ATI med surg content mastery practice
A nurse is checking the laboratory values of a client who has chronic kidney disease. The nurse should expect elevations in which of the following values? A. Potassium and magnesium B. Calcium and bicarbonate C. Hemoglobin and hematocrit D. Arterial pH and PaCO2
A Clients who have chronic kidney disease have hyperkalemia, hyperphosphatemia, and hypermagnesemia as well as elevations in serum creatinine and blood urea nitrogen.
A nurse is assessing a client who has cholecystitis. Which of the following findings should the nurse expect? A. Blumberg's sign B. Ascites C.Gastrointestinal bleeding D. Kehr's sign
A The nurse should expect to find rebound tenderness (Blumberg's sign) in a client who has cholecystitis. This response can be an indication of peritoneal inflammation.
A nurse is providing discharge teaching to a client who has AIDS about preventing infection while at home. Which of the following instructions should the nurse include in the teaching? A. "Wash your genitalia using an antimicrobial soap." B. "Rinse your dishes with cold water." c. "Clean your toothbrush once per month." D. "Incorporate raw fruits and vegetables into your diet."
A The nurse should instruct the client to bathe daily using an antimicrobial soap to prevent the spread of infection. If bathing is not possible, washing the genitalia using an antimicrobial soap is recommended.
A nurse is providing teaching to a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse provide? (Select all that apply.) A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Decrease daily fluid intake E. Avoid citrus juices
ABC The nurse should inform the client that allopurinol is an antigout medication that reduces uric acid, which helps prevent uric acid stone formation, Immobility is a risk factor for stone formation; therefore, the client should maintain a healthy lifestyle, including regular exercise. Purine increases the risk of uric acid stone formation; organ meats, poultry, fish, red wine, and gravy are high in purine.
A nurse in a provider's office is assessing a client who has GERD. The nurse should expect the client to report which of the following manifestations? (Select all that apply.) A. Regurgitation B. Nausea C. Belching D. Heartburn E. Weight loss
ABCD
A nurse is updating the plan of care for a client who is to receive total parenteral nutrition (TPN). Which of the following actions should the nurse include in the plan? (Select all that apply.) A. Weigh the client daily B. Obtain a serum blood glucose every 4 hr C. Apply a new dressing to the client's IV site every 5 days D. Change the IV tubing every 24 hr E. Infuse the TPN through a peripheral IV site
ABD The nurse should weigh the client daily while receiving TPN. Clients who are receiving TPN are typically malnourished; therefore, the client's weight needs to be monitored closely. Fluid retention can also be an indication that the client is not digesting the TPN, and the rate of the transfusion might need to be decreased. The nurse should also obtain the client's serum blood glucose; insulin can be given if needed. Finally, the nurse should change the client's IV tubing every 24 hours to prevent bacteria from developing in the client's tubing.
A nurse is caring for a postmenopausal client who is concerned that she might have an elevated risk of breast cancer. After conducting a risk assessment, the nurse should identify which of the following factors as increasing the client's breast cancer risk? (Select all that apply.) A. Increased breast density B. BMI of 32 C. Having given birth to 5 children D. Undergoing hormonal replacement therapy for 10 years E. Having 1-2 alcoholic drinks per week
ABD Women who have dense breast tissue are at an increased risk for developing breast cancer because they have more connective and glandular breast tissue. Postmenopausal obesity increases the risk of developing breast cancer. Hormone-related risks for developing breast cancer include the long-term use of oral contraceptives or hormone replacement therapy, early menarche, late menopause, and first pregnancy after 30 years of age.
A nurse is teaching a group of clients about skin cancer. The nurse should explain that basal cell carcinoma originates from which of the following tissues? A. Subcutaneous B. Epidermis C. Dermis D. Stratum corneum
B Basal cell carcinoma originates from the epidermal layer of the skin. It is the most common form of skin cancer.
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 lb."
B The client should avoid reading and any activity that can cause rapid movement of the eye due to the risk of detachment of the retina.
