ATI Exam 1 (Renal, Oncology, Neuro)

A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP). After the nurse discontinues the client's urinary catheter, which of the following findings should the nurse report to the provider? a. Pink-tinged urine b. Report of burning upon urination c. Stress incontinence d. Decreased urine output

Decreased urine output A decrease in urine output after TURP indicates obstruction to urine flow by a clot or residual prostatic tissue and should be reported to the provider.

A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain. Which of the following is the priority nursing action? a. Relieve the client's pain. b. Encourage the client to increase fluid intake. c. Monitor the client's I&O. d. Strain the client's urine.

a. Relieve the client's pain.

A nurse is assessing a client who has a new diagnosis of mastoiditis. Which of the following manifestations should the nurse expect? a. Swelling behind the affected ear b. Facial drooping on the affected side c. Nystagmus on the affected side d. Pearly gray color of the affected eardrum

a. Swelling behind the affected ear Mastoiditis refers to an inflammation of the temporal bone behind the ear. Manifestations of mastoiditis include swelling and pain behind the ear.

A nurse is teaching a client who has a new diagnosis of simple partial seizures about auras. Which of the following statements by the client indicates an understanding of the teaching? a. "An aura is a sensory warning that a seizure is imminent." b. "An aura is a continuous seizure in which seizures occur in rapid succession." c. "An aura is a period of sleepiness following the seizure." d. "An aura is a brief loss of consciousness accompanied by staring."

a. "An aura is a sensory warning that a seizure is imminent." An aura is a sensory warning that a seizure is imminent. The aura can be similar to a hallucination and involve any of the senses. The client can report hearing bells, seeing lights, or smelling an odor.

A nurse is providing teaching to a client who has cancer and is receiving external radiation therapy. Which of the following statements by the client indicates an understanding of the teaching? a. "I need to protect the area from sunlight." b. "I'm going to apply a heating pad to the area after each treatment." c. "I'll massage the area once per day." d. "I'll wash the markings off after each therapy treatment."

a. "I need to protect the area from sunlight." To prevent skin irritation and subsequent breakdown, the nurse should instruct the client to protect areas of skin from sunlight that receive radiation.

A nurse on an oncology unit is providing discharge teaching to an adolescent female client who received a bone marrow transplant for leukemia. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. "Take your temperature twice each day." b. "You may return to school if you feel strong enough." c. "It is important to always wear shoes." d. "Clean your toothbrush weekly with isopropyl alcohol." e. "Avoid using tampons."

a. "Take your temperature twice each day." Clients who are postoperative bone marrow transplants are immunosuppressed and should continually monitor for manifestations of infection. A temperature that is greater than 38° C (100° F) should be reported immediately to the provider. c. "It is important to always wear shoes.". A client who had a bone marrow transplant is immunosuppressed and should wear shoes to prevent injury and decrease the risk for infection. d. "Avoid using tampons" The use of tampons is discouraged because they can disrupt the mucosal layer of the vagina and, if left in too long, can support the growth of bacteria.

A nurse is teaching a client who has acute pyelonephritis. Which of the following instructions should the nurse include in the teaching? a. "You should complete the entire cycle of antibiotic therapy." b. "You should maintain complete bed rest until manifestations decrease." c. "You should drink 1,000 milliliters of fluid per day." d. "You should use NSAIDs for pain."

a. "You should complete the entire cycle of antibiotic therapy." The client should take the full prescription of the antibiotic therapy to decrease the chance of regrowth of the causative organism.

A nurse is assessing a client who is 1 week postoperative following a living donor kidney transplant. Which of the following findings should indicate to the nurse that the client is experiencing acute kidney rejection? a. Blood pressure 160/90 b. Creatinine 0.8 mg/dL c. Sodium 137 mg/dL d. Urinary output 100 mL/hr

a. Blood pressure 160/90 Due to the kidney's role in fluid and blood pressure regulation, a client who is experiencing rejection can have hypertension.

