Saunders Adult Health Practice

Isotreinoin is prescribed for a client w severe acne. Before the administration of this medication, the nurse anticipates that which lab test will be prescribed? a. potassium level b. triglyceride level c. hemoglobin A1C d. total cholesterol level

B

The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial-thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determine the adequacy? a. vital signs b. urine output c. mentals tatus d. peripheral pulses

B

The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. ?Based on this level, the nurse would anticipate noting which sign in the client? a. coma b. flushing c. dizziness d. tachycardia

B

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? a. Age younger than 50 years b. History of colorectal polyp c. Family history of colorectal cancer d. Chronic inflammatory bowel disease

A

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? Select all that apply. a. Pathological fracture b. Urinalysis positive for nitrites c. Hemoglobin level of 15.5 g/dL (155 mmol/L) d. Calcium level of 8.6 mg/dL (2.15 mmol/L) e. Serum creatinine level of 2.0 mg/dL (176.6 mmmol/L)

A, B, E

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 health care provider will request which prescriptions? Select all that apply. a. Radiation b. Chemotherapy c. Increased fluid intake d. Decreased oral sodium intake e. Serum sodium level determination f. Medication that is antagonistic to antidiure- tic hormone

A, B, E, F

The nurse is caring for a client w lung cancer & bone metastasis. What s/s would the nurse recognize as indications of a possible oncological emergency? Select all that apply a. facial edema in the morning b. weight loss of 20 lb in 1 month c. serum calcium level of 12 mg/dL d. serum sodium level of 136 mg/dL e. serum potassium level of 3.4 mg/dL f. numbness & tingling of lower extremities

A, C, E

The nurse is applying a topical corticosteroid to a client w eczema. The nurse should apply the medication to which body area? Select all that apply. a. back b. axilla c. eyelids d. soles of feet e. palms of the hands

A, D, E

A client calls the ED and tells the nurse that he came directly into contact poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response? a. "come to the ED" b. apply calamine lotion immediately to the exposed skin areas" c. "take a shower immediately, lathering and rinsing several times" d. "it is not necessary to do anything if you cannot see anything on your skin"

C

A client is undergoing fluid replacement after being burned on 20% of her body 12 hrs ago. The nursing assessment reveals a BP of 90/50 mm Hg, a pulse rate of 110 bpm, and a urine output of 20 mL over the past hr. The nurse reports the findings to the HCP and anticipates which prescription? a. transfusing 1 unit of packed RBCs b. administering a diuretic to increase urine output c. increasing the amount of IV located Ringers solution administered per hour d. changing the IV lactated Ringer's solution to one that contains 5% dextrose in water

C

A client w severe acne is seen in the clinic and the healthcare provider (HCP) prescribes isotretinoin. The nurse reviews the clients medications cord and would contact the HCP is the client is also taking which med? a. Digoxin b. phenytoin c. vitamin A d. furosemide

C

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 should take which most appropriate action? a. Measure abdominal girth b. Irrigate the nasogastric tube. c. Continue to monitor the drainage. d. Notify the health care provider (HCP).

C

An adult client was burned in an explosion. The burn initially affects the clients entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The clients clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? a. 18% b. 24% c. 36% d. 48%

C

As part of chemotherapy education, the nurse teaches a female client about the risk for bleeding and self-care during the period of greatest bone marrow suppression (the nadir). The nurse under- stands that further teaching is needed if the client makes which statement? a. "I should avoid blowing my nose." b. "I may need a platelet transfusion if my platelet count is too low." c. "I'm going to take aspirin for my headache as soon as I get home." d. "I will count the number of pads and tampons I use when menstruating."

C

Silver sulfadiazine is prescribed for a client w 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? a. "the medication is an antibacterial" b. "the medication will help heal the burn" c. "the medication is likely to cause stinging every time it is applied" d. "the medication should be applied directly to the wound"

C

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? a. "I change my pouch every week." b. "I change the appliance in the morning." c. "I empty the urinary collection bag when it is two-thirds full." d. "When I'm in the shower I direct the flow of water away from my stoma."

