250 Foundations Comprehensive Final
A pregnant client with iron-deficiency anemia is prescribed iron supplements daily. To help the client increase iron absorption, the nurse should suggest that the client eat foods high in which substance? 1 Vitamin C 2 Fat content 3 Water content 4 Vitamin B complex
1 Vitamin C Rationale: Vitamin C aids the absorption of iron.
A client with gastroesophageal reflux disease is being treated with dietary management. The client states, "I like to have a glass of juice every day." Which juice will the nurse recommend? 1 Apple 2 Orange 3 Tomato 4 Grapefruit
1 Apple Rationale: Apple juice is nonirritating to the stomach and intestine. Orange juice, tomato juice, and grapefruit juice are acidic juices that decrease the pH of the stomach and irritate the gastrointestinal mucosa.
The nurse in a campus health clinic is assessing female students for risk factors associated with the future development of osteoporosis. What factors are included in this assessment? Select all that apply. 1 Cigarette smoking 2 Moderate exercise 3 Use of street drugs 4 Familial predisposition 5 Inadequate intake of dietary calcium
1 Cigarette smoking, 4 Familial predisposition, 5 Inadequate intake of dietary calcium Rationale: Cigarette smoking is a high-risk behavior associated with an increased incidence of osteoporosis in later life. Familial predisposition is considered a risk factor for the development of osteoporosis. Inadequate calcium intake during the premenopausal years is a risk factor for the development of osteoporosis after menopause.
A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. 1 Hips 2 Knees 3 Ankles 4 Shoulders 5 Metacarpals
1 Hips, 2 Knees Rationale: Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first, because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage.
After a client has a total gastrectomy, the nurse plans to include in the discharge teaching the need for what treatment? 1 Monthly injections of cyanocobalamin 2 Regular daily use of a stool softener 3 Weekly injections of iron dextran 4 Daily replacement therapy of pancreatic enzymes
1 Monthly injections of cyanocobalamin Rationale: Intrinsic factor is lost with removal of the stomach, and cyanocobalamin is needed to maintain the hemoglobin level once the client is stabilized; injections are given monthly for life.
A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which medications are within the classification of an H2 receptor antagonist? Select all that apply. 1 Nizatidine 2 Ranitidine 3 Famotidine 4 Lansoprazole 5 Metoclopramide
1 Nizatidine, 2 Ranitidine, 3 Famotidine Rationale: Nizatidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Ranitidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD. Famotidine is an H2 receptor antagonist that reduces gastric acid secretion and provides for symptomatic improvement in GERD.
The nurse understands that the BEST way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? 1 Perform catheter care twice a day. 2 Replace the catheter on a routine basis. 3 Administer cranberry tablets three times each day. 4 Give antibiotics for the duration of catheter placement.
1 Perform catheter care twice a day. Rationale: A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter-associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day.
A client diagnosed with gastroesophageal reflux disease (GERD) is being treated with antacid therapy. When teaching the client about the therapy, what does the nurse reinforce? 1 Antacids should be taken 1 hour before meals 2 These should be scheduled at 4-hour intervals 3 Antacid tablets are just as fast and effective as the liquid form 4 Antacids commonly interfere with the absorption of other drugs
4 Antacids commonly interfere with the absorption of other drugs Rationale: Antacids interfere with absorption of drugs such as anticholinergics, barbiturates, tetracycline, and digoxin.
Which nursing interventions are beneficial in the event of fire in the hospital? Select all that apply. 1 Opening the doors and windows 2 Moving ambulatory clients in wheelchairs to a safe location 3 Putting out the fire first and then removing the clients from fire area 4 Asking ambulatory clients to help push wheelchair clients out of danger 5 Maintaining injured clients' respiratory status manually until removed from the fire area
4 Asking ambulatory clients to help push wheelchair clients out of danger, 5 Maintaining injured clients' respiratory status manually until removed from the fire area Rationale: The nurse should ask ambulatory clients to help push wheelchair clients out of danger. The nurse should maintain the respiratory status of injured clients manually until they can be removed from the fire area.
An older client with macular degeneration comes to the eye clinic. Which response reported by the client does the nurse identify as consistent with the diagnosis? 1 Sees best in dim light 2 Sees halos around lights 3 Cannot see objects in the periphery 4 Cannot see objects in the center of the visual field
4 Cannot see objects in the center of the visual field Rationale: The macula is the central vision area of the retina; therefore macular degeneration affects central vision and makes it difficult to see objects within direct, central vision.