A nurse is providing dietary teaching a client who has late-stage chronic kidney disease (CKD). Which of the following nutrients should the nurse instruct the client to increase in her diet? a. Calcium b. Phosphorus c. Potassium d. Sodium

a. Calcium A client who has CKD can develop hypocalcemia due to the reduced production of active vitamin D, which is needed for calcium absorption. The client should supplement dietary calcium.

A nurse is performing a neurologic assessment for a client who has a brain tumor. Which of the following findings should indicate to the nurse cranial nerve involvement? a. Dysphagia b. Positive Babinski sign c. Decreased deep-tendon reflexes d. Ataxia

a. Dysphagia Dysphagia, or difficulty swallowing, can occur as a result of damage to cranial nerves IX (glossopharyngeal) or X (vagus).

A nurse is providing teaching to the partner of a client who has a new diagnosis of Parkinson's disease about degenerative complications. The nurse should include in the teaching that which of the following manifestations is the priority? a. Dysphagia b. Emotional lability c. Impaired speech d. Self-care dependency

a. Dysphagia dysphagia is the priority manifestation because it can lead to aspiration.

A nurse is monitoring a client who is undergoing extracorporeal shockwave lithotripsy (ESWL). The nurse should identify that which of the following findings is the priority? a. Dysrhythmias b. Pink-tinged urine c. Bruising on the flank area d. Stone fragments in the urine

a. Dysrhythmias ESWL is the application of sound, laser, or dry shock wave energies to break a kidney stone into small pieces. The shock waves are initiated during the R wave of the ECG to prevent dysrhythmias. When using the airway, breathing, circulation approach to client care, the nurse determines dysrhythmias are the priority finding.

A nurse is teaching a client who has chronic kidney disease (CKD). Which of the following instructions should the nurse include? a. Limit fluid intake. b. Limit caloric intake. c. Eat a diet high in phosphorus. d. Eat a diet high in protein.

a. Limit fluid intake A client who has CKD should limit fluid intake to prevent hypervolemia or excessive fluid overload.

A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? a. The client rigidly extends his arms. b. The client internally flexes his wrists. c. The client curls into a fetal position. d. The client internally rotates his legs.

a. The client rigidly extends his arms A client who exhibits a decerebrate posture rigidly extends and pronates his four extremities and externally rotates his wrists. Decerebrate posturing indicates severe brain stem injury and late neurologic decline.

A nurse is assessing a client who has a closed head injury and has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that the medication is having a therapeutic effect? a. The client's serum osmolarity is 310 b. The client's pupils are dilated. c. The client's heart rate is 56/min. d. The client is restless.

a. The client's serum osmolarity is 310 Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolality of 310 is desired. A decrease in cerebral edema should result in a decrease in ICP.

A nurse is assessing a client who has sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? a. Widened pulse pressure b. Tachycardia c. Periorbital edema d. Decrease in urine output

a. Widened pulse pressure A widening of the pulse pressure, the difference between the systolic and diastolic pressure, is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the level of consciousness, and nausea and vomiting.

A nurse is providing teaching to a client who has a new diagnosis of migraine headaches about interventions to reduce pain at the onset of a migraine. Which of the following instructions should the nurse include in the teaching? a. "Place a warm compress on your forehead." b. "Darken the lights." c. "Light a scented candle." d. "Drink a caffeinated beverage."

b. "Darken the lights." The nurse should instruct the client to lie down in a dark room to reduce migraine pain.

A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? a. "I will sleep on the affected side." b. "I will avoid bending over." c. "I will restrict caffeine in my diet." d. "I will take aspirin to relieve my pain."

b. "I will avoid bending over." The nurse should instruct the client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can result in intraocular hemorrhage.

A nurse is providing discharge teaching to a client following open radical prostatectomy. The client is going home with an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching? a. "I will be able to take a tub bath in 1 week." b. "I will change the catheter drainage bag once each week." c. "I will use suppositories to prevent constipation." d. "I will regain my bladder control once the catheter is removed."

b. "I will change the catheter drainage bag once each week." The nurse should teach the client how to change the catheter drainage bag and to change the bag at least once each week.

