Adult Health final study guide

A kidney biopsy has been scheduled for a client with a history of acute kidney injury. The client asks the nurse why this test has been scheduled. What is the nurse's best response?

"A biopsy is sometimes necessary for diagnosing and evaluating the extent of kidney disease."

A 56-year-old client at a screening event has a blood pressure reading of 146/96 mm Hg. Upon hearing the reading, the client states, "My pressure has never been this high. Do you think my doctor will prescribe medication to reduce it?" What is the nurse's best response?

"A single elevated blood pressure does not confirm hypertension. Diagnosis requires multiple elevated readings."

A female client has presented to the emergency department with right upper quadrant pain; the health care provider has ordered abdominal ultrasound to rule out cholecystitis. The client expresses concern to the nurse about the safety of this diagnostic procedure. How should the nurse best respond?

"Abdominal ultrasound poses no known safety risks of any kind."

A client with diabetes is asking the nurse what causes diabetic ketoacidosis (DKA). Which of the following is a correct statement by the nurse?

"DKA can be caused by taking too little insulin."

Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns?

"Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

A triage nurse in the emergency department is assessing a client who presented with reports of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this client's presentation?

"How many alcoholic drinks do you typically consume in a week?"

A 55-year-old client comes to the clinic for a routine check-up. The client's BP is 159/100 mm Hg and the health care provider diagnoses hypertension after referring to previous readings. The client asks why it is important to treat hypertension, since the client denies any discomfort. What would be the nurse's best response?

"Hypertension greatly increases your risk of stroke and heart disease."

The management of the client's gastrostomy is an assessment priority for the home care nurse. What statement would indicate that the client is managing the tube correctly?

"I flush my tube with water before and after each of my medications."

A client is ready to be discharged home after a cataract extraction with intraocular lens implant and the nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which of the client's statements best demonstrates an adequate understanding?

"I need to call the doctor if I see flashing lights."

A client with heart failure is placed on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional teaching plan has been effective?

"I will have a baked potato with broiled chicken for dinner."

The nurse is preparing to change a client's abdominal dressing. The nurse recognizes that the first step is to provide the client with information regarding the procedure. Which explanation should the nurse provide to the client?

"I will provide privacy. The dressing change should not be painful; you may look at the incision and help."

A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond?

"In fact, glaucoma usually requires lifelong treatment with medications."

A client seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?

"Instead of eating three meals a day, try eating smaller amounts more often."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client is specific to the presence of a duodenal ulcer?

"My pain resolves when I have something to eat."

A client has sought care because of recent dark-colored stools. As a result, a fecal occult blood test has been ordered. The nurse should give what instructions to the client?

"Take no NSAIDs within 72 hours of the test."

A client with obesity has been taking orlistat for the past several days. During the client's most recent follow-up assessment with the nurse, the client states, "I'm embarrassed to even say it, but I've had a few episodes of leaking stool since I've started this medication." What is the nurse's best response?

"That sounds stressful for you. That's definitely one of the adverse effects of this medication."

A client has been newly diagnosed with acute pancreatitis and admitted to the acute medical unit. How should the nurse explain the pathophysiology of this client's health problem?

"The enzymes that your pancreas produces have damaged the pancreas itself."

A client's severe asthma has necessitated the use of a long-acting beta2-agonist (LABA). Which of the client's statements suggests a correct understanding of this medication?

"This drug is particularly good at preventing asthma attacks during exercise."

A newly diagnosed client with hypertension is prescribed a thiazide diuretic. What client education should the nurse provide to this client?

"This medication can cause low blood pressure and dizziness, especially when you get up suddenly."

A nurse is providing self-care education to a client who has been receiving treatment for acne vulgaris. What instruction should the nurse provide to the client?

"Wash your face with water and gentle soap each morning and evening."

A client is undergoing diagnostic testing for mitral stenosis. What statement by the client during the nurse's interview is most suggestive of this valvular disorder?

"Whenever I do any form of exercise I get terribly short of breath."

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply.

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A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin?

11:15 AM

A nurse is preparing to administer dextrose 5% in water (D5W) 500 mL IV to infuse over 4 hours. The nurse should set the IV infusion pump to deliver how many mL/hr?

125 mL/ hr

The nurse is planning the care of a client who has been diagnosed with hypertension, but who otherwise enjoys good health. When assessing the response to an antihypertensive drug regimen, which blood pressure would be the goal of treatment?

130/80 mm Hg or lower

A nurse is preparing to administer cefotaxime 1 g intermittent IV bolus over 45 minutes. Available is cefotaxime 1 g in 100 mL 0.9% sodium chloride (0.9% NaCl). The nurse should set the IV infusion pump to deliver how many mL/hr?

133mL/hr

A nurse is preparing to administer phenytoin 0.2 g PO every 8 hours. The amount available is phenytoin 100 mg/capsule. How many capsules should the nurse administer per dose?

2 capsules

A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what amount?

30 mL

You are to administer 1 L of normal saline (NS), intravenously, over 24 hours. You have on hand 250 mL bags of NS. How many bags of NS should you hang in 24 hours?

4 bags

The nurse is administering eye drops to a client with glaucoma. After instilling the client's first medication, how long should the nurse wait before instilling the client's second medication into the same eye?

5 minutes

A diabetes nurse educator is presenting current recommendations for levels of caloric intake. What are the current recommendations that the nurse would describe?

50% to 60% of calories from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein

The nurse should recognize the greatest risk for the development of blindness in which of the following clients?

A 58-year-old Caucasian woman with macular degeneration

A client with a hypertensive emergency is being treated in the intensive care unit. The nurse knows that which client is at risk for developing this type of emergency?

A client who stops their antihypertensive medication abruptly

At a blood pressure screening, the nurse learns that a client has a family history of hypertension, high cholesterol, and elevated lipid levels. The client says reports smoking one pack of cigarettes daily and drinking "about a pack of beer" every day. The nurse notes which nonmodifiable risk factor for hypertension?

A family history of hypertension

The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngitis. The nurse should encourage the client to use which appliance during recovery at home?

A room humidifier

A nurse's assessment of a client's knee reveals edema, tenderness, muscle spasms, and ecchymosis. The client states that 2 days ago the client ran in a long-distance race and now it "really hurts to stand up." The nurse should plan care based on the belief that the client has experienced what injury?

A second-degree strain

The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)?

Abnormalities in the structure and function of RBCs

A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?

Absence seizure

A nurse is planning the care of a client with herpes zoster. What medication, if given within the first 24 hours of the initial eruption, can arrest herpes zoster?

Acyclovir

A school nurse is caring for a 10-year-old client who is having an asthma attack. What is the preferred intervention to alleviate this client's airflow obstruction?

Administer an inhaled beta-adrenergic agonist.

A nurse is amending a client's plan of care in light of the fact that the client has recently developed ascites. What should the nurse include in this client's care plan?

Administration of diuretics as prescribed

A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?

Administration of pneumococcal vaccine to vulnerable individuals

A nurse is working for the summer at a camp for adolescents with diabetes. When providing information on the prevention and management of hypoglycemia, what action should the nurse promote?

Always carry a form of fast-acting sugar.

What should the nurse teach a client on corticosteroid therapy in order to reduce the client's risk of adrenal insufficiency?

Always have enough medication on hand to avoid running out.

A client with a history of rheumatic heart disease knows that the client is at risk for bacterial endocarditis when undergoing invasive procedures. Prior to a scheduled cystoscopy, the nurse should ensure that the client knows the importance of taking which drug?