A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal? 1 Rest the eye 2 Dilate the pupil 3 Prevent secondary infections 4 Control the intraocular pressure
4 Control the intraocular pressure Rationale: Individuals with glaucoma have increased intraocular pressure that must be returned to the expected range, or blindness will result.
Which nursing intervention is indicated for aging clients with decreased bone density? 1 Teaching the client isometric exercises 2 Advising the client to take a moist heat shower 3 Providing supportive armchairs to the client 4 Demonstrating weight-bearing exercises to the client
4 Demonstrating weight-bearing exercises to the client Rationale: Decreased bone density leads to osteoporosis; weight-baring exercises help to build and maintain bone density.
An obese adult develops an abscess after abdominal surgery. The wound is healing by secondary intention and requires repacking and redressing every 4 hours. Which diet should the nurse expect the healthcare provider to prescribe the BEST meet this client's immediate nutritional needs? 1 Low in fat and vitamin D 2 High in calories and fiber 3 Low in residue and bland 4 High in protein and vitamin C
4 High in protein and vitamin C Rationale: Protein and Vitamin C promote wound healing; this is a postoperative priority.
Which client statement indicates to the nurse that a client who is receiving cyanocobalamin (Vitamin B12) therapy for an intrinsic factor deficiency understands the treatment? 1 "I should have a vitamin B12 injection every month." 2 "I'll take my B12 vitamin every morning with my breakfast." 3 "I'll have a salad every day because vitamin B12 is in green vegetables." 4 "I should feel better because my vitamin B12 treatments will improve my aplastic anemia."
1 "I should have a vitamin B12 injection every month." Rationale: Vitamin B12 is administered via injection on a weekly or monthly basis. Vitamin B12 is destroyed by stomach acid and therefore cannot be taken in pill form.
A registered nurse is teaching a client regarding preventive measures for genital tract infections. Which statement made by the client indicates the need for further education? Select all that apply. 1 "I should take frequent bubble baths." 2 "I should decrease the use of dietary sugar." 3 "I should choose hosiery with a nylon crotch." 4 "I should use colored and scented toliet tissues." 5 "I should limit the time spent in damp exercise clothes."
1 "I should take frequent bubble bathes." 3 "I should choose hosiery with a nylon crotch." 4 "I should use colored and scented toilet tissues." Rationale: Exposure to bath salts and bubble baths should be limited to prevent genital tract infections. Hosiery with a cotton crotch should be selected to prevent genital tract infections because cotton fabric absorbs wetness. Colored and scented toilet tissues should be avoided because they can increase the risk of genital tract infections. The use of dietary sugar should be decreased to prevent genital tract infections. Damp exercise clothes should be removed immediately because they increase the risk of genital tract infections.
A registered nurse is teaching a student nurse about the role of nurses in case of a fire in the hospital. Which statement made by the student nurse indicates ineffective learning? 1 "I will continue oxygen for all clients, even those who can breathe without it." 2 "I will seek to put out the fire by closing doors and windows and use an ABC extinguisher." 3 "I will manually maintain the respiratory status for clients on life support until they are removed from the fire area." 4 " I will take the help of staff members to move bedridden clients on blankets or carry them from the fire area."
1 "I will continue oxygen for all clients, even those who can breathe without it." Rationale: In case of fire in a hospital, the role of a nurse is to discontinue oxygen for clients who can breathe without it.
The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by nursing student indicate effective learning? Select all that apply. 1 "I will elevate the head of the client's bed to no more than 30 degrees." 2 "I will ensure that the client is turned and repositioned at least every two hours." 3 "I will advise the client to apply talc directly to the perineum." 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day 5 "I will teach the client to refrain from eating a high-protein and calorie diet
1 "I will elevate the head of the client's bed to no more than 30 degrees.", 2 "I will ensure that the client is turned and repositioned at least every two hours.", 4 "I will ensure that the client's fluid intake is 2000 to 3000 mL/ day Rationale: The client's bed should not be elevated more than 30 degrees, which minimizes shearing and reduces the risk of pressure ulcers. Turning and repositioning the client frequently improves circulation, and redistributed body weight over bony prominences, both of which reduce the risk of pressure ulcer formation. It is very important to maintain the client's fluid intake of 2000 to 3000 mL/day, which helps to nourish the skin.
