saunders

The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care. A staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator would make which most appropriate response? "A group of individuals identifying as a part of the Iroquois tribe among Native Americans." "A person who moves from China to the United States (U.S.) and learns about and adapts to the U.S. culture." "A group of individuals living in the Azores who identify autonomously but are a part of the larger population of Portugal." "A person who has grown up in the Philippines and chooses to stay there because of the sense of belonging to their cultural group."

"A person who moves from China to the United States (U.S.) and learns about and adapts to the U.S. culture."

A client with hypovolemia experiences activation of the renin-angiotensin system to maintain blood pressure. The registered nurse determines that the new nurse understands that what substance is secreted if which statement is made? "Cortisol will be secreted." "Aldosterone will be secreted." "Additional glucagon will be produced." "Adrenocorticotropic hormone production will increase."

"Aldosterone will be secreted."

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information would the nurse include in the teaching? "A bone fragment has injured the nerve supply in the area." "An injured artery caused impaired arterial perfusion through the compartment." "Bleeding and swelling caused increased pressure in an area that couldn't expand." "The fascia expanded with injury, causing pressure on underlying nerves and muscles."

"Bleeding and swelling caused increased pressure in an area that couldn't expand."

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. Which question would best help the nurse discriminate pain caused by a noncardiac problem? "Can you describe the pain to me?" "Have you ever had this pain before?" "Does the pain get worse when you breathe in?" "Can you rate the pain on a scale of 1 to 10, with 10 being the worst?"

"Does the pain get worse when you breathe in?"

The nurse has provided instructions to a client with pruritus regarding measures to relieve the discomfort. Which statement, if made by the client, indicates a need for further instruction? "I need to use tepid water for bathing."" I need to keep my skin lubricated and cool." "After bathing, I would pat my skin dry rather than rubbing it." "I would apply a lubricant to my skin after bathing when my skin is thoroughly dry."

"I would apply a lubricant to my skin after bathing when my skin is thoroughly dry."

The ambulatory care nurse is providing discharge instructions to a client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? "I need to take sitz baths every 4 hours for the next week." "I would expect the vaginal discharge to be clear and watery." "Very strong pain medications will be needed to relieve any discomfort I may have." "If I note any odor to the vaginal discharge, I would call the primary health care provider immediately."

"I would expect the vaginal discharge to be clear and watery."

A topical corticosteroid is prescribed for a client with dermatitis. The nurse provides instructions to the client regarding the use of the medication. Which statement by the client would indicate a need for further instruction? "I need to apply the medication in a thin film." "I would gently rub the medication into the skin." "The medication will help relieve the inflammation and itching." "I would place a bandage over the site after applying the medication."

"I would place a bandage over the site after applying the medication."

The nurse is performing an assessment on a client with suspected acute pancreatitis. Which complaint made by the client supports the diagnosis? "I have epigastric pain radiating to my neck." "I have severe abdominal pain that is relieved after vomiting." "My temperature has been running between 96° F (35.5° C) and 97° F (36.1° C). "I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

"I've been experiencing constant, severe abdominal pain that is unrelieved by vomiting."

The nurse is caring for a client who had a transsphenoidal hypophysectomy. Which statements would the nurse include in the discharge teaching instructions? Select all that apply. "Include adequate fiber and fluids in your diet." "Wear slip-on shoes rather than those that need to be tied." "A postnasal drip may be expected for several weeks after surgery." "Brushing your teeth will not be permitted for at least 2 weeks after surgery." "Contact your primary health care provider immediately if you develop any headache, fever, or neck stiffness."

"Include adequate fiber and fluids in your diet." "Brushing your teeth will not be permitted for at least 2 weeks after surgery."

The nurse is listening to a lecture on Advanced Cardiac Life Support (ACLS). The instructor is discussing electrocardiographic (ECG) changes caused by myocardial ischemia. Which statement by the nurse indicates that teaching has been effective? "Tall, peaked T waves can indicate ischemia." "Prolonged PR interval can indicate ischemia." "Widened QRS complex can indicate ischemia." "ST segment elevation or depression can indicate ischemia."

"ST segment elevation or depression can indicate ischemia."

Sulfasalazine is prescribed for a client with a diagnosis of ulcerative colitis, and the nurse instructs the client about the medication. Which statement made by the client indicates a need for further teaching? "The medication will cause constipation." "I need to take the medication with meals." "I may be more sensitive to sunlight than usual." :This medication needs to be taken as prescribed."

"The medication will cause constipation."

The parent of a 5-year-old child tells the nurse that the child scolds the floor or a table if the child hurts themself on the object. The nurse educates the parent according to Piaget's theory of cognitive development and its terminology and definitions. Which statement by the parent indicates that the teaching has been effective? "This is an example of animism." "This is an example of egocentric speech." "This is an example of object permanence." "This is an example of global organization."

"This is an example of animism."

A client is being admitted to the hospital for treatment of acute cellulitis of the lower left leg, and a nursing student is assigned to provide care for the client. The nursing instructor asks the student to describe this diagnosis. Which answer demonstrates the student's understanding of the diagnosis? "It is an acute superficial infection." "It is an inflammation of the epidermis." "Staphylococcus is the cause of this epidermal infection." "This skin infection involves the deep dermis and subcutaneous fat."

"This skin infection involves the deep dermis and subcutaneous fat."

The nurse has completed giving discharge instructions to a client after total knee arthroplasty and replacement with a prosthetic system. The nurse teaches the client about weight-bearing status. What information would the nurse include? "You will use full weight bearing by discharge." "You will not be able to bear weight at all by discharge." "You will need to remain on bed rest even after discharge." "You will be able to bear some weight as tolerated with a walker or crutches by discharge."

"You will be able to bear some weight as tolerated with a walker or crutches by discharge."