A charge nurse is observing a newly licensed nurse provide care for a client who is receiving internal radiation therapy for the treatment of cervical cancer. For which of the following actions by the newly licensed nurse should the charge nurse intervene? A. Leaving soiled linens in a container in the client's room i B. Instructing visitors to remain 2 m (6 feet) away from the client C. Borrowing a dosimeter film badge from another nurse before entering the client's room D. Removing an extra IV pole from the client's room to be used for another client
C A nurse should never borrow a dosimeter film badge from another staff member. Nurses who are caring for the client should each have a personal badge and wear it while in the client's room. The badge measures the radiation exposure that the nurse is receiving, and each film badge will indicate the nurse's cumulative radiation exposure.
A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates that the client is developing dialysis disequilibrium syndrome (DDS)? A. Elevated BUN B. Bradycardia C. Headache D. Temperature 39.2°C (102.5°F)
C DDS is a CNS disorder that can develop in clients who are new to dialysis due to the rapid removal of solutes and changes in the blood pH. Clients beginning hemodialysis are at greatest risk, particularly if their BUN is above 175. DDS causes headaches, nausea, vomiting, a decreased level of consciousness, seizures, and restlessness. When the condition is severe, clients progress to confusion, seizures, coma, and death.
A nurse is caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results should the nurse identify as an Indication of pancreatitis? A. Decreased white blood cell (WBC) count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level
C Due to the release of lipase into the pancreas and autodigestion, pancreatitis causes an increased serum lipase level.
A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)
C The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space.
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 after surgery C. Change the collection pouch in the early morning D. Place an aspirin in the collection pouch to control odor
C The nurse should plan to change the urinary collection pouch in the early morning when urine output is reduced.
A nurse is caring for a client who is scheduled to undergo surgery to repair an open hip fracture. In which of the following positions should the nurse plan to place the client postoperatively? A. With the leg on the affected side adducted B. With the hip externally rotated on the affected side C. With the leg on the affected side abducted D. With the hip flexed to 90° on the affected side
C The nurse should plan to place the client with the leg abducted on the affected side postoperatively. Adduction or external rotation of the leg will cause the hip to dislocate.
A nurse is providing discharge teaching to a client who had a sickle cell crisis. Which of the following statements indicates that the client understands the instructions? A. "I should try to drink at least 2 liters of fluid per day, B. "I can still fly out to visit my sister in Colorado for a while. C. "Physical activity is good for me, but I need to avoid overexertion." D. "I can still go skiing during the cold winter months.
C To help prevent a recurrence of sickle cell crisis, the client should avoid overexertion from especially strenuous activities.
A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula
D A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.
A nurse is caring for a client who will receive brachytherapy to treat uterine cancer. The nurse should ensure the client understands that she will receive which of the following interventions? A. Chemotherapy via a central venous access device B. Radiation to the tumor from an external source C. Precise delivery of high-dose radiation after tumor imaging D. Radioactive infusions or insertions into or near the tumor
D Brachytherapy is a type of radiation therapy during which the radiation source, either an implant or via infusion, is in direct contact with the client's tumor continuously for a specific duration.
A nurse is planning an in-service training session for a group of nurses regarding the role of enzymes in digestion. Which of the following enzymes plays a role in the digestion of protein? A. Amylase B. Lipase C. Steapsin D. Pepsin
D Pepsin is an enzyme secreted by the gastric mucosa that breaks down protein into polypeptides. Other enzymes such as trypsin and aminopeptidase further break down the polypeptides into amino acids, which can be used by the body.
A nurse is assessing a 66-year-old client during a routine physical examination. This is the client's first clinic visit, and she does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I've had any immunizations. Which of the following responses should the nurse provide? A. "In case you had the immunization before, we can't give you another one." B. "You'll need a series of 3 injections." C. "This immunization is unsafe for people over the age of 65 years old." D. "Let's go ahead and give you this immunization."
D The Centers for Disease Control and Prevention recommend this immunization for people who are 65 years of age and older. If the client did receive this immunization more than 5 years ago, the nurse should administer another because the client is over 65.
A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis. C. CT scan of the chest D. Chest tube insertion
D The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.
A nurse is providing teaching to a client who has cancer and is undergoing external radiation treatment. Which of the following statements by the client indicates an understanding of the teaching? A. "I should use petroleum-based lotions on the areas being radiated." B. "I will dry the areas being radiated by rubbing in a circular pattern." C. "I will apply sunscreen to the areas being radiated when I spend time in the sun." D. "I should use my hand, instead of a washcloth, to wash the areas being radiated."