A female client has a history of recurrent urinary tract infections. What should the nurse include in the teaching plan when educating the client about health practices that may help decrease future urinary tract infections? 1 "Wear cotton underpants." 2 "Void at least every 6 hours." 3 "Increase foods containing alkaline ash in the diet." 4 "Wipe from back to front after toileting."
1 "Wear cotton underpants." Rationale: Cotton allows air to circulate and does not retain moisture the way synthetic fabrics do; microorganisms multiply in warm, moist environments.
A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? 1 An increase in the pressure within the eyeball 2 An opacity of the crystalline lens or its capsule 3 A curvature of the cornea that becomes unequal 4 A separation of the neural retina from the pigmented retina
1 An increase in the pressure within the eyeball Rationale: An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow.
A client with localized redness and swelling due to a bee sting reports intense local pain, a burning sensation, and itching. What would be the MOST appropriate nursing action? 1 Applying cold compress to the affected area 2 Ensuring the client keeps the skin clean and dry 3 Monitoring for neurological and cardiac symptoms 4 Advising the client to launder all clothes with bleach
1 Applying cold compress to the affected area Rationale: A client with a bee sting may have localized redness, swelling, pain, and itching due to an allergic reaction. The nurse should apply cold compresses to the affected area to reduce the pain in the client.
A nurse is providing discharge instructions for a client with diagnosis of gastroesophageal reflux disease (GERD). What should the nurse advise the client to do to limit symptoms of GERD? Select all that apply. 1 Avoid heavy lifting 2 Lie down after eating 3 Avoid drinking alcohol 4 Eat small, frequent meals 5 Increase fluid intake with meals 6 Wear an abdominal binder or girdle
1 Avoid heavy lifting, 3 Avoid drinking alcohol, 4 Eat small, frequent meals Rationale: Heavy lifting increases intraabdominal pressure, allowing gastric contents to move up through the lower esophageal sphincter (regurgitation), causing heartburn (Pyrosis). Alcohol, in addition to peppermints, caffeine, and chocolate, decreases lower esophageal sphincter (LES) pressure, which permits gastric contents to move from the stomach into the esophagus. Eating small, frequent meals limits the amount of food in the stomach, which limits gastroesophageal reflux.
A client is admitted with thrombocytopenia. Which specific nursing actions are appropriate to include in the plan of care for this client? Select all that apply. 1 Avoid intramuscular injections 2 Institute neutropenic precautions 3 Monitor the white blood cell count 4 Administer prescribed anticoagulants 5 Examine the skin for ecchymotic areas
1 Avoid intramuscular injections, 5 Examine the skin for ecchymotic areas Rationale: Intramuscular injections should be avoided because of the increased risk for bleeding and possible hematoma formation. Decreased platelets increase the risk for bleeding, which leads to ecchymoses.
Which drug is derived from a natural source and may be prescribed for the treatment of osteoporosis? 1 Calcitonin 2 Raloxifene 3 Clomiphene 4 Bisphosphonates
1 Calcitonin Rationale: Calcitonin is derived from natural sources such as fish; this drug may be prescribed to prevent osteoporosis.
A nurse is providing education about excellent food sources of vitamin A for a client who is deficient in this vitamin. Which foods should the nurse include in the teaching? Select all that apply. 1 Carrots 2 Oranges 3 Tomatoes 4 Green leafy greens 5 Yellow/Orange vegetables
1 Carrots, 4 Green leafy greens, 5 Yellow/Orange vegetables Rationale: Yellow/Orange vegetables, like carrots, contain large quantities of Vitamin A in human nutrition. Cantaloupe, sweet potatoes, and apricots also are high in vitamin D. Dark-Green leafy vegetables contain large quantities of vitamin A in human nutrition.
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. 1 Clean the eyelid and eyelashes. 2 Place the dropper against the eyelid. 3 Apply clean gloves before beginning the procedure. 4 Instill the solution directly onto the cornea. 5 Press on the nasolacrimal duct after instilling the solution.
1 Clean the eyelid and eyelashes, 3 Apply clean gloves before beginning the procedure, 5 Press on the nasolacrimal duct after instilling the solution. Rationale: Cleaning the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye.