C

The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? a. out-of-bed activities b. bathroom privileges c. immobilization of the affected leg d. placing the affected leg in a dependent position

C

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? a. Cyanosis b. Arm edema c. Periorbital edema d. Mental status changes

C

The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protecting isolation technique? a. using sterile sheets and linens b. performing strict hand-washing technique c. wearing gloves and a gown only when giving care to a client d. wearing protective garb, including a mask, cap, shoe covers, gowns, and plastic apron

C

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? a. restrict all visitors b. restrict fluid intake c. teach the client and family about the need for hand hygiene d. insert an indwelling urinary catheter to prevent skin breakdown

C

The nurse manager is planning the clinical assignments for the day. Which staff members cannot be assigned for a client w herpes zoster? Select all that apply. a. the nurse who never had roseola b. the nurse who never had mumps c. the nurse who never had chickenpox d. the nurse who never had German measles e. The nurse who never received the varicella-zoster vaccine

C, E

Salicylic acid is prescribed for a client w a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? a. tinnitus b. diarrhea c. constipation d. decreased respirations

A

A client arrives at the ED following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipates to be prescribed for this client? a. 100% oxygen via an aerosol mask b. oxygen via nasal cannula at 6L/minute c. oxygen nasal cannula at 15 L/minute d. 100% oxygen via. tight fitting non-rebreather face mask

D

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? a. Headache b. Dysphagia c. Constipation d. Electrocardiographic changes

D

While giving care to client w an interval cervical radiation implant, the nurse finds the implant in the bed. The nurse should take which initial action? a. call the health care provider b. reinsert the implant into vagina c. pick up the implant w gloved hands and flush down toilet d. pick up implant w ling-handled forceps and place It in the lead container

D

The nurse is creating a plan of care for the client w multiple myeloma and included which priority intervention in the plan? a. encouraging fluids b. providing frequent oral care c. coughing and deep breathing d. monitoring the RBC

A

The nurse is reviewing the lab results of a client diagnosed w multiple myeloma. Which would the nurse expect to note specifically in this ds? a. increased calcium level b. increased WBCs c. decreased blood urea nitrogen level d. decreased number of plasma cells in the bone marrow

A

The nurse is preparing to care for a burn client scheduled for an escharatomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? a. return of distal pulses b. brisk bleeding from the site c. decreasing edema formation d. formation of granulation tissue

A

A burn client is receiving treatment 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? a. hyperventilation b. elevated BP c. local rash at the burn site d. local pain at the burn site

A

The clinic nurse is perfuming an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated w use of this medication? a. itching b. euphoria c. drowsiness d. frequent urination

A

The home health care nurse is caring for a client w cancer who is complaining of acute pain. The most appropriate determination of the clients pain should include which assessment? a. the clients pain rating b. nonverbal cues from the pt c. the nurses impression of the clients pain d. pain relief after appropriate nursing intervention

A

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? a. The passage of flatus b. Absent bowel sounds c. The client's ability to tolerate food d. Bloody drainage from the colostomy

A

The nurse is caring for a client who is postop following a pelvic exenteration and the healthcare provider changes the clients diet from NPO to clear liquids. The nurse should check which priority item before administering the diet? a. bowel sounds b. ability to ambulate c. incision appearance d. urine specific gravity

A

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. an inflammation of the epidermis only b. a skin infection of the dermis and underlying hypodermis c. an acute superficial infection of the dermis and lymphatics d. an epidermal and lymphatic infection caused by Staphylococcus

B

A client who has been receiving radiation therapy for bladder cancer tells the nurse that it feels as if she is voiding through the vagina. The nurse interprets that the client may be experiencing which condition? a. rupture of the bladder b. the development of a vesicovaginal fistula c. extreme stress caused by the diagnosis of cancer d. altered perineal sensation as a side effect of radiation therapy

B

The clinic nurse notes that the health care provider has documented a diagnosis of herpes zoster (shingles) in the clients chart. Based on an understanding of the cause of this ds, the nurse determines that this definitive diagnosis was made by which diagnostic test? a. positive patch test b. positive culture results c. abnormal biopsy results d. woods light examination indicative of infection

B

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 intervention is most appropriate? a. Clamp the surgical drain. b. Change the dressing as prescribed c. Notify the health care provider (HCP) d. Remove and replace the perineal packing.