A nurse is providing discharge teaching to the family of a client who has a new diagnosis of a seizure disorder. The nurse should instruct the client's family to take which of the following actions first in the event of a seizure? a. Reorient the client. b. Protect the client's head. c. Loosen constrictive clothing. d. Turn the client on his side.

b. Protect the client's head. The client is at greatest risk for injury from hitting his head; therefore, the first action is to protect the client's head from injury.

A nurse is caring for a client who has breast cancer and is receiving a combination of chemotherapy medications. The client expresses confusion about the therapy. Which of the following explanations should the nurse provide? a. "The risk of renal toxicity is lessened when a combination of chemotherapy medications are used." b. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed." c. "The use of more chemotherapy medications will shorten the time you have to be in treatment." d. "The combination of chemotherapy medications will eliminate the potential for bone marrow suppression."

b. "The chemotherapy medications act at different stages of cell division so more tumor cells are destroyed." Different chemotherapeutic agents act at various stages of cellular mitosis (division). By combining agents, medication therapy is more effective in stopping or slowing the growth of cancerous cells by interfering with their ability to multiply.

A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following information should the nurse include in the teaching? a. "You will need to continue to use some form of birth control for 6 months." b. "You might experience manifestations of menopause." c. "Do not lift anything heavier than 15 pounds." d. "Pain or burning on urination is an expected outcome of this surgery."

b. "You might experience manifestations of menopause." The nurse should inform the client that a panhysterectomy includes the removal of the uterus and the ovaries that might cause manifestations of menopause to occur. Manifestations of menopause include hot flashes, night sweats, and vaginal dryness.

A nurse is providing discharge teaching to a client who is postoperative following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? a. "You can expect your vision to return immediately after the procedure." b. "You should avoid reading for 1 week." c. "You can remove eye shields when you're sleeping." d. "You should not lift objects that weigh more than 25 pounds."

b. "You should avoid reading for 1 week." The client should avoid reading and any activity that can cause rapid movement of the eye because of the risk for detachment of the retina.

A nurse is teaching a client about urinary tract infections (UTIs). Which of the following manifestations should the nurse include? a. Weight gain b. Back pain c. Vaginal discharge d. Muscle cramps

b. Back pain Back pain and flank pain are manifestations of a UTI. Other manifestations include frequency, urgency, and cloudy, foul-smelling urine.

A nurse is caring for a client who is in the oliguric-anuric stage of acute kidney injury. The client reports diarrhea, a dull headache, palpitations, and muscle tingling and weakness. Which of the following actions should the nurse take first? a. Administer an analgesic to the client. b. Check the client's electrolyte values. c. Measure the client's weight. d. Restrict the client's protein intake.

b. Check the client's electrolyte values.

A nurse is assessing a client who is unconscious and has a rhythmical breathing pattern of rapid deep respirations, followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? a. Orthopnea b. Cheyne-Stokes c. Paradoxical d. Kussmaul

b. Cheyne-Stokes Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths, followed by periods of apnea. Cheyne-Stokes respirations can be the result of a drug overdose or increased intracranial pressure and can precede death.

A nurse in a rehabilitation center is performing an assessment for a client who is recovering from a left-hemisphere stroke. Which of the following findings should the nurse expect? a. Reduced left-side motor function b. Difficulty with speech c. Impulsive behavior d. Neglect of the left side of the body

b. Difficulty with speech The left hemisphere of the brain is usually the dominant side and is responsible for language. This is always true for right-handed clients and for the majority of left-handed clients. Since this client is recovering from a left-hemisphere stroke, the nurse should anticipate that the client will have aphasia and require speech therapy to establish communication.

A nurse is reviewing the laboratory results of a lumbar puncture (LP) for a client who has manifestations of bacterial meningitis. Which of the following findings should the nurse expect? a. Elevated glucose b. Elevated protein c. Presence of RBCs d. Presence of D-dimer

b. Elevated protein An LP is a diagnostic test in which cerebrospinal fluid is extracted for examination. Manifestations of bacterial meningitis include an increase of protein in the cerebrospinal fluid.