What should the nurse do to prevent deformities of the knee in a client with an exacerbation of arthritis? Select all that apply. 1 Encourage motion of the joint 2 Maintain a knee brace on the leg 3 Keep the client on a regimen of bed rest 4 Maintain joints in functional alignment when resting 5 Immobilize the joint with pillows until pain subsides
1 Encourage motion of the joint, 4 Maintain joints in functional alignment when resting Rationale: Exercise of involved joints is important to maintain optimal mobility and prevent buildup of calcium deposits. Functional alignment places the least strain on joints, muscles, and tendons.
A client with renal disorder is scheduled for an intravenous pyelogram (IVP). Which interventions should the nurse undertake prior to the procedure? Select all that apply 1 Ensure that the consent form is signed 2 Assess the client for iodine sensitivity 3 Have the client remove all metal objects 4 Administer an enema or cathartic to the client 5 Instruct the client to lie still during the procedure
1 Ensure that the consent form is signed, 2 Assess the client for iodine sensitivity, 4 Administer an enema or cathartic to the client Rationale: The presence, position, shape, and size of kidneys, ureters, and bladder can be evaluated using an intravenous pyelogram (IVP). The contrast medium used in the procedure may cause hypersensitivity reactions. Therefore, the nurse should assess the client for sensitivity to iodine prior to the procedure. The nurse should use a cathartic or enema to empty the colon of feces and gas. An IVP does need a consent form since the procedure is invasive.
A client is diagnosed with hyperthyroidism and is treated with 131I. Before discharge the nurse teaches the client to observe for signs and symptoms of therapy-induced hypothyroidism. What signs and symptoms should be included in the teaching? Select all the apply. 1 Fatigue 2 Dry Skin 3 Insomnia 4 Intolerance to heat 5 Progressive weight gain
1 Fatigue, 2 Dry Skin, 5 Progressive weight gain Rationale: Fatigue is caused by a decreased metabolic rate associated with hypothyroidism. Dry skin most likely is caused by decreased glandular function associated with hypothyroidism. Progressive weight gain is associated with hypothyroidism in response to a decreased in the metabolic rate because of sufficient thyroid hormone.
Which client responses does the nurse determine represent the HIGHEST risk for the development of pressure ulcers? 1 Incontinence and inability to move independently 2 Periodic diaphoresis and occasional sliding down in bed 3 Reaction to just painful stimuli and receiving tube feedings. 4 Adequate nutritional intake and spending extensive time in a wheelchair
1 Incontinence and inability to move independently Rationale: Constant exposure to moisture (urine) and prolonged pressure that compresses capillary beds place a client at high risk for pressure ulcers.
A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? 1 Loss of central vision 2 Attacks of acute pain 3 Constant blurred vision 4 Decreased peripheral vision
1 Loss of central vision Rationale: The main characteristic of dry age-related macular degeneration is loss of central vision, which is gradual.
Which key feature does the nurse associate with a stage 2 pressure ulcer? 1 Presence of non-intact skin 2 Development of sinus tracts 3 Damage to the subcutaneous tissues 4 Appearance of a reddened area over a bony prominence
1 Presence of non-intact skin Rationale: The skin is nonintact in stage 2 of pressure ulcers.
A client who takes daily megadoses of vitamins is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver due to vitamin toxicity. What type of toxicity does the nurse suspect? 1 Retinol (Vitamin A) 2 Thiamine (Vitamin B1) 3 Pyridoxine (Vitamin B6) 4 Ascorbic acid (Vitamin C)
1 Retinol (Vitamin A) Rationale: Joint pain, hair loss, jaundice, anemia, irritability, pruritus, and enlarged liver and spleen are signs of vitamin A toxicity.
Which site is best for the nurse to obtain a urinalysis specimen for a critical care client with an indwelling urine catheter? 1 Tubing luer-lok port 2 Distal end of the tubing 3 Urinary drainage bag 4 Catheter insertion site
1 Tubing luer-lok port Rationale: The tubing luer-lok port is the best site for obtaining a urine specimen for a critical care client with an indwelling urine catheter. The nurse applies a clamp to the drainage tubing distal to the luer-lok port, cleans the port with antiseptic, attaches a sterile 5-mL or 10-mL syringe onto the port, and aspirates the urine quantity desired. The tubing luer-lok sampling port should not be confused with the bladder and does not provide access to urine in the catheter.
What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? 1 Urinate small amount, stop flow, fill half a cup 2 Collect the las urine sample voided in the night 3 Keep the urine sample in dry warm area if delay is anticipated 4 Send the urine sample to the laboratory within 6 hours of collection
1 Urinate small amount, stop flow, fill half a cup Rationale: The nurse instructs the client to always collect the midstream urine to send as a test specimen. The client should be instructed to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling the cup at least half way.