The nurse is making initial rounds at the beginning of the shift and notes that the total parenteral nutrition (TPN) bag of an assigned client is empty. Which solution would the nurse hang until another TPN solution is mixed and delivered to the nursing unit? 5% dextrose in water 10% dextrose in water 5% dextrose in Ringer's lactate 5% dextrose in 0.9% sodium chloride

10% dextrose in water

The home care nurse visits a client with a diagnosis of unstable angina. The client is taking acetylsalicylic acid (aspirin) on a daily basis to reduce the risk of myocardial infarction (MI). Which medication dose would the nurse expect the client to be taking? 3 g daily 1.3 g daily 650 to 700 mg daily 300 to 325 mg daily

300 to 325 mg daily

The nurse is reviewing the laboratory test results for an adult client who is being treated for anemia. The nurse determines that the hematocrit level is normal if which value is noted on the laboratory report? 58% (0.58) 250% (0.50) 340% (0.40) 432% (0.32)

50% (0.50)

The nurse is planning to teach a client with a muscle ligament injury how to stand on crutches. The nurse will incorporate into written instructions that the client would be told to place the crutches in what manner? 3 inches (8 cm) to the front and side of the toes 6 inches (15 cm) to the front and side of the toes 15 inches (38 cm) to the front and side of the toes 20 inches (51 cm) to the front and side of the toes

6 inches (15 cm) to the front and side of the toes

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? An inflammation of the epidermis only A skin infection of the dermis and underlying hypodermis An acute superficial infection of the dermis and lymphatics An epidermal and lymphatic infection caused by Staphylococcus

A skin infection of the dermis and underlying hypodermis

Which individuals are most likely to be at risk for development of psoriasis? Select all that apply. An individual with darker skin A client experiencing menopause A client with a family history of the disorder An individual who has experienced a significant amount of emotional distress A client with a thin body frame who adheres to a regular exercise program

A client experiencing menopause A client with a family history of the disorder An individual who has experienced a significant amount of emotional distress

The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for total parenteral nutrition (TPN)? Select all that apply. A client with extensive burns A client with cancer who is septic A client who has had an open cholecystectomy A client with severe exacerbation of Crohn's disease A client with persistent nausea and vomiting from chemotherapy

A client with extensive burns A client with cancer who is septic A client with severe exacerbation of Crohn's disease A client with persistent nausea and vomiting from chemotherapy

The home care nurse is visiting a postnatal client 1 week after the client gave birth to an infant who is at risk for developing neonatal congenital syphilis. After teaching the client about the signs and symptoms of this disorder, the nurse instructs the client to monitor the infant for which findings? Select all that apply. Loose stools High-pitched cry Vigorous feeding habits A copper-colored skin rash Mucopurulent nasal drainage (snuffles)

A copper-colored skin rash Mucopurulent nasal drainage (snuffles)

The nurse is caring for a client with prostate cancer who is being treated with a hormone therapy. What would the nurse monitor for in order to evaluate the effect of this treatment? An increase in testosterone levels An increase in prostaglandin levels An increase the amount of circulating androgens A decline in the amount of circulating androgens

A decline in the amount of circulating androgens

In preparation for cataract surgery, the nurse is to administer prescribed eye drops. The nurse reviews the primary health care provider's prescriptions, expecting which type of eye drops to be prescribed? A miotic agent A thiazide diuretic An osmotic diuretic A mydriatic medication

A mydriatic medication

When assessing a lesion diagnosed as basal cell carcinoma, the nurse most likely expects to note which findings? Select all that apply. An irregularly shaped lesion A small papule with a dry, rough scale A firm, nodular lesion topped with crust 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

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

The nurse is repositioning a client who has been returned to the nursing unit after internal fixation of a fractured right hip with a femoral head replacement. The nurse would plan to use which method to reposition the client? A trochanter roll to prevent abduction during turning A pillow to keep the right leg abducted during turning A pillow to keep the right leg adducted during turning A trochanter roll to prevent external rotation during turning

A pillow to keep the right leg abducted during turning

The nurse would include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. Provide a warm environment for the client. Instruct the client to consume a low-fat diet. A thyroid-releasing inhibitor will be prescribed. Encourage the client to consume a well-balanced diet. Instruct the client that thyroid replacement therapy will be needed. Instruct the client that episodes of chest pain are expected to occur.

A thyroid-releasing inhibitor will be prescribed. Encourage the client to consume a well-balanced diet.

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 pink edematous hand Fiery red skin with edema in the nail beds Black fingertips surrounded by an erythematous rash A white color to the skin, which is insensitive to touch

A white color to the skin, which is insensitive to touch

The nurse is caring for a client with a perforated duodenal ulcer. Which of the following imaging studies would the nurse anticipate the primary health care provider ordering to most accurately diagnose this condition?

Abdominal computed tomography (CT) scan with oral contrast

A client has had surgery to repair a fractured left hip. When repositioning the client from side to side in the bed, what would the nurse plan to use as the most important item for this maneuver? Bed pillow Abductor splint Adductor splint Overhead trapeze

Abductor splint

Hydrochlorothiazide has been prescribed for a client with hypertension. The nurse contacts the primary health care provider (PHCP) to verify the prescription if which condition is noted in the assessment data? Hypertension Allergy to eggs Nephrotic syndrome Allergy to sulfonamides

Allergy to sulfonamides

A nursing instructor is teaching the class about Addison's disease. The instructor determines that the class understands the disease process if they indicate which are affected in this disease? Select all that apply. Androgens Bicarbonate Electrolytes Glucocorticoids Mineralocorticoids

Androgens Glucocorticoids Mineralocorticoids

A client has been hospitalized for impaired function of the posterior pituitary gland. The nurse plans to monitor for signs and symptoms of which hormone imbalance? Growth hormone (GH) Luteinizing hormone (LH) Antidiuretic hormone (ADH) Follicle-stimulating hormone (FSH)

Antidiuretic hormone (ADH)

The nurse performs an assessment on a client who is 4 hours postpartum. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. What immediate action would the nurse take? Provide oral fluids and begin fundal massage. Begin hourly pad counts and reassure the client. Elevate the head of the bed and assess vital signs. Assess for hypovolemia and notify the primary health care provider (PHCP).