A nurse in an oncology clinic is assessing a client who has early stage Hodgkin's lymphoma. Which of the following findings should the nurse expect? a. Bone and joint pain b. Enlarged lymph nodes c. Intermittent hematuria d. Productive cough

b. Enlarged lymph nodes Hodgkin's lymphoma is a malignancy of lymphoid tissue found in the lymph nodes, spleen, liver, and bone marrow. The first manifestation of this cancer is often an enlarged painless lymph node, or nodes, which appear without a known cause. Other early manifestations include night sweats, unexplained weight loss, fever, and pruritus. The disease can spread to adjacent lymph nodes and later might spread outside the lymph nodes to the lungs, liver, bones, or bone marrow. The spread of Hodgkin's lymphoma is usually in an ordered pattern.

A nurse is assessing a client who was brought to the emergency department following a motor-vehicle crash. The nurse should recognize that which of the following findings is a manifestation of bladder trauma? a. Stress incontinence b. Hematuria c. Pyuria d. Fever

b. Hematuria Manifestations of bladder trauma include hematuria, or blood in the urine; blood at the urinary meatus; pelvic pain; and anuria, or the absence of urine.

A nurse is assessing a client who is receiving continuous ambulatory peritoneal dialysis. Which of the following findings should the nurse report to the provider? a. WBC 6,000/mm3 b. Potassium 3.0 mEq/L c. Clear, pale yellow drainage d. Report of abdominal fullness

b. Potassium 3.0 mEq/L A potassium level of 3.0 mEq/L is below the expected reference range and can cause dysrhythmias. The dialysis removes fluid, waste products, and electrolytes from the blood and can cause hypokalemia.

A nurse is planning care for a client who has cancer and has developed thrombocytopenia following chemotherapy. Which of the following precautions should the nurse offer to minimize the adverse effects of thrombocytopenia? a. Monitor visitors for manifestations of infection. b. Remind the client to use an electric razor. c. Encourage frequent rest periods. d. Instruct the client to rinse mouth daily with normal saline.

b. Remind the client to use an electric razor. Thrombocytopenia is a decrease in the client's blood platelet count, which places the client at an increased risk of bleeding due to the blood's inability to clot. Therefore, the nurse should institute bleeding precautions, which includes the use of an electric razor.

A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing bladder cancer? a. The client is a hairdresser. b. The client uses tobacco. c. The client is over 60 years of age. d. The client has frequent urinary tract infections (UTIs)

b. The client uses tobacco. client's tobacco use as being the greatest risk factor for developing bladder cancer.

A nurse is caring for a client who has testicular cancer and is experiencing peripheral neuropathy as an adverse effect of chemotherapy. Which of the following client manifestations is an expected finding of peripheral neuropathy? a. Thinning of the scalp hair b. Tingling of the hands and feet c. Reduced ability to concentrate d. Sores in the mucous membranes

b. Tingling of the hands and feet Several chemotherapeutic agents might cause peripheral neuropathy. One of the major manifestations of peripheral neuropathy is numbness and tingling of an extremity.

A nurse is providing teaching to the family of a client who has a new diagnosis of amyotrophic lateral sclerosis (ALS). The nurse should include in the teaching that which of the following findings is an early manifestation of ALS? a. Sensory dysfunction b. Weakness of the distal extremities c. Decreased vision d. Altered temperature regulation

b. Weakness of the distal extremities ALS is a progressive neurodegenerative disease that involves the motor nerve cells in the brain and the spinal cord causing muscle wasting, spasticity, and eventually paralysis. Early manifestations of ALS include increasing muscle weakness, especially involving the distal arms and legs (hands and feet), speech, swallowing, and breathing.

A nurse is teaching a newly licensed nurse about caring for a client who has a new left arteriovenous fistula. Which of the following statements should the nurse make? a. "Check the fistula site daily for a vibration." b. "Instruct the client to restrict movement of his left arm." c. "Avoid taking blood pressure on the client's left arm." d. "Instruct the client to sleep on his left side."

c. "Avoid taking blood pressure on the client's left arm." The nurse should avoid taking blood pressure measurements on the client's left arm, which can decrease blood flow and cause clotting.