Elbow restraints have been prescribed for a confused client to keep the client from pulling out a nasogastric tube and indwelling urinary retention catheter. What is MOST important for the nurse to do? 1 Have the prescription renewed every 48 hours. 2 Assess the client's condition per hospital protocol. 3 Provide range of motion to the client's elbows every shift. 4 Document output from the tube and catheter every two hours.
2 Assess the client's condition per hospital protocol. Rationale: A restraint impedes the movement of a client; therefore a client's condition needs to be assessed every hour. All restraints required to be deprescribed every 24 hours. Restraints should be removed and activity and skin care provided at least every two hours to prevent contractures and skin breakdown. Output from tubes is emptied, measured, and documented at the end of each shift.
A nurse provides dietary instruction to a client who has iron deficiency anemia. Which food choices by the client does the nurse consider MOST desirable? Select all that apply. 1 Raw carrots 2 Boiled spinach 3 Dried apricots 4 Brussels Sprouts 5 Asparagus spears
2 Boiled spinach, 3 Dried apricots Rationale: According to the nutritional table, the food sources highest in iron are, "Liver and muscle meats, dried fruits, legumes, dark green leafy vegetables, whole-grain and enriched bread and cereals, and beans."
While assessing the skin of a light-skinned client, the nurse concludes that the client has ecchymosis. Which skin color variation would confirm this diagnosis? 1 Gray color 2 Dark red color 3 Deep brown color 4 White color
2 Dark red color Rationale: Dark red skin coloring is identified as ecchymosis.
A healthcare provider prescribes dietary and medication therapy for a client with the diagnosis of gastroesophageal reflux disease (GERD). What is MOST appropriate for the nurse to teach the client about meal management? 1 Snack daily in the evenings 2 Divide food into four to six meals a day 3 Eat the last of three daily meals by 8:00 PM 4 Suck a peppermint candy after each meal
2 Divide food into four to six meals a day Rationale: The volume of food in the stomach should be kept small to limit pressure on the lower esophageal sphincter.
A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? 1 Insert a urinary retention catheter 2 Institute measures to prevent constipation 3 Encourage an increase in the intake caffeine 4 Suggest that a carbonated beverage be ingested daily
2 Institute measures to prevent constipation Rationale: A full rectum may exert pressure on the urinary bladder, which may precipitate urinary incontinence.
A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals. Which food items will the nurse recommend? 1 Meatloaf and tea 2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread
2 Meatloaf and strawberries Rationale: Meat provides protein, and fruit provides vitamin C; both promote would healing wound healing.
A client has been experiencing extreme fatigue lately. The nurse suspects anemia and examines the client to identify additional clinical manifestations to support this inference. Which locations on the client's body should be the nurse assess? Select all that apply. 1 Sclera 2 Nail beds 3 Conjunctivae 4 Palms of hands 5 Bony Prominences
2 Nail beds, 3 Conjunctivae, 4 Palms of hands Rationale: Nail beds lose their pink coloration because of reduced hemoglobin. A reduced amount of hemoglobin decreases pink color of the lining of the eyelids (Conjunctiva). Palms of the hands will become pale because of the deceased hemoglobin.
A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client? 1 Thyroxine (T4) and x-ray films 2 Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) 3 Thyroglobulin level and PO2 4 Protein-bound iodine and sequential multichannel autoanalyzer (SMA)
2 Thyroid-Stimulating hormone (TSH) assay and triiodothyronine (T3) Rationale: A decreased TSH assay together with an elevated T3 level may indicate hyperthyroidism.
A nurse is caring for a client who reports urinary problems, and the healthcare provider prescribes a cholinergic medication. Which urinary problem will this medication correct? 1 Urinary frequency due to bladder spasticity 2 Urinary retention due to bladder atony 3 Pain due to urinary tract calculi 4 Urinary urgency due to urinary tract infections
2 Urinary retention due to bladder atony Rationale: Cholinergics intensify and prolong the action of acetylcholine, which increases tone in the genitourinary tract, preventing urinary retention. Anticholinergics are prescribed for frequency and urgency associated with a spastic bladder.