Amoxicillin

The nurse is performing a physical assessment on a client suspected of having heart failure. The presence of which sound would tend to confirm the suspicion for heart failure?

An S3 heart sound

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?

An absence of blood in stool

Which of the following clients should the nurse recognize as being at the highest risk for the development of osteomyelitis?

An older adult client with an infected pressure ulcer in the sacral area

A client has just undergone surgery for malignant melanoma. Which of the following nursing actions should be prioritized?

Anticipate the need for, and administer, appropriate analgesic medications.

A nurse in a busy emergency department provides care for many clients who present with contusions, strains, or sprains. What are treatment modalities that are common to all of these musculoskeletal injuries? Select all that apply.

Apply ice, compression, resting the affected extremity, elevating the injured limb

An adult client has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiologic factors? Select all that apply.

Are you exposed to any toxins or chemicals at work, how would you describe your ability to cope with stress, what medications are you currently taking, does anyone else in your family struggle with headahces.

The nurse is planning teaching for a client who is scheduled for an open hemicolectomy. The nurse intends to address the topics of incision splinting and leg exercises during this teaching session. When is the best time for the nurse to provide teaching?

As soon as possible, and before the surgical procedure

A nurse is caring for a client who experiences debilitating cluster headaches. The client should be taught to take appropriate medications at what point in the course of the onset of a new headache?

As soon as the client senses the onset of symptoms

A client has become legally blind as a result of macular degeneration. When attempting to meet this client's psychosocial needs, what nursing action is most appropriate?

Assess and promote the client's coping skills during interactions with the client.

A nurse is providing care for a client who has psoriasis. Following the appearance of skin lesions, the nurse should prioritize what assessment?

Assessment of the client's joints for pain and decreased range of motion

A client's plan of care specifies postural drainage. Which action should the nurse perform when providing this noninvasive therapy?

Assist the client into a position that will allow gravity to move secretions.

A perioperative nurse is caring for a postoperative client. The client has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the client's increased risk for what complication?

Atelectasis

The perioperative nurse is providing care for a client who is recovering on the postsurgical unit following a transurethral prostate resection (TUPR). The client is reluctant to ambulate, citing the need to recover in bed. For what complication is the client most at risk?

Atelectasis

A nurse is preparing to perform an admission assessment on a client with chronic obstructive pulmonary disease (COPD). It is most important for the nurse to review which of the following?

Available diagnostic tests

A client with mitral valve stenosis is receiving health education at an outpatient clinic. To minimize the client's symptoms, the nurse would teach the client to take which action?

Avoid activities that cause an increased heart rate.

A client with a peptic ulcer disease has had metronidazole added to their current medication regimen. What health education related to this medication should the nurse provide?

Avoid drinking alcohol while taking the drug.

The nurse has implemented a bladder retraining program for an older adult client. The nurse places the client on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the client typically has approximately 50 mL of urine remaining in the bladder after voiding. What would be the nurse's best response to this finding?

Avoid further interventions at this time, as this is an acceptable finding.

A client with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the client?

Avoid hot-water bottles and heating pads.

A nurse is caring for an adult client diagnosed with a back strain. What health education should the nurse provide to this client?

Avoid lifting more than one-third of body weight without assistance.

A nurse is creating an education plan for a client with venous insufficiency. Which measure should the nurse include in the plan?

Avoid normal stockings that are tight.

The nurse is providing care for a client who was recently diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

Avoid taking aspirin to treat pain or fever.

An older adult resident of a long-term care facility has been experiencing generalized pruritus that has become more severe in recent weeks. What intervention should the nurse add to this resident's plan of care?

Avoid using hot water during the client's baths

The nurse is providing care for a client who has recently been diagnosed with chronic gastritis. What health practice should the nurse address when teaching the client to limit exacerbations of the disease?

Avoiding taking aspirin to treat pain or fever

A client's most recent laboratory results show a slight decrease in potassium. The health care provider has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium. What should the nurse recommend?

Bananas

Which of the following nurse's actions carries the greatest potential to prevent hearing loss due to ototoxicity?

Be aware of clients' medication regimens and collaborate with other professionals accordingly.

A woman who is in her third trimester of pregnancy has been experiencing an exacerbation of iron-deficiency anemia in recent weeks. When providing the client with nutritional guidelines and meal suggestions, what foods would be most likely to increase the woman's iron stores?

Beef liver accompanied by orange juice

A nurse practitioner is seeing a 16-year-old client who has come to the dermatology clinic for treatment of acne. The nurse practitioner would know that the treatment may consist of which of the following medications?

Benzoyl peroxide and erythromycin

A nurse is caring for a client who is being assessed following reports of severe and persistent low back pain. The client is scheduled for diagnostic testing in the morning. Which of the following are appropriate diagnostic tests for assessing low back pain? Select all that apply.

CT, MRI, XRAY

A nurse is reviewing the pathophysiology that may underlie a client's decreased bone density. What hormone should the nurse identify as inhibiting bone resorption and promoting bone formation?

Calcitonin

A client tells the nurse that they haves pain and numbness in the thumb, first finger, and second finger of the right hand. The nurse discovers that the client is employed as an auto mechanic, and that the pain is increased while working. This may indicate that the client has what health problem?

Carpel tunnel syndrome

An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care?

Cautious hydration

A 69-year-old client has maintained a consistent diet and activity level throughout adulthood. Over the past few years, however, the client has reported a gradual increase in adipose tissue. When providing health education, the nurse should address what topic?

Changes in metabolism that accompany the aging process

The nurse is administering total parenteral nutrition (TPN) to a client who underwent surgery for gastric cancer. Which of the nurse's assessments most directly addresses a major complication of TPN?

Checking the client's capillary blood glucose levels regularly

A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply.

Chest tightness, wheezing, coughing

The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications?

Cholinergics

A nurse is developing the teaching portion of a care plan for a client with COPD. What would be the most important component for the nurse to emphasize?

Chronic inhalation of indoor toxins can cause lung damage.

A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing which health problem?

Chronic kidney disease

A hearing-impaired client is scheduled to have an MRI. What would be important for the nurse to remember when caring for this client?

Client is likely unable to hear the nurse during test.

The nurse just received a postoperative client from the postanesthesia care unit to the medical-surgical unit. The client had surgery for a left hip replacement. Which concern should the nurse prioritize for this client in the first few hours on the unit?

Closely monitoring neurologic status

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?

Colonoscopy

Radiographs of a client's upper arm shows three fragments of the humeral bone. This diagnostic result suggests what type of fracture?

Comminuted

A nurse admits a client who has a fracture of the nose that has resulted in a skin tear and involvement of the mucous membranes of the nasal passages. The orthopedic nurse should plan to care for what type of fracture?

Compound

A client who has been taking corticosteroids for several months is experiencing muscle wasting. The client has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend?

Consumption of a high-protein diet

A client admitted with acute diverticulitis has experienced a sudden increase in temperature and reports a sudden onset of exquisite abdominal tenderness. The nurse's rapid assessment reveals that the client's abdomen is uncharacteristically rigid on palpation. What is the nurse's best response?

Contact the primary care provider promptly and report these signs of perforation.

A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments?

Daily weights and abdominal girth measurement

The nurse is caring for a client in the emergency department who was admitted for a hypertensive emergency. The nurse knows the goal of intravenous vasodilator therapy for a hypertensive emergency would be which outcome?