A nurse is providing preoperative teaching for a client who has colorectal cancer and is to undergo placement of a colostomy with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? a. "It will be a relief to not have any further rectal pain." b. "I will need to sit on a rubber donut when I am out of bed in the chair." c. "I can have only liquids for 2 days before the surgery." d. "The colostomy will start working about 7 days after the surgery."

c. "I can have only liquids for 2 days before the surgery." The client should consume a full or clear liquid diet for 24 to 48 hr before the surgery to decrease bulk. The client should consume a low-residue diet for several days prior to surgery to decrease peristalsis.

A nurse is providing teaching to a client who has a history of urinary tract infections (UTIs). Which of the following statements should indicate to the nurse the need for additional teaching? a. "I will empty my bladder every 4 hours." b. "I will drink 2 liters of fluids per day." c. "I will use a vaginal douche daily." d. "I will wear cotton underwear."

c. "I will use a vaginal douche daily." The client should avoid vaginal douches, bubble baths, and any substances that can increase the risk for UTIs. The client should use mild soap and water to wash the perineal area.

A nurse is providing discharge teaching to a client who is postoperative following a right mastectomy for breast cancer. The client will be discharged with two Jackson-Pratt drains. Which of the following information should the nurse include in the teaching? a. "Empty the drainage tubes once per day." b. "Showering is permitted before the drainage tubes are removed." c. "The drainage tubes often are removed at the same time as the stitches." d. "Do not begin exercising the arm until the provider removes the drainage tubes."

c. "The drainage tubes often are removed at the same time as the stitches." The nurse should instruct the client that the provider will remove the drainage tubes at the same time the stitches are removed, usually within 7 to 10 days.

A nurse is teaching a client who is preoperative for a renal biopsy. Which of the following statements should the nurse make? a. "You will be NPO for 8 hours following the procedure." b. "An allergy to shellfish is a contraindication to this procedure." c. "You will need to be on bed rest following the procedure." d. "A creatinine clearance is needed prior to the procedure."

c. "You will need to be on bed rest following the procedure." A renal biopsy involves a tissue biopsy through needle insertion into the lower lobe of the kidney. The client should maintain bed rest in a supine position with a back roll for support for 2 to 24 hr following the procedure to reduce the risk for bleeding. The nurse can elevate the head of the bed.

A nurse is providing teaching to a client who has a new diagnosis of Menière's disease. Which of the following instructions should the nurse include in the teaching? a. Avoid bearing down b. Increase caffeine intake c. Avoid sudden movements d. Increase sodium intake

c. Avoid sudden movements Ménière's disease is a disorder of the inner ear affecting balance and hearing, characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input, and his abdomen is distended. Which of the following actions should the nurse take? a. Insert an indwelling urinary catheter. b. Administer pain medication to the client. c. Change the client's position. d. Place the drainage bag above the client's abdomen.

c. Change the client's position. The client is retaining the dialysate solution after the dwell time. The nurse should ensure that the clamp is open and the tubing is not kinked, and reposition the client to facilitate the drainage of the solution from the peritoneal cavity.

A nurse in a clinic is providing teaching to an adolescent client who has recurrent external otitis. Which of the following instructions should the nurse include in the teaching? a. Dry the ear canal with a cotton swab after swimming. b. Apply an ice pack to the ear to relieve pain. c. Instill a diluted alcohol solution into the ear after swimming. d. Irrigate the ear with cool tap water to clean.

c. Instill a diluted alcohol solution into the ear after swimming External otitis is an inflammation of the external auditory canal often due to the retention of water in the ear from swimming. After the inflammation is gone, the client can prevent recurrence of external otitis by instilling diluted alcohol drops to decrease bacteria and dry the external ear canal.

A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment data the nurse should collect to determine a change in the client's neurologic status? a. Vital signs b. Body posture c. Level of consciousness d. Examination of pupils

c. Level of consciousness A change in the client's level of consciousness can be the first indication of a change in neurologic status.