D Washing the areas being radiated with the hand is gentler than using a washcloth.
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of 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.
DE Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.
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. Phosphorous C. Potassium D. Sodium
A 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 in a provider's office is assessing a client's skin lesions. The nurse notes that the lesions are 0.5 cm (0.20 in) in size, elevated, and solid with distinct borders. The nurse should document these findings as which of the following skin lesions? A. Papules B. Macules C. Wheals D. Vesicles
A A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of warts and elevated moles.
A nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. Which of the following strategies should the nurse include? A. Eat crackers and yogurt regularly B. Chew minty gum throughout the day C. Drink orange juice every day D. Put an aspirin in the pouch
A Crackers, toast, and yogurt can help reduce flatus, which contributes to odor. Chewing any flavor of gum can increase flatus, which contributes to odor. Cranberry juice and buttermilk can help prevent odor. Aspirin in the pouch can cause ulceration of the stoma.
A nurse is planning care for a client who had a stroke. The client has hemiplegia and occasional urinary incontinence. Which of the following actions should the nurse include in the client's plan of care? A. Offer the client a bedpan every 2 hr B. Limit the client's daily fluid intake until he is no longer incontinent C. Request a prescription for an indwelling urinary catheter from the client's provider. D. Ambulate the client to the bathroom every 30 min
A Following a stroke, the client might have bladder incontinence due to confusion, impaired sensation in response to bladder fullness, and decreased sphincter control. The nurse should encourage and assist the client to void every 2 hours while awake to promote bladder control. By offering a bedpan, the nurse promotes client safety.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased intracranial pressure (ICP). Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L. B. The client's pupils are dilated. C. The client's heart rate is 56/min.. D. The client is restless.
A Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/Lis desired. A decrease in cerebral edema should result in a decrease in ICP.
A nurse is preparing a client for magnetic resonance imaging (MRI) of the spine. Which of the following pieces of information should the nurse give the client prior to the procedure? A. "You can have a mild sedative before the procedure." B. "You'll have to lie still on your back for 15 to 20 min." C. "You can't have this test if you've had cataract surgery." D. "Your exposure to radiation will be minimal."
A Some clients need mild sedation, especially when using an older closed MRI machine. Clients can feel claustrophobic and anxious as they slowly pass through what seems like a tunnel.
A nurse is monitoring a client for reperfusion following thrombolytic therapy to treat acute myocardial infarction (MI). Which of the following indicators should the nurse identify to confirm reperfusion? A. Ventricular dysrhythmias B. Appearance of Q waves C. Elevated ST segments D. Recurrence of chest pain
A The appearance of ventricular dysrhythmias following thrombolytic therapy is a sign of reperfusion of the coronary artery. The appearance of Q waves indicates infarction, not reperfusion.
A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted into the client's trachea. C. The client will receive a bowel preparation with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices.
A The client will require intubation and mechanical ventilation prior to this procedure to protect the airway.
A nurse is planning care for a client who has deep partial thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute. phase of burn injury. Which of the following interventions should the nurse include in the plan? A. Initiate range-of-motion exercises B. Use clean technique to provide wound care C. Place the client on a low-protein diet D. Maintain the client on bed rest
A The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures
A nurse is preparing a client for an electroencephalogram (EEG). Which of the following pieces of information should the nurse share with the client? A. "Expect the test to take about 3 hr." B. "You'll begin by lying still with your eyes closed." C. "You'll sleep for the duration of the procedure." D. "Expect some mild electrical shocks during the test."
B The client will have to lie still in a reclining chair or bed and keep her eyes closed for the initial recording.
A nurse is monitoring a newly licensed nurse who is caring for a client. The client has active pulmonary tuberculosis, was placed on airborne precautions, and is scheduled for a chest X-ray. The nurse should instruct the newly licensed nurse to take which of the following actions? A. Have the client wear a surgical mask. B. Wear a gown for protection from the client's infection. C. Ask the radiology staff to perform a portable chest X-ray in the client's room. D. Place an N-95 respirator on the client.
A The nurse should instruct the client to wear a surgical mask. The mask will protect anyone who comes into contact with the client, including the nurse.