Decrease the systolic blood pressure by no more than 25% within the first hour

The cardiac nurse is caring for a client who has been diagnosed with dilated cardiomyopathy (DCM). Echocardiography is likely to reveal what pathophysiological finding?v

Decreased ejection fraction

A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the condition. The nurse explains to this client that this condition occurs due to which factor?

Decreased production of platelets

A nurse in a long-term care facility is caring for an 83-year-old client who has a history of heart failure (HF) and peripheral arterial disease (PAD). At present, the client is unable to stand or ambulate. The nurse should implement measures to prevent which complication?

Deep vein thrombosis

A client who has undergone a valve replacement with a mechanical valve prosthesis is due to be discharged home. During discharge teaching, the nurse would discuss the importance of antibiotic prophylaxis prior to which event?

Dental procedures

A nurse is performing a health history on a client with obesity. Which condition is the client most at risk for with a diagnosis of obesity?

Diabetes

A nurse is assessing a teenage client with acne vulgaris. The client's mother states, "I keep telling him that this is what happens when you eat as many french fries as he does." What aspect of the pathophysiology of acne should inform the nurse's response?

Diet is thought to play a minimal role in the development of acne.

The nurse is caring for a client that has undergone bariatric surgery. Which indication is a complication from the surgery?

Dumping syndrome

The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?

Early ambulation

The nurse is admitting a client with a diagnosis of left ventricular hypertrophy. The client reports dyspnea on exertion, as well as fatigue. Which diagnostic tool would be most helpful in diagnosing this type of myopathy?

Echocardiogram

An asthma nurse educator is working with a group of adolescent asthma clients. What intervention is most likely to prevent asthma exacerbations among these clients?

Educating clients about recognizing and avoiding asthma triggers

The nurse is planning care for a client with venous insufficiency. Which nursing intervention would be appropriate for this client's plan of care?

Elevate lower extremities.

The surgeon's preoperative assessment of a client finds that the client is at a high risk for venous thromboembolism. Once the client is admitted to the postsurgical unit, what intervention should the nurse prioritize to reduce the client's risk of this complication?

Encourage early ambulation.

A client with a total hip replacement has developed decreased breath sounds. What is the nurse's best action?

Encourage use of the incentive spirometer.

The operating room nurse is participating in the appendectomy of a client who has a dangerously low body mass index. The nurse recognizes the client's consequent risk for hypothermia. Which action should the nurse implement to prevent the development of hypothermia?

Ensure that intravenous (IV) fluids are warmed to the client's body temperature.

A client will be undergoing a total hip arthroplasty later in the day and it is anticipated that the client may require blood transfusion during surgery. How can the nurse best ensure the client's safety if a blood transfusion is required?

Ensure that the client has had a current cross-match.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances?

Ensure the client has sufficient potassium intake.

A nurse is planning the care of an older adult client with osteomalacia. What action should the nurse recommend in order to promote vitamin D synthesis?

Ensuring adequate exposure to sunlight

A nurse is caring for a client who just has been diagnosed with a peptic ulcer. When teaching the client about his new diagnosis, how should the nurse best describe it?

Erosion of the lining of the stomach or intestine

The nurse providing care for a client with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk?

Establish fall-prevention measures.

A client with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. What is the priority nursing diagnosis for a client with this condition?

Excess fluid volume

A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?

Fasting plasma glucose greater than 126 mg/dL (7.0 mmol/L)

An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status?

Fatigue related to decreased oxygen-carrying capacity

The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. On day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client?

Finish all the antibiotics to eliminate the organism completely.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

Fluids must be increased to facilitate the evacuation of the stool.

A nurse is assisting with serving dinner trays on the unit. Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation, the nurse will question which of the following foods on the tray?

Fried chicken

A client presents to the emergency department (ED) reporting severe right upper quadrant pain. The client states that the family doctor said the pain was caused by gallstones. The ED nurse should recognize what possible complication of gallstones?

Gangrene of the gallbladder

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

A client presents at the ED after receiving a chemical burn to the eye. What would be the nurse's initial intervention for this client?

Generously flush the affected eye with normal saline or water.

The nurse is caring for a client suspected of having renal dysfunction. When reviewing laboratory results for this client, the nurse interprets the presence of which substances in the urine as most suggestive of pathology?

Glucose and protein

A client comes to the clinic reporting a red rash of small, fluid-filled blisters and is suspected of having herpes zoster. What presentation is most consistent with this diagnosis?

Grouped vesicles in linear patches along a dermatome

A student with diabetes reports feeling nervous and hungry. The school nurse assesses the student and finds the child has tachycardia and is diaphoretic with a blood glucose level of 50 mg/dL (2.8 mmol/L). What should the school nurse administer?

Half of a cup of juice, followed by cheese and crackers

A nurse caring for a client with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding?

Highly dilute urine

A pediatric nurse practitioner is caring for a 2-year-old client who has just been diagnosed with asthma. The nurse has provided the parents with information that includes potential causative agents for an asthmatic reaction. Which potential causative agent that may trigger an attack should the nurse describe?

Household pets

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

Hydrostatic pressure resulting from the pumping action of the heart

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance?

Hypercalcemia

The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance would a positive Chvostek sign indicate?

Hypermagnesemia

The nurse is providing care for a client who has recently been diagnosed with chronic obstructive pulmonary disease. When educating the client about exacerbations, the nurse should prioritize which topic?

Identifying specific causes of exacerbations

A nurse is developing a care plan for a client with chronic obstructive pulmonary disease (COPD) admitted to the hospital for the second time this year with pneumonia. Which nursing diagnoses would be appropriate for this client? Select all that apply.

Impaired gas exchange R/T oxygen supply and demand, ineffective health management related to fatigue.

A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include which action?

Implementing of a plan for fall prevention

The nurse is creating a plan of care for a client with cardiomyopathy. Which goal would be a priority for the client?

Improved cardiac output

The nurse is caring for a client at risk for atelectasis. The nurse implements a first-line measure to prevent atelectasis development in the client. What is an example of a first-line measure to minimize atelectasis?

Incentive spirometry

The intraoperative nurse knows that the client's emotional state can influence the outcome of the surgical procedure. How should the nurse best address this?

Incorporate cultural and religious considerations, as appropriate.

A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action?

Increase fluid intake.

A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?

Increase oral fluids unless contraindicated.

A client's abdominal ultrasound indicates cholelithiasis. When the nurse is reviewing the client's laboratory studies, what finding is most closely associated with this diagnosis?

Increased bilirubin

An older adult woman's current medication regimen includes alendronate. What outcome would indicate successful therapy?

Increased bone mass

A client with chronic obstructive pulmonary disease has recently begun a new bronchodilator. Which therapeutic effect(s) should the nurse expect from this medication? Select all that apply.

Increased expiratory flow rate, relief of dyspnea

During a client's scheduled home visit, an older adult client has stated to the community health nurse that the client has been experiencing hemorrhoids of increasing severity in recent months. The nurse should recommend which of the following?

Increased fluid and fiber intake

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)?

Increased serum sodium

The nursing care plan for a client in traction specifies regular assessments for venous thromboembolism (VTE). When assessing a client's lower limbs, what sign or symptom is suggestive of deep vein thrombosis (DVT)?

Increased warmth of the calf

A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventive measure should the nurse encourage the client to adopt?

Increasing fluid intake

A nurse is caring for a client who is receiving parenteral nutrition. When writing this client's plan of care, which of the following nursing diagnoses should be included?