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside? a. Metered-dose inhaler b. Continuous passive motion machine c. Oral-nasal suction equipment d. External defibrillator pads

c. Oral-nasal suction equipment The client who has myasthenia gravis is at risk for aspiration because of progressive weakness of the oropharyngeal muscles. Myasthenia gravis causes muscle weakness due to an autoimmune disease that affects the acetylcholine receptors. The nurse should place oxygen and oral-nasal suction equipment at the bedside in the event of aspiration or respiratory distress.

A nurse is teaching a newly licensed nurse about collecting a 24-hour urine specimen for creatinine clearance. Which of the following instructions should the nurse include? a. Include the first voided specimen at the start of the collection period. b. Discard the last voided specimen at the end of the collection period. c. Place signs in the bathroom as a reminder about the test in progress. d. Instruct the client to increase exercise during the 24-hr period.

c. Place signs in the bathroom as a reminder about the test in progress. The nurse should place signs in the bathroom and alert family members of the test in progress so that everyone saves the specimens appropriately throughout the test.

A nurse is caring for a client who is postoperative following a frontal craniotomy. The nurse should place the client in which of the following positions? a. Trendelenburg b. Prone c. Semi-Fowler's d. Sims'

c. Semi-Fowler's To prevent an increase in intracranial pressure, the nurse should position the client with his head midline and the head of the bed elevated 30º. This positioning permits blood flow to the client's brain while allowing venous drainage, thereby decreasing the postoperative risk of increased intracranial pressure.

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? a. Multiple floaters b. Flashes of light in front of the eye c. Severe eye pain d. Double vision

c. Severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headache, brow pain, and nausea and vomiting.

A nurse is monitoring a client who has cancer and is receiving chemotherapy by peripheral IV infusion. The client reports pain at the insertion site and the nurse notes fluid leaking around the catheter. Which of the following actions should the nurse take first? a. Take a photograph of the peripheral IV site. b. Obtain and record the client's vital signs. c. Stop the infusion. d. Identify all medications administered through the IV site for the past 24 hr.

c. Stop the infusion. Many chemotherapy medications are vesicants that can cause extensive tissue damage if extravasation occurs; therefore, the nurse's first action should be to stop the infusion immediately.

A nurse is obtaining a health history from a client who has cancer of the cervix. Which of the following manifestations should the nurse expect? a. Weight gain b. Oliguria c. Vaginal bleeding d. Back pain

c. Vaginal bleeding The most common manifestation of cancer of the cervix is painless vaginal bleeding.

A nurse is assessing a client who has Guillain-Barre syndrome. Which of the following findings should the nurse expect? a. Tonic-clonic seizures b. Report of a severe headache c. Weakness of the lower extremities d. Decreased level of consciousness

c. Weakness of the lower extremities Guillain-Barré syndrome, also called acute inflammatory demyelinating polyneuropathy, is an inflammatory disorder of the peripheral nerves. It is characterized by the rapid onset of ascending weakness and paralysis, starting at the lower extremities, and can advance to the upper extremities.

A nurse is teaching a client who is preoperative for a cystoscopy. Which of the following statements should the nurse make? a. "You will need to keep the sutures clean after this procedure." b. "You will be placed on your left side for this procedure." c. "Expect to be on bed rest for 24 hours after this procedure." d. "Expect to have pink-tinged urine after this procedure."

d. "Expect to have pink-tinged urine after this procedure." A cystoscopy is a procedure in which a scope is inserted into the urethra to diagnose or treat bladder problems. Following the procedure, pink-tinged urine is expected.

A hospice nurse is providing education about palliative care to the partner of a client who has end-stage liver cancer. Which of the following statements by the partner indicates an understanding of teaching? a. "I will do my best to try to get him to eat something." b. "I will lay him flat if his breathing becomes shallow." c. "I will use an electric blanket to keep him warm." d. "I will continue to talk to him even when he's sleeping."

d. "I will continue to talk to him even when he's sleeping." The nurse should reinforce to the partner that the client's hearing is thought to be the last sense to leave when in the dying process. Therefore, continue to softly communicate with the client.