A 60 year old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? 1 Oral hydroxyurea 2 Vitamin B12 injections 3 Oral iron supplements 4 Erythropoietin injections
2 Vitamin B12 injections Rationale: A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200-835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B12 deficiency and should be given injections. Vitamin B12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb vitamin B12
The nurse is preparing to initiate intravenous antibiotic therapy for a client who developed an infection along the incision after having a total knee replacement. Before starting the first dose of intravenous antibiotics, which task should the nurse insure has been completed? 1 Red blood cell count 2 Wound culture 3 Knee x-ray 4 Urinalysis
2 Wound Culture Rationale: A wound culture always should be completed before the first dose of antibiotic. A wound culture is obtained to determine the organism that is growing. A broad spectrum antibiotic often is given first; after the organism has been identified an organism-specific antibiotic can be given.
A client comes for an annual physical examination. To provide appropriate nutritional counseling, the nurse calculates the client's body mass index (BMI). The client's weight is 65 kg, and the height is 1.7 meters. What is the client's BMI?
22.5 The square of the client's height is 1.7x1.7=2.89; 65/2.89=22.5. The desirable BMI for adults is 18.5 to 24.9.
Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences? 1 Irish Americans 2 African Americans 3 Chinese Americans 4 Egyptian Americans
3 Chinese Americans Rationale: Chinese Americans have an increased incidence of osteoporosis because they have shorter and smaller bones with lower bone density.
A think 24-year-old women who runs 10 miles each week asks the nurse for advice about preventing osteoporosis. Which vitamin and other dietary supplement should the nurse recommend? 1 Vitamin E and ginseng tea 2 Vitamin B and ginkgo biloba 3 Vitamin D and calcium citrate 4 Vitamin C and glucosamine/chondroitin
3 Vitamin D and calcium citrate Rationale: All women except those who are pregnant or lactating, should ingest between 1000 to 1300 mg of calcium daily; if the client is unable to ingest enough calcium in food, supplements of calcium and vitamin D are recommended.
A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should they nurse instruct the client to do? 1 Void after a urinary catheter is removed 2 Collect a specimen of urine during midstream 3 Attempt to void when a urinary catheter is in place 4 Empty the bladder before a urinary catheter is inserted
4 Empty the bladder before a urinary catheter is inserted Rationale: Emptying the bladder before a urinary catheter is inserted measure how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating.
After surgery to repair a retinal detachment, an older adult client is transferred to the postanesthetic care unit with the affected eye patched. During the first four hours after surgery, the nurse should plan to notify the primary healthcare provider if the client reports which information? 1 Has not voided 2 Cannot open the eye 3 Cannot remember the date 4 Has sharp pain in the affected eye
4 Has sharp pain in the affected eye Rationale: Reports of sharp pain in the eye indicate that hemorrhage may be occurring in the eye. Four hours is too soon to be concerned that the client has not voided.
Which clinical indicator is the nurse MOST likely to identify when exploring the history of a client with open-angle glaucoma? 1 Constant blurring 2 Abrupt attacks of acute pain 3 Sudden, complete loss of vision 4 Impairment of peripheral vision
4 Impairment of peripheral vision Rationale: Open-angle glaucoma has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes.
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial
4 Nosocomial Rationale: A nosocomial infection is acquired in a health care setting. This is also referred to as a hospital-acquired infection. It is a result of poor infection control procedures such as a failure to wash hands between clients.
A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer 1 cup of fluid every hour 3 Manually remove facial impactions 4 Offer a cup of prune juice.
4 Offer a cup of prune juice Rationale: Prune juice does not require a primary healthcare provider's order and helps to promote bowel movement because it contains sorbitol that increase water retention in feces.
A client is being discharged from the hospital with an indwelling urinary catheter. The client asks about the best way to prevent infection and keep the catheter clean. Which would be appropriate for the nurse to include in the client teaching? 1 Once a day, clean the tubing with a mild soup and water, starting at the drainage bag and moving toward the insertion site. 2 After cleaning the catheter site, it is important to keep the foreskin pushed back for 30 minutes to ensure adequate drying. 3 Clean the insertion site daily using a solution of one part vinegar to two parts water. 4 Replace the drainage bag with a new bag once a week.
4 Replace the drainage bag with a new bag once a week. Rationale: It is recommended to changed the bag at least once a week.