A nurse is preparing to provide self-care teaching to a client who is 4 days postoperative following the creation of a colostomy and refuses to look at the stoma. Which of the following actions should the nurse take? A. Postpone any teaching with the client at this time. B. Reinforce the preoperative information with the client C. Encourage the client to empty the colostomy bag first D. Ask the client to begin assuming responsibility for self-care of the colostomy.
A The nurse should postpone any teaching with the client at this time and should encourage the client to look at and touch the stoma before continuing to teach about self-care. Refusal to look at the stoma indicates the client is in the denial stage of grief and might not be able to learn anything further at this time about self-care of the colostomy.
A nurse is caring for a client who had a below-the-knee amputation for gangrene of the right foot. The client reports sensations of burning and the toes of the absent right foot. Which of the following statements should the nurse make? A. "This type of pain usually decreases over time as the limb becomes less sensitive." B. "Try to look at the surgical wound as a reminder the limb is gone." C. "Use a cold compress intermittently to decrease these pain sensations." D. "Grief over the lost limb can sometimes cause denial that the limb is really gone."
A The nurse should recognize that the client is reporting phantom limb pain, a frequent complication following an amputation. The nurse should instruct the client that the sensation should decrease over time. The nurse should recognize the pain, provide treatment, and handle the limb gently to decrease the risk of triggering pain.
A nurse is preparing to test the function of cranial nerve X. Which of the following assessment procedures should the nurse use? A. Have the client open his mouth and say, "aah" B. Ask the client to identify the scent of coffee C. Use a tongue blade to provoke a gag reflex D. Have the client smile and raise his eyebrows
A The vagus or X nerve has both sensory and motor functions. To test the motor function, the nurse should have the client open his mouth an say, "aah. The palate and the uvula should move upward in response. The nurse should also assess the client's voice quality for hoarseness
A nurse is providing teaching to a client who has cervical cancer and is scheduled to receive brachytherapy in an ambulatory care clinic. Which of the following statements by the client indicates an understanding of the teaching? A. "I need to lie still in bed during my brachytherapy treatment." B. "I will have an implant placed once a month during my brachytherapy treatment." C. "I must stay at least 3 feet away from others between brachytherapy treatments. D. "I should expect some blood in my urine after each brachytherapy treatment."
A remain on bedrest with limited movement while the radioactive implant is in place to prevent dislodgement
A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure. B. Verify that the client understands the purpose and nature of the procedure. C. offer the client sips of clear liquids until 1 hr before the test. D. Obtain a pre-procedural sputum specimen. E. Instruct the client to keep his neck in a neutral position.
AB For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it.
A nurse is planning care for a client who is receiving chemotherapy and has a protein deficiency. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Mix powdered skim milk into liquid milk B. Add a raw egg to fruit smoothies C. Add a slice of cheese to hot vegetables D. Add honey to hot tea E. MIX yogurt into fresh fruit
ACE
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 pieces of 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 wear shoes always." D. "Clean your toothbrush weekly with isopropyl alcohol." E. "Avoid using tampons."
ACE Clients who are postoperative from 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. The client should wear shoes to prevent injury and decrease the risk of infection. The use of tampons is discouraged because they can disrupt the mucosal layer of the vagina and may support the growth of bacteria if left in place for too long.
A nurse is caring for a client who is scheduled to undergo an esophagogastroduodenoscopy (EGD). The nurse should identify that this procedure is for which of the following reasons? A. To visualize polyps in the colon B. To detect an ulceration in the stomach. C. To identify an obstruction in the biliary tract D. To determine the presence of free air in the abdomen
B An EGD is used to visualize the esophagus, stomach, and duodenum with a lighted tube to detect a tumor, ulceration, or obstruction.
A nurse is teaching a client with Barrett's esophagus who is scheduled to undergo an esophagogastroduodenoscopy (EGD). Which of the following statements should the nurse include in the teaching? A. This procedure is performed to measure the presence of acid in your esophagus." B. This procedure can determine how well the lower part of your esophagus works." C. This procedure is performed while you are under general anesthesia. D. This procedure can determine if you have colon cancer."
B An EGD is useful in determining the function of the esophageal lining and the extent of inflammation, potential scarring, and strictures.