Ineffective role performance related to parenteral nutrition

The nurse is caring for a client who is diagnosed with Raynaud phenomenon. The nurse should plan interventions to address which nursing diagnosis?

Ineffective tissue perfusion

The nurse is creating the care plan for a 70-year-old obese client who has been admitted to the postsurgical unit following a colon resection. This client's age and body mass index increase the risk for what complication in the postoperative period?

Infection

A nurse is assessing a client who has peptic ulcer disease. The client requests more information about the typical causes of Helicobacter pylori infection. What would it be appropriate for the nurse to instruct the client?

Infection typically occurs due to ingestion of contaminated food and water.

A client presents to the clinic reporting vomiting and burning in the mid-epigastria. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

Infection with Helicobacter pylori

While assessing a client's peripheral IV site, the nurse observes edema and coolness around the insertion site. How should the nurse document this observation?

Infiltration

A client has experienced symptoms of dumping syndrome following gastric surgery. To what physiologic phenomenon does the nurse attribute this syndrome?

Influx of extracellular fluid into the small intestine

A postsurgical client has illuminated the call light to inform the nurse of a sudden onset of lower leg pain. On inspection, the nurse observes that the client's left leg is visibly swollen and reddened. Which action by the nurse would be most appropriate?

Inform the health care provider that the client has signs and symptoms of venous thromboembolism (VTE).

The nurse is caring for a client who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response?

Inform the primary care provider that the vascular supply may be compromised.

A child has been experiencing recurrent episodes of acute otitis media (AOM). The nurse should anticipate that what intervention is likely to be ordered?

Insertion of a ventilation tube

A nurse is teaching a client with glaucoma how to administer eye drops to achieve maximum absorption. The nurse should teach the client to perform what action?

Instill the medication in the conjunctival sac.

A nurse is caring for a client who is being treated in the hospital for a spontaneous vertebral fracture related to osteoporosis. The nurse should address the nursing diagnosis of Acute Pain Related to Fracture by implementing what intervention?

Intermittent application of heat to the client's back

The nurse is taking a health history of a new client who reports pain in the left lower leg and foot when walking. This pain is relieved with rest, and the nurse observes that the left lower leg is slightly edematous and is hairless. When planning this client's care, the nurse should most likely address which health problem?

Intermittent claudication

An older adult client sought care for the treatment of a swollen, painful knee joint. Diagnostic imaging and culturing of synovial fluid resulted in a diagnosis of septic arthritis. The nurse should prioritize what aspect of care?

Intravenous administration of antibiotics

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

Intravenous diazepam

A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance?

Iron

A nurse is providing education to a client with iron deficiency anemia who has been prescribed iron supplements. What should the nurse include in health education?

Iron will cause the stools to darken in color.

Several residents of a long-term care facility have developed signs and symptoms of viral conjunctivitis. What is the most appropriate action of the nurse who oversees care in the facility?

Isolate affected residents from residents who have not developed conjunctivitis.

A nurse is providing client education for a client with peptic ulcer disease secondary to chronic nonsteroidal anti-inflammatory drug (NSAID) use. The client has recently been prescribed misoprostol. What would the nurse be most accurate in informing the client about the drug?

It protects the stomach's lining

The nurse educator on an orthopedic trauma unit is reviewing the safe and effective use of traction with some recent nursing graduates. What principle should the educator promote?

Knots in the rope should not be resting against pulleys.

A client with a cholelithiasis has been scheduled for a laparoscopic cholecystectomy. Why is laparoscopic cholecystectomy preferred by surgeons over an open procedure?

Laparoscopic cholecystectomy poses fewer surgical risks than an open procedure.

The anesthetist is coming to the surgical admissions unit to see a client prior to surgery scheduled for tomorrow morning. What is the priority information that the nurse should provide to the anesthetist during the visit?

Latex allergy

A nurse is providing preoperative teaching to a client who will soon undergo a cardiac bypass. The nurse's teaching plan includes exercises of the extremities. What is the purpose of teaching a client leg exercises prior to surgery?

Leg exercises improve circulation and prevent venous thrombosis.

The nurse is screening a number of adults for hypertension. Which range of blood pressure is considered normal?

Less than 120/80 mm Hg

A nurse is caring for a client who has been diagnosed with psoriasis. The nurse is creating an education plan for the client. What information should be included in this plan?

Lifelong management is likely needed.

The nurse is caring for a client who is scheduled to undergo mechanical valve replacement. Client education would include coverage of which intervention?

Long-term anticoagulant therapy

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing.

A school nurse is teaching a group of high school students about risk factors for diabetes. What action has the greatest potential to reduce an individual's risk for developing diabetes?

Lose weight, if obese.

A nurse is providing discharge education to a client who has undergone a laparoscopic cholecystectomy. During the immediate recovery period, the nurse should recommend what foods?

Low-fat foods high in proteins and carbohydrates

The nurse is caring for a client scheduled for a colonoscopy. The nurse should assist the client into what position during this diagnostic test?

Lying on the left side with legs drawn toward the chest

The advanced practice nurse is attempting to examine the client's ear with an otoscope. Because of impacted cerumen, the tympanic membrane cannot be visualized. The nurse irrigates the client's ear with a solution of hydrogen peroxide and water to remove the impacted cerumen. What nursing intervention is most important to minimize nausea and vertigo during the procedure?

Maintain the irrigation fluid at a warm temperature.

While performing an initial assessment of a client admitted with appendicitis, the nurse observes an elevated blue-black lesion on the client's ear. The nurse knows that this lesion is consistent with what type of skin cancer?

Malignant melanoma

A client has a gastrostomy tube that has been placed to drain stomach contents by low intermittent suction. What is the nurse's priority during this aspect of the client's care?

Measure and record drainage.

An adult client has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this client's plan of care?

Measure the client's abdominal girth daily.

A client with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the client may be prescribed what drug?

Metoclopramide

A client who underwent a gastric resection 3 weeks ago is having their diet progressed on a daily basis. Following the latest meal, the client reports dizziness and palpitations. Inspection reveals that the client is diaphoretic. What is the nurse's best action?

Monitor the client closely for further signs of dumping syndrome.

The nurse is providing discharge education to a client diagnosed with heart failure. What should the nurse teach this client to do to assess fluid balance in the home setting?

Monitor weight daily.

The nurse is caring for a client with a diagnosis of Addison disease. What sign or symptom is most closely associated with this health problem?

Muscle weakness

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. Which method of oxygen delivery is most appropriate for the client's needs?

Nasal cannula

A school nurse has sent home four children who show evidence of pediculosis capitis. What is an important instruction the nurse should include in the note being sent home to parents?

Nits may have to be manually removed from the child's hair shafts.

A client is 2 hours' postoperative with an indwelling urinary catheter. The last hourly urine output recorded for this client was 10 mL. The tubing of the catheter is confirmed to be patent. What should the nurse do?

Notify the health care provider and continue to monitor the hourly urine output.

A client who had a total hip replacement two days ago reports new onset calf tenderness to the nurse. Which action should the nurse take?

Notify the health care provider.

A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching?

Oral candidiasis

An 80-year-old man in a long-term care facility has a chronic leg ulcer and states that the area has become increasingly painful in recent days. The nurse notes that the site is now swollen and warm to the touch. The client should undergo diagnostic testing for what health problem?

Osteomyelitis

The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching?

Overuse of nasal spray may cause rebound congestion.

The clinic nurse is assessing a child who has been brought to the clinic with signs and symptoms that are suggestive of otitis externa. What assessment finding is characteristic of this diagnosis?