Assess for hypovolemia and notify the primary health care provider (PHCP).

A client is experiencing chronic pruritus. To promote hydration of the skin, the nurse would tell the client to take which measure? Maintain room humidity at less than 40%. Use very hot or very cold water for bathing. Apply emollients once the skin is thoroughly dry. Avoid bathing in the shower or tub more than once daily.

Avoid bathing in the shower or tub more than once daily.

A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn would be classified as which type? Superficial Full-thickness Deep partial-thicknessP Partial-thickness superficial

Full-thickness

A client who is human immunodeficiency virus seropositive has been taking stavudine. The nurse would monitor which most closely while the client is taking this medication? Gait Appetite Level of consciousness Gastrointestinal function

Gait

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? "Autonomy is the fundamental right of each and every client." "A client's rights are guaranteed by both state and federal laws." "Being respectful and concerned will ensure that I'm attentive to my client's rights." "Regardless of the client's condition, all nurses have the duty to value client rights."

Being respectful and concerned will ensure that I'm attentive to my client's rights.

The nurse is caring for a client with a history of a small perforated duodenal ulcer that spontaneously healed on its own. The client asks the nurse about potential complications from a healed ulcer. The nurse would tell the client that which of the following is a complication of a self-healed duodenal ulcer?

Bowel stricture

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? Bradycardia Hyperthermia Hypoglycemia Increased cardiac output

Bradycardia

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding would the nurse expect to note in this client? Dry skin Bulging eyeballs Periorbital edema Coarse facial features

Bulging eyeballs

A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse would have which medication available for local injection if IV infiltration and medication extravasation occur? Vitamin K Phentolamine Atropine sulfate Protamine sulfate

Phentolamine

The nurse is preparing to administer medication using a client's nasogastric tube. Which actions would the nurse take before administering the medication? Select all that apply. Check the residual volume. Aspirate the stomach contents. Turn off the suction to the nasogastric tube. Remove the tube and place it in the other nostril. Test the stomach contents for a pH indicating acidity.

Check the residual volume. Aspirate the stomach contents. Turn off the suction to the nasogastric tube Test the stomach contents for a pH indicating acidity.

The nurse is caring for a client with metabolic alkalosis. The nurse plans care, knowing that most problems of metabolic alkalosis are related to increased stimulation of what systems? Select all that apply. Buffer Cardiac Nervous Chemical Respiratory Neuromuscular

Cardiac Nervous Neuromuscular

Assessment and diagnostic evaluation reveal that a client seen in the ambulatory care clinic has stage II Lyme disease. The clinic nurse identifies which assessment finding as most characteristic of this stage? Arthralgias Joint enlargement Erythematous rash Cardiac conduction deficits

Cardiac conduction deficits

The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? Heart failure Pulmonary edema Cardiogenic shock Aortic insufficiency

Cardiogenic shock

A client has begun taking phenelzine. At the initiation of therapy, the client is taught which foods are acceptable to consume? Select all that apply. Avocados Figs and raisins Bologna or salami Carrots or radishes Sweet potatoes and squash Red wine, such as Chianti or sherry

Carrots or radishes Sweet potatoes and squash

The nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast is applied, the client reports a significant increase in pain level even after administration of the prescribed dose of opioid analgesic. What is the initial nursing action? Elevate the casted leg. Contact the primary health care provider. Administer another dose of pain medication. Check the neurovascular status of the toes on the casted leg.

Check the neurovascular status of the toes on the casted leg.

The nurse is caring for a client who has had an adrenalectomy and is monitoring the client for signs of adrenal insufficiency. Which signs and symptoms indicate adrenal insufficiency in this client? Hypotension and fever Mental status changes and hypertension Subnormal temperature and hypotension Complaints of weakness and hypertension

Hypotension and fever

Which finding noted in the client on continuous ambulatory peritoneal dialysis (CAPD) would be reported to the primary health care provider (PHCP)? Cloudy yellow dialysate output Client refusal to take the stool softener Previous evening's dwell time of 8 hours Peritoneal catheter site is not red, and the skin has grown around the cuff

Cloudy yellow dialysate output

The nurse is caring for a client with a radius fractured across the shaft and bone splintered into fragments. Information about which type of fracture would be included by the nurse in the client's education? Simple fracture Greenstick fracture Compound fracture Comminuted fracture

Comminuted fracture

The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would be most concerned with which assessment finding? Temperature of 101.6° F (38.7° C) orally Complaints of discomfort during repositioning Old bloody drainage outlined on the surgical dressing Discomfort during coughing and deep-breathing exercises

Complaints of discomfort during repositioning

A client has begun medication therapy with propylthiouracil. The nurse would assess the client for which condition as an adverse effect of this medication? Joint pain Renal toxicity Hyperglycemia Hypothyroidism

Hypothyroidism

An older client is admitted to the hospital with a diagnosis of malnutrition. Other than cognitive status, what other factors can increase the risk of malnutrition and dehydration? Select all that apply. Past profession Physical fatigue Limited mobility Sensory decreases Inadequate dental care Family history of malnutrition

Physical fatigue Limited mobility Sensory decreases Inadequate dental care

The home care nurse is providing instructions to a client with a musculoskeletal injury regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How would the nurse accurately demonstrate this technique? Crutches and the affected leg down, followed by the unaffected leg Crutches and the unaffected leg down, followed by the affected leg Unaffected leg down first, followed by the crutches and the affected leg Affected leg down first, followed by the crutches and the unaffected leg