A nurse is presenting an in-service training session about nutrition. How many of the amino acids must be obtained from dietary intake? A.6 B.9 C. 11 D. 15
B Proteins are made up of chains of amino acids, which are composed of carbon, hydrogen, oxygen, and nitrogen. Nine amino acids are considered essential for the human body and must be obtained from diet. These include histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, and valine.
A nurse is monitoring a client who has heart failure related to mitral stenosis. The client reports shortness of breath on exertion. Which of the following conditions should the nurse expect? A. Increased cardiac output B. Increased pulmonary congestion C. Decreased left atrial pressure D. Decreased pulmonary artery pressure
B Pulmonary congestion is a manifestation of mitral valve stenosis. Because of the defect in the mitral valve, the left atrial pressure rises and the left atrium dilates. The increased pressure results in a backflow of blood from the left atrium through the pulmonary vein and into the lungs resulting in pulmonary congestion.
A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? A. "During this illness, she may take acetaminophen for fevers or discomfort." B. "Encourage her to eat foods that are high in carbohydrates." C. The provider will prescribe a medication to help her liver heal faster." D. "Have her perform moderate exercise to restore her strength more quickly."
B The client's diet should be high in carbohydrates and calories with only moderate amounts of protein and fat, especially if nausea is present.
A nurse is caring for a client who is 3 days postoperative following a below-the-knee amputation. Which of the following actions should the nurse take? A. Place the client on a soft mattress B. Rewrap the residual limb with a bandage 3 times per day C. Assist the client into a prone position for 20 min every 8 hr daily D. Turn the client every 4 hr while in bed
B The nurse should rewrap the client's residual limb with a pressure bandage 3 times daily. This keeps the bandage taught, which ensures the residual limb will shrink. Rewrapping the bandage also allows the nurse to check the skin for redness or skin breakdown.
A nurse is providing teaching to a client who has stomatitis due to chemotherapy and radiation therapy. Which of the following statements by the client indicates a need for further teaching? A. "I will use a soft toothbrush or foam swab for oral care." B. "I will use lemon and glycerin swabs after meals." C. "I will remove my dentures except while eating." D. "I will rinse my mouth frequently with hydrogen peroxide solution."
B This client statement indicates a need for further teaching. The nurse should instruct the client who has stomatitis to avoid the use of lemon glycerin swabs because they cause drying and irritation of the mucous membranes.
A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary sinuses C. Intercostal spaces D. Salivary glands
B Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination.
A nurse is providing postoperative discharge teaching to a client following a panhysterectomy for uterine cancer. Which of the following pieces of 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 lb." D. "Pain or burning with urination is an expected outcome of this surgery.
B a panhysterectomy includes the removal of the uterus and the ovaries, which might cause, manifestations of menopause (e.g. hot flashes, night sweats, and vaginal dryness).
A nurse is assessing a client who has an exacerbation of herpes zoster. Which of the following manifestations of the client's skin should the nurse expect? A. Confluent, honey-colored, crusted lesions B. A large, tender nodule located on a hair follicle C. Unilateral, localized, nodular skin lesions D. A fluid-filled vesicular rash in the genital region
C Herpes zoster, or shingles, results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces localized, nodular skin lesions.
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 is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, headaches, brow pain, and nausea and vomiting.
A nurse is providing preoperative teaching for a client with colorectal cancer who is scheduled to undergo colostomy placement with a perineal wound. Which of the following statements by the client indicates an understanding of the teaching? A. "Not having any more rectal pain will be a relief." B. "I will need to sit on a rubber donut when I am 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 The client should consume a full or clear liquid diet for 24 to 48 hours 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 assessing a female client who reports severe joint pain. The nurse should identify that which of the following factors places the client at risk for gout? A Perimenopause B. Migraine headaches C. Diuretic use D. Irritable bowel syndrome
C The client's use of diuretics is a risk factor for gout. Gout is a systemic disorder that affects the joints as a result of high uric acid levels in the blood.
A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi-to high-Fowler's position
C The first action the nurse should take using the nursing process is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency reintubation.
A home health nurse is performing an assessment on a client who is 1 week postoperative following a total knee replacement. Which of the following statements by the client indicates an understanding of the teaching? A. "I will discontinue the blood thinner my doctor prescribed once I am at home." B. "I will keep a pillow under my knee when I am in bed." C. "I plan to use a walker to help me get around." D. "I will discontinue using the CPM machine when I get home."