Pain on manipulation of the auricle

The nurse is caring for a hospice client who is scheduled for a surgical procedure to reduce the size of a spinal tumor in an effort to relieve pain. The nurse should plan this client care with the knowledge that this surgical procedure is classified as which of the following?

Palliative

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low?

Paresthesias

A client diagnosed with a stasis ulcer has been hospitalized. There is an order to change the dressing and provide wound care. Which activity should the nurse first perform when providing wound care?

Perform hand hygiene.

A nurse is caring for a client who is postoperative day 1 following a total arthroplasty of the right hip. How should the nurse position the client?

Place a pillow between the legs.

The nurse is caring for a client who is postoperative day 2 following a colon resection. While turning the client, wound dehiscence with evisceration occurs. What should be the nurse's first response?

Place saline-soaked sterile dressings on the wound.

A client is on call to the OR for an aortobifemoral bypass and the nurse administers the prescribed preoperative medication. After administering a preoperative medication to the client, what should the nurse do?

Place the bed in a low position with the side rails up.

A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?

Place the client in a side-lying position.

A client with difficulty voiding and elevated BUN and creatinine values has been referred by the health care provider for further evaluation. The nurse should anticipate the use of what initial diagnostic test?

Portable bladder ultrasound

The nurse is caring for an adult client whom the nurse suspects has digoxin toxicity. In addition to physical assessment, the nurse should monitor what assessment information?

Potassium level

The circulating nurse will be participating in a 78-year-old client's total hip replacement. Which consideration should the nurse prioritize during the preparation of the client in the operating room?

Pressure points should be assessed and well padded.

A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions?

Prevention of viral infections from another person's blood

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse is unable to palpate the client's dorsalis pedis or posterior tibial pulse and the client's foot is pale. What is the nurse's most appropriate action?

Promptly inform the primary care provider.

The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply.

Protein level, albumin level, glucose level

A nurse is caring for a client who has a leg cast. The nurse observes the client using a pencil to scratch the skin under the edge of the cast. How should the nurse respond to this observation?

Provide a fan to blow cool air into the cast to relieve itching,

The nurse is caring for a client with a large venous leg ulcer. What intervention should the nurse implement to promote healing and prevent infection?

Provide a high-calorie, high-protein diet.

The nurse is caring for a client who has returned to the postsurgical unit following abdominal surgery. The client is unable to ambulate and is now refusing to wear external pneumatic compression stockings. The nurse should explain that refusing to wear external pneumatic compression stockings increases the risk of which postsurgical complication?

Pulmonary embolism

A nurse is teaching basic "survival skills" to a client newly diagnosed with type 1 diabetes. What topic should the nurse address?

Recognition of hypoglycemia and hyperglycemia

The nurse is caring for a client who has been involved in a motor vehicle accident. The client's labs indicate a minimally elevated serum creatinine level. The nurse should further assess which body system for signs of injury?

Renal

The nurse is caring for a client with mitral stenosis who is scheduled for a balloon valvuloplasty. The client reports being unsure of why the surgeon did not opt to replace the damaged valve rather than repair it. Which statement indicates an advantage of valvuloplasty that the nurse should cite?

Repaired valves tend to function longer than replaced valves.

A nurse caring for a client with a newly created ileostomy assesses the client and notes that the client has not had ostomy output for the past 12 hours. The client also reports worsening nausea. What is the nurse's priority action?

Report signs and symptoms of obstruction to the health care provider.

A nurse is caring for a client with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the client's cognition and behavior. What is the nurse's most appropriate response?

Report this finding to the primary provider due to the possibility of hepatic encephalopathy.

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg. Which condition does the ABG reflect?

Respiratory acidosis

A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Respiratory alkalosis

A client with primary hypertension comes to the clinic reporting a gradual onset of blurry vision and decreased visual acuity over the past several weeks. The nurse is aware that these symptoms could be indicative of which condition?

Retinal blood vessel damage

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments?

Reviewing the client's creatinine and BUN levels

A nurse is assessing a client who has been diagnosed with cholecystitis, and is experiencing localized abdominal pain. When assessing the characteristics of the client's pain, the nurse should anticipate that it may radiate to what region?

Right shoulder

A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize?

Rising slowly from a lying or sitting position

A nurse is caring for a client with a subclavian central line who is receiving parenteral nutrition (PN). In preparing a care plan for this client, what nursing diagnosis should the nurse prioritize?

Risk for infection related to the presence of a subclavian catheter

The nurse is developing a care plan for a client with Cushing syndrome. What nursing diagnosis should the nurse prioritize?

Risk for injury related to weakness

A client presents at a clinic reporting back pain that goes all the way down the back of the leg to the foot. The nurse should document the presence of what type of pain?

Sciatica

A 50-year-old female client reports a new onset, moderate headache after a lumbar puncture. What is the most likely condition that the client is experiencing?

Secondary headache

The hospital case manager for a group of recently discharged clients with asthma is providing health education. Which aspect of client teaching would have the greatest impact on preventing readmissions?

Self-care and the therapeutic regimen

The nurse is admitting a 55-year-old client diagnosed with a left eye retinal detachment. While assessing this client, what characteristic symptom would the nurse expect to find?

Sensation of a curtain being pulled over the eye

A nurse is planning the care of a client with emphysema who will soon be discharged. What teaching should the nurse prioritize in the plan of care?

Setting realistic short- and long-term goals

A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common?

Severe fatigue

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process?

Severed blood vessels constrict.

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

Shallow respirations

A client has been living with a diagnosis of anemia for several years and has experienced recent declines in hemoglobin levels despite active treatment. Which assessment finding would signal complications of anemia?

Shortness of breath and peripheral edema

The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following?

Signs and symptoms of infection

A client with otosclerosis has significant hearing loss. What should the nurse do to best facilitate communication with the client?

Sit or stand in front of the client when speaking.

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action?

Slow the infusion rate and monitor the client closely.

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan?

Small, frequent meals, high in protein and calories

A nurse is completing a health history on a client whose diagnosis is chronic gastritis. Which of the data should the nurse consider most significantly related to the etiology of the client's health problem?

Smokes one pack of cigarettes daily.

The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?

Smoking cessation

A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and the client's condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include which intervention?

Splenectomy

A client presents to a clinic reporting a leg ulcer that isn't healing; subsequent diagnostic testing suggests osteomyelitis. The nurse is aware that the most common pathogen to cause osteomyelitis is:

Staphylococcus aureus.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take?

Stop the transfusion immediately.

A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's postprocedure care?

Strain the client's urine following the procedure.

A client with type 2 diabetes normally achieves adequate glycemic control through diet and exercise. Upon being admitted to the hospital for a cholecystectomy, however, the client has required insulin injections on two occasions. The nurse would identify what factor most likely caused this short-term change in treatment?

Stress has likely caused an increase in the client's blood sugar levels.

A 42-year-old woman comes to the clinic reporting occasional urinary incontinence when sneezing. The clinic nurse should recognize what type of incontinence?

Stress incontinence

A client is admitted to the unit with acute cholecystitis. The health care provider has stated that surgery will be scheduled in 4 days. The client asks why the surgery is being put off for a week when he has a "sick gallbladder." What rationale would underlie the nurse's response?

Surgery is delayed until the acute symptoms subside.

A client is exploring treatment options after being diagnosed with age-related cataracts that affect her vision. What treatment is most likely to be used in this client's care?

