneously. the client can self administer an additional bolus dose from the pump before each meal.
4. A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication?
4. orthostatic hypotension.
6. A client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which manifestation indicates an adverse effect specific to this medication?
4. peripheral neuropathy Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes.
9. During the admission assessment of a client with advanced ovarian cancer, the nurse recognizes which manifestation as typical of the disease?
4.Abdominal distention
2. A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.
4.Gray-blue color at the flank 5. Abdominal guarding and tenderness 6. Left upper quadrant pain with radiation to the back
24. The community health nurse is instructing a group of young clients about breast self-examination. The nurse would instruct the clients to perform the examination at which time?
4.One week after menstruation begins
The nurse is conducting a session about the principles of first aid and is discussing the interventions for a snakebite to an extremity. The nurse would inform those attending the session that the first priority intervention in the event of this occurrence is which action?
Move the victim to a safe area away from the snake and encourage the victim to rest.
5. The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the client's chart. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test?
Positive culture results
6. A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse recognizes that melanoma has which characteristics? Select all that apply.
lesion is highly metastatic. lesion is a nevus that has changes in color.
9. The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area?
partial thickness skin loss of the dermis
10. The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned to care for a client with herpes zoster? Select all that apply.
the nurse who never had chicken pox. the nurse who never recieved the varicella zoster vaccine.
4. The clinic nurse assesses the skin of a client with psoriasis after the client has used a new topical treatment for 2 months. The nurse identifies which characteristics as improvement in the manifestations of psoriasis? Select all that apply.
thinner reddish papules and a decrease in their number. scarce amount of silvery-white scaly patches on the arms.