A nurse is providing teaching to a client who is preoperative prior to a transurethral resection of the prostate (TURP). Which of the following statements indicates an understanding of the information? a. "I will not need to have a urinary catheter following this procedure." b. "I will expect my urine to be cloudy after having this procedure." c. "At least I won't have leakage of urine after having this procedure." d. "I will feel the urge to urinate following this procedure."

d. "I will feel the urge to urinate following this procedure." After a TURP, the client will feel the urge to urinate. The nurse should reassure him that he will receive analgesics to help relieve this discomfort.

A nurse is teaching a client about the prostate-specific antigen (PSA) test. Which of the following statements should the nurse make? a. "You should fast for 8 hours after the PSA test." b. "Annual PSA screening should begin at age 40." c. "Expected PSA values will decrease as you get older." d. "You should not ejaculate for 24 hours prior to the PSA test."

d. "You should not ejaculate for 24 hours prior to the PSA test." PSA is a glycoprotein that is manufactured in the prostate and is used to screen for prostate cancer. Ejaculation within 24 hours prior to the test can cause falsely elevated levels of PSA.

A nurse is providing teaching to a class about transient ischemic attacks (TIAs). Which of the following information should the nurse include in the teaching? a. A TIA can cause irreversible hemiparesis. b. A TIA can be the result of cerebral bleeding. c. A TIA can cause cerebral edema. d. A TIA can precede an ischemic stroke.

d. A TIA can precede an ischemic stroke. TIAs are considered a manifestation of advanced atherosclerotic disease and often precede an ischemic stroke. Manifestations of a TIA include loss of vision in one eye, inability to speak, transient hemiparesis, vertigo, diplopia, numbness, and weakness.

A nurse is admitting a client who has multiple myeloma and a white blood cell count of 2,200/mm3. Which of the following foods should the nurse prohibit the family members from bringing to the client? a. Fried chicken from a fast food restaurant b. A case of canned nutritional supplements c. A factory-sealed box of chocolates d. A fresh fruit basket

d. A fresh fruit basket Raw fruits and vegetables are contraindicated for a client who has neutropenia, as the skin might harbor bacteria that can cause an infection. The nurse should prohibit these foods from entering the client's room.

A nurse is caring for a client who is postoperative following a urinary diversion to treat bladder cancer. Which of the following interventions should the nurse include in the plan of care? a. Empty the collection pouch when it is 2/3 full. b. Expect urine outflow into pouch to begin 1 to 2 days following surgery. c. Change the collection pouch in the early morning. d. Place an aspirin in the collection pouch to control odor.

d. Change the collection pouch in the early morning. The nurse should plan to change the urinary collection pouch in the early morning when urine output is reduced.

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following information should the nurse include in the teaching? (Select all that apply.) a. Lost vision can improve with eye drops. b. Administer eye drops as needed for vision loss. c. Glasses will be necessary to correct the accompanying presbyopia. d. Driving can be dangerous due to the loss of peripheral vision. e. Laser surgery can help reestablish the flow of aqueous humor.

d. Driving can be dangerous due to the loss of peripheral vision. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can cause complete vision loss if not treated. e. Laser surgery can help re-establish the flow of aqueous humor. Laser surgery can reopen the trabecular meshwork and widen the Canal of Schlemm.

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. The nurse should include in the teaching that which of the following is an adverse effect of LASIK surgery? a. Eyelid twitching b. Photosensitivity c. Intraocular hemorrhage d. Dry eyes

d. Dry eyes LASIK surgery is a procedure that can correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. Adverse effects of LASIK surgery include dryness of the eyes and blurred vision.

A nurse is caring for a client who has lung cancer that has metastasized. Which of the following findings indicates the client is developing superior vena cava syndrome? a. Irregular cardiac rhythm b. Numbness in the hands c. Muscle cramps d. Facial edema

d. Facial edema Superior vena cava syndrome is a medical emergency resulting from partial occlusion of the superior vena cava, leading to a decreased blood flow through the vein. Most cases of superior vena cava syndrome are associated with cancers involving the client's upper chest, such as advanced lung and breast cancers and lymphoma. The earliest manifestations of superior vena cava syndrome are facial and upper extremity edema. Death can result if the compression is not corrected.