Surgical intervention

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?

Symptom management is the main focus of medical and nursing care.

A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence?

Tachycardia, hypotension, and tachypnea

A nurse is developing a teaching plan for an adult client with asthma. Which teaching point should have the highest priority in the plan of care that the nurse is developing?

Take prescribed medications as scheduled.

A nurse is admitting a new client who has been admitted with a diagnosis of COPD exacerbation. How can the nurse best help the client achieve the goal of maintaining effective oxygenation?

Teach the client strategies for promoting diaphragmatic breathing.

The nurse is assessing a woman who is pregnant at 27 weeks' gestation. The client is concerned about the recent emergence of varicose veins on the backs of her calves. What is the nurse's best action?

Teach the client that circulatory changes during pregnancy frequently cause varicose veins.

A nurse is caring for a client receiving skeletal traction. Due to the client's severe limits on mobility, the nurse has identified a risk for atelectasis or pneumonia. What intervention should the nurse provide in order to prevent these complications?

Teach the client to perform deep breathing and coughing exercises.

A nurse is leading a health promotion workshop that is focusing on cancer prevention. What action is most likely to reduce participants' risks of basal cell carcinoma (BCC)?

Teaching participants to limit their sun exposure

A client's sigmoidoscopy has been successfully completed and the client is preparing to return home. What teaching point should the nurse include in the client's discharge education?

The client can resume a normal routine immediately.

A client with a history of peptic ulcer disease has presented to the emergency department (ED) in distress. What assessment finding would lead the ED nurse to suspect that the client has a perforated ulcer?

The client has a rigid, "board-like" abdomen that is tender.

The nurse is assessing a new adult client. What characteristic of this client's status should the nurse identify as increasing the client's risk for glaucoma?

The client has diabetes.

A client underwent an open bowel resection 2 days ago, and the nurse's most recent assessment of the client's abdominal incision reveals that it is dehiscing. Which factor should the nurse suspect may have caused the dehiscence?

The client has vomited three times in the past 12 hours.

A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency?

The client is a vegan.

A nurse is caring for a 78-year-old client with a history of osteoarthritis (OA). When planning the client's care, what goal should the nurse prioritize?

The client will express satisfaction with the ability to perform ADLs.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?

The client's activities immediately prior to the seizure.

The nurse is assessing an older adult client with numerous health problems. Which assessment finding indicates an increase in the client's risk for heart failure?

The client's age is greater than 65.

The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. Which assessment should the nurse prioritize?

The client's airway patency

A nurse is assessing a client for risk factors known to contribute to osteoarthritis. What assessment finding should the nurse interpret as a risk factor?

The client's body mass index is 34 (obese).

A client's screening colonoscopy revealed the presence of numerous polyps in the large bowel. What principle should guide the subsequent treatment of this client's health problem?

The client's polyps constitute a risk factor for cancer.

A pregnant client has been diagnosed with gestational diabetes. The client is shocked by the diagnosis, stating that they are conscientious about their health, and asks the nurse what causes gestational diabetes. The nurse should explain that gestational diabetes is a result of what etiologic factor?

The effects of hormonal changes during pregnancy

The nurse is discussing macrovascular complications of diabetes with a client. The nurse would address what topic during this dialogue?

The fact that clients with diabetes have an elevated risk of myocardial infarction

A client diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this client?

The hearing loss will likely resolve with time after the drug is discontinued.

Graduated compression stockings have been prescribed to treat a client's venous insufficiency. What education should the nurse prioritize when introducing this intervention to the client?

The importance of ensuring the stockings are applied evenly with no pressure points

A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of the nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?

The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

The nurse is admitting a client who is insulin dependent to the same-day surgical suite for carpal tunnel surgery. How should this client's diagnosis of type 1 diabetes affect the care that the nurse plans?

The nurse should assess the client's blood glucose levels frequently.

A nurse is assessing a client who has diabetes for the presence of peripheral neuropathy. The nurse should question the client about what sign or symptom that would suggest the possible development of peripheral neuropathy?

The presence of a tingling sensation

A female client has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the client, the nurse should address what topic?

The risk of developing a vaginal yeast infection as a consequence of antibiotic therapy

A client states that the client's family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to which factor?

The virus is shed for 2 days prior to the emergence of symptoms.

A client is postoperative day 6 following tympanoplasty and mastoidectomy. The client has phoned the surgical unit and states experiencing occasional sharp, shooting pains in the affected ear. How should the nurse best interpret this client's report?

These pains are an expected finding during the first few weeks of recovery.

The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority?

Tilt the head back and push forward on the angle of the lower jaw.

A nurse is explaining to a client with asthma with a new prescription for prednisone what it is used for. What would be the most accurate explanation that the nurse could give?

To gain prompt control of inadequately controlled, persistent asthma

The dressing surrounding a client's Jackson-Pratt drain has scant drainage on it. The nurse believes that the amount of drainage on the dressing may be increasing. How can the nurse best confirm this suspicion?

Trace the outline of the drainage on the dressing for future comparison.

A client is admitted to a surgical unit after a thyroidectomy. The nurse takes and maintains the inflated blood pressure cuff on the client and observes a carpopedal spasm. What does this result indicate?

Trousseau sign and overt tetany

A client is in the recovery room following a nephrectomy performed for the treatment of renal cell carcinoma. The client's vital signs and level of consciousness have stabilized, but the client then reports severe nausea and begins to vomit. What should the nurse do next?

Turn the client to one side.

A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?

Two to three soft bowel movements daily

A nurse's colleague has applied an incontinence pad to an older adult client who has experienced occasional episodes of functional incontinence. What principle should guide the nurse's management of urinary incontinence in older adults?

Urinary incontinence is not considered a normal consequence of aging.

A nurse is preparing a client diagnosed with benign prostatic hyperplasia (BPH) for a lower urinary tract cystoscopic examination. The nurse should caution the client about what common temporary complication of this procedure?

Urinary retention

A nurse is caring for a 73-year-old client with a urethral obstruction related to prostatic enlargement. When planning this client's care, the nurse should be aware of the risk of what complication?

Urinary tract infection

The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season?

Wash hands frequently.

A nasogastric tube is being inserted in a client with the COVID virus. Which action should the nurse take?

Wear personal protective equipment.

A nurse's assessment reveals that a client with chronic obstructive pulmonary disease may be experiencing bronchospasm. Which assessment findings would suggest that the client is experiencing bronchospasm? Select all that apply.

Wheezes or diminished breath sounds, labored and rapid breathing

A client's coronary artery bypass graft has been successful, and discharge planning is underway. When planning the client's subsequent care, the nurse should know that the postoperative phase of perioperative nursing ends at what time?

When a follow-up evaluation in the clinical or home setting is done

The nurse is caring for a hospitalized client who has class II obesity and who has limited mobility. The nurse should address the client's risk for skin breakdown by:

cleaning and drying regularly within the client's skin folds.

A school nurse is assessing a student who was kicked in the shin during a soccer game. The area of the injury has become swollen and discolored. The triage nurse should organize care for a:

contusion.

Define Diabetes Insipidus and state 2 expected findings and the nursing care item that relates to each.

deficiency of ADH polyuria - IV hydration constipation - add bulk foods and fruit juices to diet

A gerontologic nurse is assessing a client who has numerous comorbid health problems. What assessment finding(s) should prompt the nurse to suspect a UTI? Select all that apply.

fever, new onset of confusion

A client with secondary hypertension has come into the clinic for a routine check-up. When comparing this client's diagnosis to primary hypertension, the nurse recognizes that secondary hypertension:

has a specific cause.