B

The nurse is caring for a client following a mastec- tomy. Which nursing intervention would assist in preventing lymphedema of the affected arm? a. Placing cool compresses on the affected arm b. Elevating the affected arm on a pillow above heart level c. Avoiding arm exercises in the immediate postoperative period d. Maintaining an intravenous site below the ante- cubital area on the affected side

B

The nurse is instructing a client to perform a testicular self-exam (TSE). The nurse should provide the client w which information about the procedure? a. to examine the testicles while laying down b. that the best time for the exam is after a shower c. to gently feel the testicle w 1 finger for a growth d. that TSEs should be done at least every 6 months

B

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? a. Dysuria b. Hematuria c. Urgency on urination d. Frequency of urination

B

A client returns to the clinic for follow-up treatment following a skin biopsy of a suspicious lesion performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that melanoma has which characteristics? Select all that apply. a. lesion is painful to touch b. lesion is highly metastatic c. lesion is a nevus that has changes in color d. skin under lesion is reddened and warm to touch e. lesion occurs in body area explored to outdoor sunlight

B, C

When caring for a client w an intertnal radiation implant, the nurse should observe which principles? Select all that apply. a. limiting the time w the client to 1 hr per shift b. keeping pregnant women out of the clients room c. placing the client in a private room w a private bath d. wearing a lead shield when providing direct client care e. removing the dosimeter film badge when entering the clients room f. allowing individuals younger than 16 y/o in room as ling as they are 6 feet from clienT

B, C, D

Aclient is diagnosed as having a bowel tumor. The nurse should monitor the client for which complications of this type of tumor? Select all that apply. a. Flatulence b. Peritonitis c. Hemorrhage d. Fistula formation e. Bowel perforation f. Lactose intolerance

B, C, D, E

A client is brought to the ED w partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. a. restrict fluids b. assess for airway patency c. administer oxygen as prescribed d. place a coping blanket on the client e. elevate extremities if no fractures are present f. prepare to give oral pain meds as prescribed

B, C, E

The heath education nurse provides instructions to a group of clients regarding measures that will assist in preventing skin cancer. Which instructions should the nurse provide? Select all that apply. a. sunscreen should be applied q8hrs b. use sunscreen when participating in outdoor activities c. wear a heat, opaque clothing, and sunglasses when in the sun d. avoid sun exposure in the late afternoon and early evening hours e. examine your body monthly for any lesions that may be suspicious

B, C, E

A client arriving at the ED has experienced frostbite to the right hand. Which finding would the nurse note on assessment of the clients hand? a. a pin, edematous hand b. fiery red skin w edema in the nail beds c. black fingertips surrounded by an erythematous rash d. a white color to skin, which is sensitive to touch

D

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's ds. Which assessment finding would the nurse expect to note specifically in the client? a. fatigue b. weakness c. weight gain d. enlarged lymph nodes

D

During the admission assessment of a client w advances ovarian cancer, the nurse recognizes which manifestation as typical of the ds? a. diarrhea b. hypermenorrhea c. abnormal bleeding d. abdominal distension

D

Silver Sulfadiazine is prescribed for a client w a burn injury. Which lab finding requires the need for follow-up by the nurse? a. Glucose level of 99 mg.dL (5.65 mol/L) b. Magnesium level of 1.5 mEq/L (0.75 mol/L) c. platelet level of 300,000mm^3 d. WBC count of 300mm^3

D

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? a. immediately before swimming b. 5 minutes before exposure to the sun c. immediately before exposure to the sun d. at least 30 mins before exposure to the sun

D

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time? a. At the onset of menstruation b. Every month during ovulation c. Weekly at the same time of day d. 1 week after menstruation begins

D

The evening nurse reviews the nursing documentation in a clients chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the clients sacral area? a. intact skin b. full-thickness skin loss c. exposed bone, tendon or muscle d. partial-thickness skin loss of the dermis

D

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergency phase of the burn injury? a. decreased HR b. increased urinary output c. increased BP d. elevated hematocrit levels

D

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 should inform those attending the session that the first priority intervention in the event of this occurrence is what action? a. immobilize the affected extremity b. remove jewelry and constricting clothing from the victim c. place the extremity in a position that that it is below the level of the heart d. move the victim to a safe area aware from the sale and encourage victim to rest

D

The clinic nurse assess the skin of client with psoriasis after 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. a. presence of striae b. palpable radial pulses c. absence of any ecchymosis on the extremities d. thinner and decrease in number of reddish papule e. scarce amount of silvery-white scaly patches on the arms

D, E

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. a. an irregularly shaped lesion b. a small papule w a dry, rough scale c. a firm, nodular lesion topped w crust d. a pearly papule w a central crater and a waxy border e. location in the bald spot atop the head that is exposed to outdoor sunlight

D, E