Crutches and the affected leg down, followed by the unaffected leg

The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome? Select all that apply. Cyanosis Tachypnea Hypotension Retractions Audible grunts Presence of a barrel chest

Cyanosis Tachypnea Retractions Audible grunts

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? Cranial nerve I, olfactory Cranial nerve IV, trochlear Cranial nerve III, oculomotor Cranial nerve VII, facial nerve

Cranial nerve VII, facial nerve

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse would expect to note? Select all that apply. Increased heart rate Decline in visual acuity Decreased respiratory rate Decline in long-term memory Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

Decline in visual acuity Increased susceptibility to urinary tract infections Increased incidence of awakening after sleep onset

Diphenoxylate hydrochloride with atropine sulfate is prescribed for a client with ulcerative colitis. The nurse would monitor the client for which therapeutic effect of this medication? Decreased diarrhea Decreased cramping Improved intestinal tone Elimination of peristalsis

Decreased diarrhea

Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour? Ensure that the client does not have diabetes. Determine whether the client has an allergy to eggs. Add regular insulin to the fat emulsion, using aseptic technique. Contact the primary health care provider (PHCP) to have a central line inserted for fat emulsion infusion.

Determine whether the client has an allergy to eggs.

The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse would prepare to administer this medication by which method? Direct intravenous (IV) bolus Diluting the medication and administering it rapidly by the IV route Administering the medication through a nasogastric tube, followed by activated charcoal Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes

One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? Ibuprofen Acetaminophen Diphenhydramine Acetylsalicylic acid

Diphenhydramine

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding would the nurse expect to note in this client? Dry skin Thin, silky hair Bulging eyeballs Fine muscle tremors

Dry skin

The nurse is caring for a client who was just admitted to the hospital with a diagnosis of a fractured right hip sustained from a fall 5 hours earlier. The nurse creates a plan of care for the client and includes interventions related to monitoring for signs of fat embolism. Which findings would be listed in the care plan as a sign/symptom of fat embolism? Fever and chills Dyspnea and chest pain External rotation of the right leg Pallor, paresthesia, and pulselessness of the right lower leg

Dyspnea and chest pain

A client exhibits a purplish bruise to the skin after a fall. The nurse would document this finding in the health record most accurately using which term? Purpura Petechiae Erythema Ecchymosis

Ecchymosis

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child? Elevated antistreptolysin O titer Decreased erythrocyte sedimentation rate Negative result on antinuclear antibody assay Negative result on C-reactive protein determination

Elevated antistreptolysin O titer

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply. Strict bed rest Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism

Elevation of the right leg Administration of acetaminophen Application of moist heat to the right leg Monitoring for signs of pulmonary embolism

The primary health care provider prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions would the nurse plan to include in the client's plan of care? Select all that apply. Encourage coughing with deep breathing. Place in high-Fowler's position for eating. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client. Place sequential compression boots on the client. Encourage the intake of dark green, leafy vegetables.

Encourage coughing with deep breathing. Encourage increased oral intake of water daily. Place thigh-length elastic stockings on the client.

The nurse is admitting a client diagnosed with pheochromocytoma. The client is complaining of a pounding headache and palpitations and the blood pressure is 170/90 mm Hg. The nurse is aware that which substance is responsible for these clinical manifestations? Cortisol Androgens Aldosterone Epinephrine

Epinephrine

The nurse is performing an assessment of the client who is admitted with left leg cellulitis. What does the nurse anticipate finding on the assessment of the left lower extremity? Pallor Cyanosis Jaundice Erythema

Erythema

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. Fever Positive Cullen's sign Complaints of indigestion Palpable mass in the left upper quadrant Pain in the upper right quadrant after a fatty meal Vague lower right quadrant abdominal discomfort

Fever Complaints of indigestion Pain in the upper right quadrant after a fatty meal

The nurse is providing home care instructions to the client who just had surgery for squamous cell carcinoma. The nurse provides follow-up teaching and explains to the client to watch for which characteristics of this type of skin carcinoma? Irregularly shaped, pigmented papules or plaques Pearly papule with a central crater and rolled, waxy borders Small macules or papules with dry, rough, adherent yellow or brown scale Firm, nodular lesion topped with a crust or with a central area of ulceration

Firm, nodular lesion topped with a crust or with a central area of ulceration

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Flushing Hypertension Increased urine output Depressed respirations Extreme muscle weakness Hyperactive deep tendon reflexes

Flushing Depressed respirations Extreme muscle weakness

The nurse has a prescription to get a client who is paraplegic out of bed and into a chair. The nurse determines which item would be best to put in the chair under the client? Pillow Foam pad Folded blankets Plastic-lined absorbent pad

Foam pad

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. Diarrhea Black, tarry stools Hyperactive bowel sounds Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

Gray-blue color at the flank Abdominal guarding and tenderness Left upper quadrant pain with radiation to the back

The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? Disorientation to time only Heart rate of 95 beats/minute +1 palpable peripheral pulses Urine output of 30 mL over the past 2 hours

Heart rate of 95 beats/minute

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. Which are interventions to aid the client in relieving the spasm? Select all that apply. Ice Heat Analgesics Muscle relaxers Intermittent traction

Heat Analgesics Muscle relaxers Intermittent traction

The nurse is assigned to care for a client with a Sengstaken-Blakemore tube for the treatment of esophageal varices. Which laboratory result is most focused on evaluating the effectiveness of this tube? Sodium Creatinine Ammonia Hemoglobin

Hemoglobin

An infant is born to a postpartum client with hepatitis B. The nurse plans for which prophylactic measure for the infant? Hepatitis B vaccine given within 24 hours after birth Immune globulin (IG) given as soon as possible after delivery Hepatitis B immune globulin (HBIG) given within 14 days after birth Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