The laboratory report of a client reveals that the platelet count is 60,000/microliter. Which integumentary changes can be anticipated in this client? Select all that apply. 1 Cyanosis 2 Petechiae 3 Varicosity 4 Ecchymosis 5 Hematoma
2 Petechiae, 4 Ecchymosis, 5 Hematoma Rationale: Normal blood platelet counts range between 150,000 and 400,00/ uL (150-400 x 10^9/L). A count of less than 100,000/ uL (100 10^9/L) is referred to as thrombocytopenia, which results in prolonged bleeding time. Petechiae, ecchymosis, and the formation of hematoma are the results of bleeding disorders.
Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis? 1 Takes estrogen therapy 2 Receives long-term steroid therapy 3 Has a history of hypoparathyroidism 4 Engages in strenuous physical activity
2 Receives long-term steroid therapy Rationale: Increased levels of steroids will accelerate bone demineralization.
A client reports smoke coming from a utility room on the nursing unit. What is the initial action the nurse should take? 1 Pull the fire alarm on the unit 2 Remove anyone who is in immediate danger 3 Obtain a fire extinguisher and report to the fire area 4 Close all windows and fire doors and await further instructions
2 Remove anyone who is in immediate danger. Rationale: The nurse is following the standard fore safety procedure RACE: R: removing any clients from immediate danger A: alarming or activating the fire alarm C: containing the fire source by closing all windows and fire doors E: extinguishing the fire and/or evacuating
Which diagnostic study is used to determine a client's bone density? 1 Diskogram 2 Standard X-ray 3 Computed tomography scan 4 Magnetic resonance imaging
2 Standard X-ray Rationale: A standard X-ray is used to determine bone density.
A registered nurse is teaching a nursing student about how to safely use a urinary catheter. Which statement made by the nursing student indicates ineffective learning? 1 "I will avoid the pooling of urine in the tubing." 2 "I will avoid prolonged clamping of the tubing." 3 "I will avoid draining urine from the tubing before ambulation." 4 "I will avoid raising the drainage tube above the level of the bladder."
3 "I will avoid draining urine from the tubing before ambulation." Rationale: Urine should be drained from the tubing into the drainage container before ambulation or exercise.
A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. Which is the nurse's MOST appropriate response? 1 "It is a computerized scan that outlines the bladder and surrounding tissue." 2 "It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." 3 "It is the visualization of the inside of the bladder with an instrument connected to a source of light." 4 "It is the visualization of the urinary tract through ureteral catheterization and the use of radiopaque material."
3 "It is the visualization of the inside of the bladder with an instrument connected to a source of light." Rationale: The response that the procedure is "The visualization of the inside of the bladder with an instrument connected to a source of light" answers the client's question and provides an accurate description of a cystoscopy.
The nurses is reviewing the plan of care for a client who is scheduled for a barium swallow. What will the plan include? 1 Giving clear fluids on the day of the test 2 Asking the client about allergies to iodine 3 Administering cleansing enemas before the test 4 Administering a laxative after the procedure
4 Administering a laxative after the procedure Rationale: Barium will harden and may create an impaction; a laxative and increased fluids promote elimination of barium.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? 1 Stage I 2 Stage II 3 Stage III 4 Unstageable
4 Unstageable Rationale: A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged.
Which beta-adrenergic blocker is prescribed to clients with glaucoma? 1 Betaxolol 2 Carbachol 3 Brimonidine 4 Methazolamide
A. Betaxolol Rationale: Betaxolol is a beta-adrenergic blocker that is prescribed for glaucoma.
A client is being prepared for discharge from an ambulatory surgical clinic after a cataract extraction and an intraocular lens implant. Which statement indicates to the nurse that the discharge teaching is effective? 1 "I should call the clinic if my eye begins to hurt." 2 "I am so goad that I can take a shower tomorrow." 3 "There will be bright flashes of light for a few days." 4 "My vision should show some improvement by tomorrow."
1 "I should call the clinic if my eye begins to hurt." Rationale: Pain after a cataract extraction and intraocular lens implant may indicate infection, increases intraocular pressure, or hemorrhage and should be reported immediately.