A client with obesity has been prescribed liraglutide by the primary provider. When providing the client with health education, the nurse should teach the client:

how to self-administer subcutaneous injections.

A client comes to the clinic for an evaluation. While reviewing the client's history, the nurse notes that the client has a history of dry eyes. The nurse interprets this information as indicating a problem with which structure?

lacrimal apparatus

The nurse is creating a care plan for a client diagnosed with heart failure. When addressing the problem of anxiety, what interventions should the nurse include in the care plan? Select all that apply.

provide supplemental oxygen as needed, provide validation of the client expression of anxiety, ...

The nurse is preparing to collect an ordered urine sample for urinalysis. The nurse should be aware that this test will include what assessment parameters? Select all that apply.

specific gravity of the clients urine, testing for the presence of glucose in the clients urine, microscopic examination of urine sediment for RBCs, for casts

A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old child, who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?

"I'll certainly inform the doctor, but if it is a cold, antibiotics won't be used because they do not affect the virus."

The public health nurse is addressing eye health and vision protection during an educational event. What statement by a participant best demonstrates an understanding of threats to vision?

"I'm certainly going to keep a close eye on my blood pressure from now on."

A nurse is conducting a class on how to self-manage insulin regimens. A client asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer?

"If you are going to use up the vial within 1 month, it can be kept at room temperature."

A client is admitted to the orthopedic unit in skeletal traction for a fractured proximal femur. Which explanation should the nurse give the client about skeletal traction?

"Traction involves passing a pin through the bone."

A client newly diagnosed with type 2 diabetes has been told by their family that they can no longer consume alcohol. The client asks the nurse if abstaining from all alcohol is necessary. What is the nurse's best response?

"You do not need to give up alcohol entirely but there are potential side effects specific to clients with diabetes that you should consider."

One of the things a nurse has taught to a client during preoperative teaching is to have nothing by mouth for a specified time before surgery. The client asks the nurse why this is important. What is the most appropriate response for the client?

"You will need to have food and fluid restricted before surgery so you are not at risk for aspiration."

A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply.

-

A nurse suspects that an older adult client may be experiencing hearing loss. Which finding would support the nurse's suspicion? Select all that apply.

-

A nurse is preparing to administer methylprednisolone 10 mg by IV bolus. The amount available is methylprednisolone injection 40 mg/mL. How many mL should the nurse administer?

0.3 mL

Maintaining an aseptic environment in the OR is essential to client safety and infection control. When moving around surgical areas, what distance must the nurse maintain from the sterile field?

1 foot (30 cm)

A nurse is caring for a client with impaired renal function. A creatinine clearance measurement has been ordered. The nurse should facilitate collection of what samples?

A 24-hour urine specimen and a serum creatinine level midway through the urine collection process

A nurse who provides care in a community clinic assesses a wide range of individuals. The nurse should identify which client as having the highest risk for chronic pancreatitis?

A 39-year-old man with chronic alcoholism

The nurse is assessing a client whose respiratory disease is characterized by chronic hyperinflation of the lungs. Which physical characteristic would the nurse most likely observe in this client?

A barrel chest

A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care?

Administration of thorough oral hygiene

A community health nurse is planning an educational campaign addressing hypertension. The nurse should anticipate that the incidence and prevalence of hypertension are likely to be highest among members of what ethnic group?

African-Americans

The recovery room nurse is admitting a client from the OR following the client's successful splenectomy. What is the first assessment that the nurse should perform on this newly admitted client?

Airway patency

A client's health care provider has ordered a "liver panel" in response to the client's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply.

Alanine aminotransferase (ALT), Gamma-glutamyl transferase (GGT), Aspartate aminotransferase (AST)

A nurse is working with a female client who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?

Arrange for biofeedback when the client is learning to perform the exercises.

An older adult client has been diagnosed with macular degeneration and the nurse is assessing for changes in visual acuity since last visit. When assessing the client for recent changes in visual acuity, the client states that the lines on an Amsler grid as being distorted. What is the nurse's most appropriate response?

Arrange for the client to visit an ophthalmologist .

A 79-year-old client is admitted to the medical unit with digital gangrene. The client reports that the problem first began when the client stubbed the toe going to the bathroom in the dark. In addition to this trauma, the nurse should suspect that the client has a history of which health problem?

Arterial insufficiency

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply.

Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration, follow the facility policy for infusion of potassium, report a reduced urinary output to the health care provider.

A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform?

Assess the client's vital signs to establish baselines.

A nurse is teaching preventative measures for otitis externa to a group of older adults. What action should the nurse encourage?

Avoiding the use of cotton swabs

A client has presented to the emergency department with an injury to the wrist. The client is diagnosed with a third-degree strain. Why would the health care provider prescribe an x-ray of the wrist?

Avulsion fractures are associated with third-degree strains.

The nurse is caring for an older adult client who has just returned from the operating room (OR) after inguinal hernia repair. The OR report indicates that the client received large volumes of IV fluids during surgery, and the client has a history of coronary artery disease, increasing the risk for left-sided heart failure. Which signs and symptoms indicating this condition would the nurse look for?

Bibasilar fine crackles

A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?

Bilateral wheezes

A student nurse is caring for a client who has a diagnosis of acute pancreatitis and who is receiving parenteral nutrition. The student should prioritize which of the following assessments?

Blood glucose levels

A client with heart failure has met with the primary care provider and begun treatment with an angiotensin-converting enzyme (ACE) inhibitor. When the client begins treatment, the nurse would prioritize which assessment?

Blood pressure

The nurse is performing a shift assessment of a client with aldosteronism. What priority assessment(s) should the nurse include that relate to this condition? Select all that apply.

Blood pressure

An older, female client with osteoporosis has been hospitalized. Prior to discharge, when teaching the client, the nurse should include information about which major complication of osteoporosis?

Bone fracture

A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location?

Bone marrow

The nurse identifies a nursing diagnosis of Ineffective Health Maintenance related to nonadherence to therapeutic regimen in a client with hypertension who has not been taking their medication as prescribed. When planning this client's care, which outcome would be appropriate?

Client takes medication as prescribed and reports any adverse effects.

A nurse is providing care for a client who has a diagnosis of irritable bowel syndrome (IBS). When planning this client's care, the nurse should collaborate with the client and prioritize what goal?

Client will accurately identify foods that trigger symptoms.

The nurse is caring for a client with a history of endocarditis. Which topic would the nurse prioritize during health promotion education?

Dietary guidelines

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem?

Diminished deep tendon reflexes

A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate?

Discontinue the remainder of the PRBC transfusion, and inform the health care provider.

A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action?

Discontinue the transfusion.

The nurse is assessing a client who is known to have right-sided heart failure. What assessment finding is most consistent with this client's diagnosis?

Distended neck veins

A 30-year-old female client has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse prioritize when planning the client's care?

Disturbed body image related to changes in physical appearance

A public health nurse is participating in a health promotion campaign that has the goal of improving outcomes related to skin cancer in the community. What action has the greatest potential to achieve this goal?

Educating participants about the early signs and symptoms of skin cancer

How should the nurse best position a client who has leg ulcers that are venous in origin?

Elevate the client's lower extremities.

A client has been treated in the hospital for an episode of acute pancreatitis. The client has acknowledged the role that his alcohol use played in the development of his health problem, but has not expressed specific plans for lifestyle changes. What is the nurse's most appropriate response?