To detect the development of a chronic carrier state in a client with hepatitis, which laboratory test would the nurse assess? Hepatitis B virus DNA Prolonged prothrombin time Hepatitis B surface antigen (HBsAg) Antibody to surface antigen (anti-HBs)

Hepatitis B surface antigen (HBsAg)

The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? Pallor of all extremities Pulse oximetry reading of 93% Peripheral pulses are diminished High pressure alarm keeps sounding on the ventilator

High pressure alarm keeps sounding on the ventilator

A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. Hypernatremia Signs of water deficit High urine osmolality Low serum osmolality Hypotonicity of body fluids Continued release of antidiuretic hormone (ADH)

High urine osmolality Low serum osmolality Hypotonicity of body fluids Continued release of antidiuretic hormone (ADH)

The nurse is instructing a client who had a stroke and has weakness on one side how to ambulate with the use of a cane. Which instruction would the nurse provide to the client? Hold the cane on the affected (weak) side. Hold the cane on the unaffected (strong) side. Move the cane forward first along with the unaffected (strong) leg. Move the cane and the unaffected (strong) leg down first when going down stairs.

Hold the cane on the unaffected (strong) side.

The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse would tell the client that which would be noted in a hypoglycemic reaction? Thirst Hunger Polydipsia Increased urine output

Hunger

The nurse is reviewing the pathophysiology of childhood obesity. Which conditions are correlated with childhood obesity? Pneumonia Cystic fibrosis Hyperlipidemia Type 2 diabetes Fungal skin infections

Hyperlipidemia Type 2 diabetes Fungal skin infections

The nurse is planning care for a client who suffered a burn injury and has a negative self-image related to keloid formation at the burn site. The keloid formation is indicative of which condition? Nerve damage Hypertrophy of collagen fibers Compromised circulation at the burn site Increase in subcutaneous tissue at the burn site

Hypertrophy of collagen fibers

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? Out-of-bed activities Bathroom privileges Immobilization of the affected leg Placing the affected leg in a dependent position

Immobilization of the affected leg

The nurse is performing a neurovascular assessment on a client with a cast on the left lower leg. The nurse notes the presence of edema in the foot below the cast. The nurse would make which interpretation about this finding? Arterial insufficiency Impaired venous return Impaired arterial circulation The presence of an infection

Impaired venous return

The parent of a preschooler who attends day care calls a clinic nurse and tells the nurse that the child is constantly scratching the perianal area and that the area is irritated. The nurse suspects the possibility of pinworm infection (enterobiasis) and instructs the parent to obtain a rectal specimen by a tape test. At what time would the nurse tell the parent to obtain the specimen? After bathing After toileting When the child is put to bed In the morning, when the child awakens

In the morning, when the child awakens

A client immobilized in skeletal leg traction complains of being bored and restless. Based on these complaints, the nurse identifies which client problem as the priority? Lack of control Lack of physical mobility Inability to entertain self Inability to maintain health

Inability to entertain self

The home care nurse is visiting a client with a diagnosis of Parkinson's disease. The client is taking benztropine mesylate orally daily. The nurse provides information to the spouse regarding the side effects of this medication and would tell the spouse to report which side effect if it occurs? Shuffling gait Inability to urinate Decreased appetite Irregular bowel movements

Inability to urinate

The nurse is reviewing the diagnostic tests performed in an adult with a connective tissue disorder. The erythrocyte sedimentation rate (ESR) is reported as 35 mm/hr (35 mm/hr). How would the nurse interpret this finding? Normal Indicating severe inflammation Indicating moderate inflammation Indicating mild inflammation

Indicating mild inflammation

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 prescriptions would the nurse anticipate receiving? Select all that apply. Initiate an infusion of 3% NaCl. Administer intravenous furosemide. Restrict fluids to 800 mL over 24 hours. Elevate the head of the bed to high-Fowler's. Administer a vasopressin antagonist as prescribed.

Initiate an infusion of 3% NaCl. Restrict fluids to 800 mL over 24 hours. Administer a vasopressin antagonist as prescribed.

The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The primary health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse would instruct the client that which is the first step in this procedure? Draw up the correct dosage of NPH insulin into the syringe. Draw up the correct dosage of regular insulin into the syringe. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

A client is hospitalized with a diagnosis of adrenal insufficiency. Which findings does the nurse identify as supportive of this diagnosis? Select all that apply. Irritability Complaints of nausea Sodium level of 128 mEq/L (128 mmol/L) Potassium level of 3.2 mEq/L (3.2 mmol/L) Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg

Irritability Complaints of nausea Sodium level of 128 mEq/L (128 mmol/L) Blood pressure lying 138/70 mm Hg and standing 110/58 mm Hg

A client has been diagnosed with subluxation of the shoulder. The nurse explains to the client that which injury has occurred to the joint? It is strained. It is contused. It has completely dislocated. It has incompletely dislocated.

It has incompletely dislocated.

A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? Allow the client to have full liquids Give the client small glasses of clear liquids Order the client a full meal tray with extra liquids. Keep the client on NPO (nothing by mouth) status.

Keep the client on NPO (nothing by mouth) status.

The nurse is giving discharge instructions to a client who has just undergone vein ligation and stripping. The nurse evaluates that the client understands activity and positioning limitations if the client states that which action is appropriate to do? Walk for as long as possible each day. Cross the legs at the ankle only, not at the knee. Sit in a chair 3 times a day for 3 hours at a time. Lie down with the legs elevated and avoid sitting.

Lie down with the legs elevated and avoid sitting.