A nurse is teaching a class of new parents about otitis media. Which of the following manifestations should the nurse include in the teaching? a. A high-pitched sound heard in the ear b. Intermittent rapid eye movement c. Itching on the external canal d. Feeling of fullness in the ear

d. Feeling of fullness in the ear A client who has otitis media can develop a feeling of fullness in the ear. Other manifestations can include ear pain, a cracking sound when yawning or swallowing, and mild dizziness.

A nurse is providing teaching to the family of a client who has stage II Alzheimer's disease (AD). Which of the following information should the nurse include in the teaching? a. Place abstract pictures on the wall in the client's room. b. Provide music for the client using headphones. c. Reorient the client to reality frequently. d. Limit choices offered to the client.

d. Limit choices offered to the client. Choices should be limited for the client who has stage II AD to reduce confusion and frustration.

A nurse is collecting a health history from a female client who is undergoing screening for breast cancer. Which of the following factors should the nurse identify for placing the client at the greatest risk for developing breast cancer? a. Obesity b. Oral contraceptive use c. Alcohol use d. Over 50 years of age

d. Over 50 years of age A female client whose age is over 50 years has a high increased risk for developing breast cancer.

A nurse is collecting a health history from a client. Which of the following findings is the highest risk factor for the client developing skin cancer? a. Age over 60 b. Genetic predisposition c. Light-skinned race d. Overexposure to sun light

d. Overexposure to sun light

A nurse is caring for a client who is receiving chemotherapy to treat cancer. Which of the following adverse effects should the nurse anticipate from the chemotherapy? a. Gingival hyperplasia b. Hirsutism c. Pancytopenia d. Weight gain

d. Pancytopenia Pancytopenia, a deficiency of WBCs, RBCs, and platelet counts, is an expected adverse effect of chemotherapy.

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following adverse effects? a. Diarrhea b. Increased serum albumin c. Hypoglycemia d. Peritonitis

d. Peritonitis Peritonitis is an adverse effect of peritoneal dialysis. Prevention requires using sterile technique, and frequent assessment of the catheter exit site. The nurse should obtain cultures of the dialysate outflow, or effluent, if peritonitis is suspected.

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia? a. Flushing of the lower extremities b. Hypotension c. Tachycardia d. Report of a headache

d. Report of a headache Autonomic dysreflexia is a neurologic emergency that can occur in clients who have a cervical or thoracic spinal cord injury above the level of T6. Autonomic dysreflexia can be triggered by a full bladder or distended rectum. Manifestations include a severe, throbbing headache; flushing of the face and neck; bradycardia; and extreme hypertension.

A nurse is assessing a client who is postoperative following a craniotomy and has a urine output of 600 mL/hr. The nurse suspects the client has manifestations of diabetes insipidus (DI). Which of the following laboratory values should the nurse plan to obtain to assess for DI? a. Blood urea nitrogen (BUN) b. Blood glucose c. Urine ketones d. Specific gravity

d. Specific gravity Diabetes insipidus is caused by damage to the hypothalamus or the pituitary gland as a result of cranial surgery, infection, or a tumor. It is a condition in which an inadequate amount of antidiuretic hormone is released and results in polyuria. A low specific gravity (1.001 to 1.003) is a manifestation of diabetes insipidus.

A nurse is reviewing the medical history of a client who is scheduled for a magnetic resonance imaging (MRI) examination of the cervical vertebra. The nurse should alert the provider to which of the following information in the client's history that is a contraindication to the procedure? a. The client has a new tattoo. b. The client is unable to sit upright. c. The client has a history of peripheral vascular disease. d. The client has a pacemaker.

d. The client has a pacemaker. Clients who have cerebral aneurysm clips, cardiac pacemakers, or internal defibrillators cannot undergo an MRI because the strong magnetic force can interfere with these devices and obscure surrounding anatomical structures.