Encourage the client to connect with a community-based support group.

An adult client has been hospitalized with pyelonephritis. The nurse's review of the client's intake and output records reveals that the client has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding?

Encourage the client to continue this pattern of fluid intake.

The nurse is providing care for a client who has had a below-the-knee amputation. The nurse enters the client's room and finds the client resting in bed with the residual limb supported on a pillow. What is the nurse's most appropriate action?

Encourage the client to perform active ROM exercises with the residual limb.

A client has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the client's body image?

Encourage the client to speak openly and frankly about the diversion.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The plan of care includes assessment of specific gravity every four hours. The results of this test will allow the nurse to assess which aspect of the client's health?

Fluid volume status

A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate?

Help the client to sit, with head lowered below knees.

A client has received a diagnosis of irritant contact dermatitis. What action should the nurse prioritize in the client's subsequent care?

Helping the client identify and avoid the offending agent

The perioperative nurse has admitted a client who has just undergone a tonsillectomy. The nurse's postoperative assessment should prioritize which potential complication of this surgery?

Hemorrhage

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect?

Hypocalcemia

The nurse is preparing an elderly client for a scheduled removal of orthopedic hardware, a procedure to be performed under general anesthetic. For which adverse effect should the nurse most closely monitor the client?

Hypothermia

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance?

Hypovolemia

An older adult client, who is bedridden, is admitted to the unit because of a pressure injury that can no longer be treated in a community setting. During assessment, the nurse finds that the ulcer extends into the muscle and bone. At what stage should the nurse document this injury?

IV

The nurse is caring for a client who has just been transferred to the PACU from the OR. What is the highest nursing priority?

Maintaining a patent airway

A nurse is caring for a client who has a diagnosis of GI bleed. During shift assessment, the nurse finds the client to be tachycardic and hypotensive, and the client has an episode of hematemesis while the nurse is in the room. In addition to monitoring the client's vital signs and level of conscious, what would be a priority nursing action for this client?

Notify the health care provider.

A nurse is caring for a client with type 1 diabetes who is being discharged home tomorrow. What is the best way to assess the client's ability to prepare and self-administer insulin?

Observe the client drawing up and administering the insulin.

The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related?

Older adults are less able to increase blood cell production when demand suddenly increases.

The nurse is performing a health assessment of a client who has been taking antiobesity medications for several weeks. During the nurse's gastrointestinal assessment, the client reports bowel movements described as "greasy" and "oily." What medication is the client most likely taking?

Orlistat

An older adult client has fallen in the home and is brought to the emergency department by ambulance with a suspected fractured hip. X-rays confirm a fracture of the left femoral neck. When planning assessments during the client's presurgical care, the nurse should be aware of the client's heightened risk of what complication?

Osteomyelitis

A client with diabetes has been diagnosed with osteomyelitis. The nurse observes that the client's right foot is pale and mottled, cool to touch, with a capillary refill of greater than 3 seconds. The nurse should suspect what type of osteomyelitis?

Osteomyelitis with vascular insufficiency

The operating room nurse acts in the circulating role during a client's scheduled cesarean section. For which task is this nurse responsible?

Performing documentation

Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication?

Peritonitis

A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level?

Petechiae

The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?

Phenytoin

Which intervention is the most effective way to prevent rheumatic heart disease?

Recognizing and promptly treating streptococcal infections

A client with liver disease has developed ascites; the nurse is collaborating with the client to develop a nutritional plan. The nurse should prioritize which of the following in the client's plan?

Reduction in sodium intake

A client who had surgery for gallbladder disease has just returned to the postsurgical unit from postanesthetic recovery. The nurse caring for this client knows to immediately report what assessment finding to the health care provider?

Rigidity of the abdomen

The nurse is planning the care of a client with a diagnosis of vertigo. What nursing diagnosis risk should the nurse prioritize in this client's care?

Risk for falls

A nurse is writing a care plan for a client admitted to the emergency department (ED) with an open fracture. The nurse will assign priority to what nursing diagnosis for a client with an open fracture of the radius?

Risk for infection

The nurse takes the client's blood pressure, and the reading is 161/101 mm Hg. The nurse knows this blood pressure would be classified as which type?

Stage 2 hypertensive

The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?

Teach the client to perform pelvic floor muscle exercises.

A nurse is working with a family whose 5-year-old child has been diagnosed with impetigo. What educational intervention should the nurse include in this family's care?

Teaching about the importance of maintaining high standards of hygiene

A nurse is caring for a client who has had a plaster arm cast applied. Immediately after application, the nurse should provide what teaching to the client?

The cast will only have full strength when dry.

A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy?

The client is at an increased risk for developing infection.

The nurse is taking the client into the operating room (OR) when the client informs the nurse that the client's grandparent spiked a very high temperature in the OR and nearly died 15 years ago. What relevance does this information have regarding the client?

The client may be at risk for malignant hyperthermia.

The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible?

The client may chronically produce excess red blood cells.

In anticipation of a client's scheduled surgery, the nurse is teaching the client to perform deep breathing and coughing to use postoperatively. What action should the nurse teach the client?

The client should take a deep breath in through the mouth and exhale through the mouth, take a short breath, and cough from deep in the lungs.

A teenage client is brought to the emergency department with symptoms of hyperglycemia. Based on the fact that the pancreatic beta cells are being destroyed, the client would be diagnosed with what type of diabetes?

Type 1 diabetes

A nurse is assessing a new client who is diagnosed with peripheral artery disease. The nurse cannot feel the pulse in the client's left foot. How should the nurse proceed with assessment?

Use Doppler ultrasound to identify the pulses.

A nurse is creating a care plan for a client receiving nasogastric tube feedings. Which intervention should the nurse include?

Use client assessment findings to determine tolerance of feedings.

A nurse is providing discharge teaching for a client with COPD. What should the nurse teach the client about breathing exercises?

Use diaphragmatic breathing.

A 91-year-old client is slated for orthopedic surgery and the nurse is integrating gerontologic considerations into the client's plan of care. What intervention is most justified in the care of this client?

Use of a pressure-relieving mattress

An older adult is newly diagnosed with primary hypertension and has just been started on a beta-blocker. Which topic should the nurse include in health education?

Use of strategies to prevent falls stemming from orthostatic hypotension

A client with a severe exacerbation of chronic obstructive pulmonary disease requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?

Venturi mask

A client is admitted to the hospital with pernicious anemia. The nurse should prepare to administer which of the following medications?

Vitamin B12

An occupational health nurse is providing an educational event and has been asked by an administrative worker about the risk of varicose veins. Which action should the nurse suggest as a preventive measure for varicose veins?

Walk for several minutes every hour to promote circulation.

Define hypothyroidism and state 2 expected findings and the nursing care item that relates to each.

inadequate amount of circulation thyroid hormones. Fatigue- increase actives slowly. Intolerance to cold - provide blankets and clothes

A client develops a perforated eardrum. When teaching the client about this condition, the nurse would identify which condition as a most likely cause?

infection

The nurse's review of a client's most recent laboratory results indicates a bilirubin level of 3.0 mg/dL (51 mmol/L). The nurse assesses the client for:

jaundice.

A client with obesity is early in the process of preparing for a Roux-en-Y gastric bypass (RYGB). The client states, "After the surgery, the amount of food that I consume will be limited and I'll absorb fewer calories from what I do eat." When responding to the client, the nurse should:

validate what the client understands about the surgical procedure.