The nurse is instructing a client in breast self-examination (BSE). The nurse tells the client to lie down and examine the left breast. The nurse would instruct the client that while examining the left breast she would place a pillow under which area? Left shoulder Right scapula Right shoulder Small of the back

Left shoulder

The nurse is assessing a dark-skinned client for signs of anemia. The nurse would focus the assessment on which structures? Select all that apply. Lips Tongue Earlobes Conjunctiva Mucous membranes

Lips Conjunctiva Mucous membranes

A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? Eschar Intact blisters Liquefaction necrosis Cherry-red, firm tissue

Liquefaction necrosis

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions would be included in the care plan for this client? Select all that apply. Monitor daily weight. Maintain a high-sodium diet. Maintain a low-potassium diet. Monitor intake and output. Assess extremities for edema.

Monitor daily weight. Monitor intake and output. Assess extremities for edema.

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. Maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give small, frequent high-calorie feedings. Maintain the client in a supine and flat position. Give hydromorphone intravenously as prescribed for pain. Maintain intravenous fluids at 10 mL/hour to keep the vein open.

Maintain NPO (nothing by mouth) status. Encourage coughing and deep breathing. Give hydromorphone intravenously as prescribed for pain.

The nurse asks a nursing student about the uses of the medication dantrolene. The nursing student correctly states that dantrolene is used to manage hypermetabolism of skeletal muscle that occurs in which condition? Low back pain General anesthesia Malignant hyperthermia Hyperplasia of the prostate

Malignant hyperthermia

The nurse is caring for a client with acute pulmonary edema. The primary health care provider (PHCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the PHCP's statement, what medication would the nurse anticipate administering? Digoxin Prednisone Furosemide Nitroprusside sodium

Nitroprusside sodium

The nurse is caring for a client with a small bowel obstruction located in the proximal jejunum. The nurse would monitor the client for which acid-base imbalances associated with this condition?

Metabolic alkalosis

The nurse is caring for a client with an exacerbation of multiple sclerosis. Which medication(s) will the nurse expect to be prescribed to hasten recovery from the exacerbation Carbamazepine and phenytoin by mouth Lioresal by mouth and diazepam intravenously Phenytoin intravenously, then tapered to oral route Methylprednisolone and cyclophosphamide intravenously

Methylprednisolone and cyclophosphamide intravenously

A client is participating in a therapy group and focuses on viewing all team members as equally important in helping the clients meet their goals. The nurse is implementing which therapeutic approach? Milieu therapy Interpersonal therapy Behavior modification Support group therapy

Milieu therapy

A client with recurrent constipation has been prescribed psyllium, powdered form. Teaching provided by the nurse would include which instruction? Take the powder with food. Sprinkle the powder on top of a hot beverage. Mix the powder with warm applesauce. Mix the powder with a full glass of water or juice followed by drinking an additional glass of liquid.

Mix the powder with a full glass of water or juice followed by drinking an additional glass of liquid.

The nurse is developing a plan of care for a client with Addison's disease. The nurse has identified a problem of risk for deficient fluid volume and identifies nursing interventions that will prevent this occurrence. Which nursing interventions would the nurse include in the plan of care? Select all that apply. Monitor for changes in mentation. Encourage an intake of low-protein foods. Encourage an intake of low-sodium foods. Encourage fluid intake of at least 3000 mL per day. Monitor vital signs, skin turgor, and intake and output.

Monitor for changes in mentation. Encourage fluid intake of at least 3000 mL per day. Monitor vital signs, skin turgor, and intake and output.

The nurse educator is preparing to conduct a teaching session for the nursing staff regarding the theories of growth and development and plans to discuss Kohlberg's theory of moral development. What information would the nurse include in the session? Select all that apply. Individuals move through all six stages in a sequential fashion. Moral development progresses in relationship to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. In stage 1 (punishment-obedience orientation), children are expected to reason as mature members of society. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

Moral development progresses in relationship to cognitive development. A person's ability to make moral judgments develops over a period of time. The theory provides a framework for understanding how individuals determine a moral code to guide their behavior. In stage 2 (instrumental-relativist orientation), the child conforms to rules to obtain rewards or have favors returned.

The nurse is evaluating the use of a cane for a client who sustained a stroke who has residual left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client performs which action? Holds the cane on the right side Moves the cane when the right leg is moved Leans on the cane when the right leg swings through Keeps the cane 6 inches (15 cm) out to the side of the right foot

Moves the cane when the right leg is moved

The nurse would educate the client receiving pravastatin to immediately report which finding? Fatigue Diarrhea Sore throat Muscle pain

Muscle pain

The nurse is performing an admission assessment on a client diagnosed with paronychia. The nurse would plan to assess which part of the integumentary system first? Nails Hair follicles Pilosebaceous glands Epithelial layer of skin

Nails

The nurse is performing an assessment on a client with a diagnosis of pemphigus vulgaris. How would the nurse assess for the presence of Nikolsky's sign? Note a foul odor to the skin. Look for blisters that are draining. Look into the mouth for white patches. Note skin blistering and sloughing with finger pressure.

Note skin blistering and sloughing with finger pressure.

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that they would report which early symptom of compartment syndrome Cold, bluish-colored fingers Numbness and tingling in the fingers Pain that increases when the arm is dependent Pain that is out of proportion to the severity of the fracture

Numbness and tingling in the fingers

The nurse in the surgical care center will be assisting the primary health care provider to perform a punch biopsy of a client's skin lesion that is suspicious for skin cancer. Which interventions would be included in the preprocedure plan of care? Select all that apply. Obtain an informed consent. Clean the area of the lesion with water. Prepare to apply direct pressure to the biopsy site after the procedure. Tell the client that a small piece of tissue will be removed for examination. Teach the client about the need to cleanse the site postprocedure with hydrogen peroxide and a topical corticosteroid every 4 hours.

Obtain an informed consent. Prepare to apply direct pressure to the biopsy site after the procedure. Tell the client that a small piece of tissue will be removed for examination.