The fire alarm is sounding in a skilled nursing facility and smoke is pouring from the kitchen. What should the nurse do to ensure the safety of the clients. staff, and family members? Select all that apply. 1 Move bedridden clients via stretcher 2 Place ambulatory clients in 3 Turn off all sources of supplemental oxygen 4 Provide manual respiratory support to critically ill clients 5 Close all windows and doors and use an ABC fire extinguisher
1 Move bedridden clients via stretcher, 3 Turn off all sources of supplemental oxygen, 4 Provide manual respiratory support to critically ill clients, 5 Close all windows and doors and use an ABC fire extinguisher Rationale: When responding to a fire in a facility the nurse should move bedridden clients out of the area via stretchers. All sources of supplemental oxygen should be discontinued and manual respiratory support should be provided to critically ill clients. All windows and doors should be closed and an ABC fire extinguisher should be used to help contain the fire.
Which term should the nurse use to describe bone loss greater that normal but less than that caused by osteoporosis? 1 Osteopenia 2 Osteomyelitis 3 Osteomalacia 4 Osteoarthritis
1 Osteopenia Rationale: Osteopenia is defined as bone loss that is more than normal but not yet at the level for a diagnosis of osetoporosis.
A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. 1 "I may eat potatoes at dinner daily." 2 "I should drink at least six glasses of water every day." 3 "I must eat eggs for breakfast three times a week." 4 "I can include bran muffins in my breakfast daily." 5 "I will walk every day as part of my exercise regimen."
2 "I should drink at least six glasses of water every day.", 4 "I can include bran muffins in my breakfast daily.", 5 "I will walk every day as part of my exercise regimen." Rationale: At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipations. Walking increases intestinal motility, which helps prevent constipation.
A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. What is the BEST reply by the nurse? 1 "Don't worry; these tests are routine." 2 "They are done to identify other health risks." 3 "They determine whether surgery will be safe." 4 "I don't know; your healthcare provider prescribed them."
2 "They are done to identify other health risks." Rationale: Certain diagnostic test (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery.
Which client is MOST at risk for osteoporosis? 1 A nonsmoking 60-year-old women, 5 foot, 7 inches (170 cm) tall and 173 lb (78.5 kg) 2 A 66-year-old white women, 5 foot, 1 inch tall (155 cm) and 100 lb (45 kg), who is a paralegal 3 A 68-year-old black women, 5 foot, 5 inches tall (165 cm) and 140 lb (63.5 kg), who is a retired receptionist 4 A 62-year-old women, 5 foot, 4 inches tall (163 cm) and 135 lb (61 kg), who takes calcium carbonate daily
2 A 66-year-old white women, 5 foot, 1 inch tall (155 cm) and 100 lb (45 kg), who is a paralegal Rationale: A postmenopausal woman who is small-boned, thin, and relatively sedentary is at risk for osteoporosis; other risk factors are family history and white or Asian ethnicity. The post menopausal years are considered to be 65 years and older; however, each individual is unique.
Upon assessment the nurse finds to following (See Image). The nurse will prepare the client for which type of surgery? 1 Keratoplasty 2 Trabeculoplasty 3 Cataract removal 4 Laser in situ keratomileusis (LASIK)
3 Cataract removal Rationale: The given figure indicates a mature cataract due to increased lens density; surgery (Cataract removal) is the only treatment for this defect.
The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? 1 Ulnar drift 2 Heberden nodes 3 Swan-neck deformity 4 Boutonniere deformity
2 Heberden nodes Rationale: Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis.
A client with glaucoma asks a nurse about future treatment and precautions. Which information should the nurse's explanation include? 1 Avoidance of cholinergics 2 Surgical replacement of lens 3 Continuation of therapy for life 4 Prevention of high blood pressure
3 Continuation of therapy for life Rationale: Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure.
A nurse is assessing a client's eye and finds the following (see image). Which condition can be identified from the given figure? 1 Strabismus 2 Keratoconus 3 Corneal ulcer 4 Retinal detachment
3 Corneal ulcer Rationale: The condition depicted in the figure is a corneal ulcer. Tissue loss due to an infection of the cornea causes corneal ulcers; the infection can be due to bacteria, a virus, or fungi.
A nurse is assessing a client with a diagnosis of primary open-angle glaucoma. Which ocular symptom should the nurse expect the client to report? 1 Attacks of acute pain 2 Constant blurred vision 3 Decreased peripheral vision 4 Complete loss of central vision
3 Decreased peripheral vision Rationale: With glaucoma, loss of peripheral vision occurs long before central vision is affected. The client also ma complain of seeing halos around lights.
Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address? 1 Glaucoma 2 Scleroderma 3 Detached retina 4 Cerebral concussion
3 Detached retina Rationale: The detached retina is caused by vitreous traction on the retina.