The nurse caring for a client who has undergone kidney transplantation is monitoring the client for organ rejection. Which findings are consistent with acute rejection of the transplanted kidney? Select all that apply. Oliguria Hypotension Fluid retention Temperature of 99.6° F (37.6° C) Serum creatinine of 3.2 mg/dL (282 mcmol/L)

Oliguria Fluid retention Serum creatinine of 3.2 mg/dL (282 mcmol/L)

The nurse is assessing a dark-skinned client for the presence of petechiae. Which body area is the best for the nurse to check in this client? Sclera Oral mucosa Soles of the feet Palms of the hands

Oral mucosa

The nurse is assessing a client with a history of cardiac valve problems. Where would the nurse place the stethoscope to hear the first heart sound (S1) the loudest? Over the second intercostal space at the left sternal border Over the fourth intercostal space at the right sternal border Over the second intercostal space at the right sternal border Over the fifth intercostal space in the left midclavicular line

Over the fifth intercostal space in the left midclavicular line

The nurse assesses a client for the presence of Homans' sign. Which could be an indication that this sign is positive? Absent bowel sounds Client complaints of wound pain Pain with dorsiflexion of the foot Crackles on auscultation of the lungs

Pain with dorsiflexion of the foot

The nurse is creating a care plan for a client diagnosed with a nonmechanical small bowel obstruction. Which client data would the nurse identify as contributing factors to the development of a nonmechanical small bowel obstruction? Select all that apply.

Paralytic ileus Serum calcium 8.2 mg/dL (2.05 mmol/L) Serum potassium 3.1 mEq/L (3.1 mmol/L)

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. Polyuria Headache Bone pain Nervousness Weight gain

Polyuria Bone pain

The nurse is preparing to administer furosemide to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? Creatinine level Potassium level Cholesterol level Blood urea nitrogen (BUN)

Potassium level

Which are considered normal findings in a newborn less than 12 hours old? Select all that apply. Grunting respirations Presence of vernix caseosa Heart rate of 190 beats/minute Anterior fontanel measuring 5 cm Bluish discoloration of hands and feet Yellow discoloration of the sclera and body

Presence of vernix caseosa Anterior fontanel measuring 5 cm Bluish discoloration of hands and feet

A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse would plan to do which to administer this medication? Monitor the blood pressure every 15 minutes during administration. Protect the sodium nitroprusside from light with an opaque material. Check the solution for a faint brown coloration and discard it if this is noticed. Piggyback the sodium nitroprusside into the IV line containing the potassium chloride.

Protect the sodium nitroprusside from light with an opaque material.

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Provide a soft diet Position the child on left side Irrigate the ear with normal saline every 8 hours Administer ibuprofen for fever every 4 hours as prescribed as needed Instruct the parents about the need to administer prescribed antibiotics for the full course of therapy

Provide a soft diet Administer ibuprofen for fever every 4 hours as prescribed as needed Instruct the parents about the need to administer prescribed antibiotics for the full course of therapy

The nurse is preparing to interview a client to collect data about the client's health history. The nurse would take which actions to make sure that the physical environment is ready? Select all that apply. Provide sufficient lighting. Set the room temperature at a comfortable level. Ensure that the distance between the nurse and client is no more than 2 ft (60 cm). Arrange seating so that the nurse sits behind the desk across from the client. Make sure that the client will be seated comfortably at eye level with the nurse. Leave equipment needed for the physical exam on the desk so that it is readily available.

Provide sufficient lighting. Set the room temperature at a comfortable level. Make sure that the client will be seated comfortably at eye level with the nurse.

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. Alcohol Red meats Whole-grain cereals Low-calorie desserts Carbonated beverages

Red meats Whole-grain cereals Carbonated beverages

The nurse is preparing to perform an assessment on a client being seen in the clinic. On review of the client's record, the nurse notes that the client has psoriasis. The nurse would expect to observe which characteristics on assessment of the client's psoriatic lesions? Select all that apply. Red, raised papules Large plaques covered by silvery scales Tiny red vesicles that weep serous material Erythema noted mostly under the breast area Pink to dark red patchy eruptions on the skin

Red, raised papules Large plaques covered by silvery scales

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that they have a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention would the nurse anticipate to be prescribed initially for the client? Glyburide via the oral route Glucagon via the subcutaneous route Insulin aspart via the subcutaneous route Regular insulin via the intravenous (IV) route

Regular insulin via the intravenous (IV) route

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of separate posturing on assessment of the child. The nurse expects the note which characteristic of this type of posturing? Flaccid paralysis of all extremities Abduction of the arms at the should Rigid extension and pronation of the arms and legs Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

Rigid extension and pronation of the arms and legs

A client with an infected leg wound that is draining purulent material has a prescription for sodium hypochlorite to be used in the care of the wound. The nurse would implement which action while using this solution? Rinse off immediately following irrigation. Pour onto sterile sponges, and pack in wound. Let the solution run freely over normal skin tissue. Use each bottle of solution for 2 weeks before replacing.

Rinse off immediately following irrigation.

A client diagnosed with schizophrenia has been prescribed clozapine. The nurse would monitor the client for which side/adverse effects of this medication? Select all that apply. Diarrhea Sedation Dry mouth Weight loss Orthostatic hypotension Presence of a fixed stare

Sedation Dry mouth Orthostatic hypotension Presence of a fixed stare

The nurse explaining the procedure of indium imaging to a client with a bone infection would plan to include which information? Indium is injected into the bloodstream and collects in normal bone but not in infected areas. Indium is injected into the bloodstream and outlines the extent of the blood supply to the bone. Some of the client's red blood cells are tagged with indium, which will later accumulate in normal bone. Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

Some of the client's white blood cells are tagged with indium, which will later accumulate in infected bone.

An older client's physical examination reveals the presence of a fiery star-shaped marking with a circular, solid center. The nurse recognizes that these findings, which are caused by capillary radiations extending from the central arterial body, are representative of which lesions? Purpura Venous star Spider angioma Cherry angioma

Spider angioma

The nurse is evaluating a client's cardiac rhythm strip to determine whether there is proper function of the VVI mode pacemaker. Which denotes proper functioning? Spikes precede all P waves and QRS complexes. There are consistent spikes before each P wave. Spikes occur before QRS complexes when intrinsic ventricular beats do not occur. Spikes occur before all QRS complexes regardless of intrinsic ventricular activity.

Spikes occur before QRS complexes when intrinsic ventricular beats do not occur.

A client with human immunodeficiency virus infection (HIV) has signs and symptoms of cryptosporidiosis. The nurse would prepare the client for which test that will assist in confirming the diagnosis?

Stool culture

The nurse is reviewing the diagnostic tests prescribed for an assigned client and notes that an "LE cell prep" has been prescribed. Which immune disorder would the nurse primarily anticipate? Histoplasmosis Progressive systemic sclerosis Systemic lupus erythematosus (SLE) Human immunodeficiency virus infection

Systemic lupus erythematosus (SLE)

A client is prescribed trimethoprim-sulfamethoxazole for a recurrent urinary tract infection (UTI). The nurse would give the client which instruction regarding this medication? Expect rashes or skin changes as a result of therapy. Discontinue the medication when symptoms subside. Take most doses early in the day when fluid intake is greatest. Take each dose with 8 oz of water, and drink extra water each day.

Take each dose with 8 oz of water, and drink extra water each day.

The nurse prepares to assist the primary health care provider to examine the client's skin with a Wood's lamp. Which would be included in the preprocedure plan of care? Shave the skin site. Prepare a local anesthetic. Obtain an informed consent. Tell the client that the procedure is painless.

Tell the client that the procedure is painless.

A client has been discharged to home on total parenteral nutrition (TPN). With each visit, the home care nurse would assess which parameters most closely in monitoring this therapy? Pulse and weight Temperature and weight Pulse and blood pressure Temperature and blood pressure

Temperature and weight

The home care nurse has instructed a client with a ligament injury to the knee how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait?

The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation would the nurse make? The client has no risk of acquiring TB and needs no further workup. The client is at increased risk for acquiring TB and needs immediate medication therapy. The client's test result will be negative, and a sputum culture will be required for diagnosis. The client's test result will be positive, and a chest x-ray study will be required for evaluation.

The client's test result will be positive, and a chest x-ray study will be required for evaluation.

The nurse monitors the client for which condition as a complication of polycythemia vera? Thrombosis Hypotension Cardiomyopathy Pulmonary edema

Thrombosis

A rheumatoid factor assay is performed in a client with a suspected diagnosis of rheumatoid arthritis (RA). Which laboratory result would the nurse anticipate? The presence of inflammation The presence of infection in the body The presence of antigens of immunoglobulin A (IgA) The presence of unusual antibodies of the IgG and IgM types

The presence of unusual antibodies of the IgG and IgM types

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. Presence of striae Palpable radial pulses Absence of any ecchymosis on the extremities Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms

Thinner and decrease in number of reddish papules Scarce amount of silvery-white scaly patches on the arms

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply. Sclerae Tongue Nail beds Elbows and heels Mucous membranes

Tongue Nail beds Mucous membranes

The prenatal clinic nurse is performing an assessment on a culturally diverse client. Besides conversational style, what are some of the most important cultural and communication considerations the nurse must be aware of? Select all that apply. Touch Eye contact Personal space Family presence Time orientation Facial expression

Touch Eye contact Personal space Time orientation

The nurse is obtaining blood from a client's double-lumen central venous catheter for blood cultures. Which actions are correct for performing this procedure? Select all that apply. Use the distal port of the catheter for obtaining the blood specimen. Flush with 5 to 10 mL of normal saline before obtaining the specimen. Turn the infusion off for at least 1 minute before obtaining the specimen. Use the initial specimen of blood obtained from the catheter for the blood cultures. Discard the first syringe of blood and use the second syringe for the blood cultures.

Turn the infusion off for at least 1 minute before obtaining the specimen. Use the initial specimen of blood obtained from the catheter for the blood cultures.

The nursing instructor is reviewing the pathophysiology of gastrointestinal (GI) bleeding. The nursing instructor determines there is a need for further teaching if the nursing student identifies which of the following conditions as a cause of upper GI bleeding? Peptic ulcer Ulcerative colitis Mallory-Weiss tear Esophageal varices

Ulcerative colitis

The nurse is reviewing the pathophysiology of bowel obstruction and the mechanical and nonmechanical causes of obstruction. Which would the nurse identify as a mechanical cause of intestinal obstruction? Select all that apply.

Ventral hernia Gastric malignancy Bowel intussusception

A hospitalized client is diagnosed with type 1 diabetes mellitus. The nurse plans care for the client, understanding that which factors are likely causes of the beta cell destruction that accompanies this disorder? Select all that apply. Viruses Genetic factors Autoimmune factors Human leukocyte antigen (HLA) Primary failure of glucagon secretion

Viruses Genetic factors Autoimmune factors Human leukocyte antigen (HLA)

A client is taking benztropine mesylate orally daily. In monitoring this client for medication side effects, the nurse would plan to focus the assessment on which item? Pupil response Voiding pattern Prothrombin time Muscle strength and mobility

Voiding pattern

A nurse should educate the client receiving pravastatin (Pravachol) to immediately report which finding? a) Fatigue b) Diarrhea c) Sore throat d) Muscle pain

d) Muscle pain Rationale: Pravastatin is used to treat hyperlipidemia. Muscle pain could indicate rhabdomyolysis, a serious complication of this medication. It must be reported immediately.

The nurse is preforming an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? pallor edema anorexia proteinuria weight loss decreased serum lipids

pallor edema anorexia proteinuria

early sign infant heart faliure pallor cough tachycardia slow and shallow breathing

tachycardia