C The nurse should identify that the client will receive a prescription for a walker, cane, or crutches to promote ambulation following a total knee replacement.
A nurse is caring for a client who has expressive aphasia following a stroke. The nurse should identify that the stroke affected which of the following lobes of the client's brain? A. Occipital B. Temporal C. Frontal D. Limbic
C The nurse should identify that the posterior portion of the frontal lobe is responsible for the verbal expression of thoughts
A nurse is caring for a client with Clostridium difficile who has contact-isolation precautions in place. Which of the following actions should the nurse perform? A. Instruct visitors to maintain a distance of at least 1 m (3 ft) from the client. B. Wash hands with antimicrobial soap after leaving the client's room. C. Use dedicated equipment for the client. D. Keep the doors to the client's room closed at all times.
C The nurse should use dedicated equipment that is left in the room for a client who has contact-isolation precautions in place.
A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. "Two tubes were necessary due to excessive bleeding from the area of the surgery." B. "The tubes drain blood from 2 different lung areas." C. "The lower tube will drain blood, and the higher tube will remove air." D. "The second tube will take over if blood clots block the first tube."
C The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air.
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 that 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 Rate the quality of this g C. Change the client's position D. Place the drainage bag above the client's abdomen
C This 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 should reposition the client to facilitate the drainage of the solution from the peritoneal cavity.
A nurse on a surgical unit is caring for 4 clients who have healing wounds. Which of the following wounds should the nurse expect to heal by primary intention? A. Partial-thickness burn B. Stage III pressure ulcer C. Surgical incision D. Dehisced sternal wound
C With primary intention, a clean wound is closed mechanically, leaving well-approximated edges and minimal scarring. A surgical incision is an example of a wound that heals by primary intention.
A nurse is monitoring a client who has Graves' disease for the development of thyroid storm. The nurse should report which of the following findings to the provider? A. Constipation B. Headache C. Bradycardia D. Hypertension
D A client who is experiencing a thyroid storm will have an exaggerated condition of hyperthyroidism associated with the development of a fever, hypertension, abdominal pain, and tachycardia. Graves' disease is a common cause of hyperthyroidism, which is an imbalance of metabolism caused by overproduction of thyroid hormone.
A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the client's condition? A. High-calorie diet B. Prior gastrointestinal illnesses C. Tobacco use D. Alcohol use
D Alcohol consumption is a major cause of chronic pancreatitis in the US. Long-term alcohol use disorder produces hypersecretion of protein in pancreatic secretions, which results in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage to these cells is more likely to occur and to be more severe in clients whose diets are poor in protein content and either very high or very low in fat.
A nurse is assessing a client who has a complete intestinal obstruction. Which of the following findings should the nurse expect? A. Absence of bowel sounds in all 4 abdominal quadrants B. Passage of blood-tinged liquid stool C. Presence of flatus. D. Hyperactive bowel sounds above the obstruction
D The nurse should expect the client to have hyperactive bowel sounds above the obstruction because the intestinal peristalsis above the obstruction attempts to push the obstruction through the intestines. With a complete intestinal obstruction, there are no bowel sounds below the obstruction.
A nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching? A. "Because most of my colon is still intact and functioning, my stool will be formed." B. "My stoma will appear large at first, but it will shrink over the next several weeks." C. "My colostomy will begin to function in 2 to 6 days after surgery." D. "I'll have to consume a soft diet after surgery."
D The nurse should identify that this statement requires further teaching. After surgery, the client quickly returns to a regular diet, and there are no food restrictions unless the client chooses to decrease the intake of foods that increase gas or odor.
A nurse is teaching a client with arthritis who is experiencing joint pain that impairs mobility. Which of the following instructions should the nurse include? A. "Engage your joints in resistance exercises." B. Avoid using assistive devices when walking." C. Perform passive exercises." D. "Apply heat to your joints prior to exercising.
D The nurse should instruct the client to apply heat to the joints prior to exercising to increase mobility and reduce pain.
A nurse is providing dietary teaching to a client who has dumping syndrome following gastric bypass surgery 4 days ago. Which of the following recommendations should the nurse include in the teaching? A. Avoid foods containing protein B. Drink liquids during each meal C. Eat foods that contain simple sugars D. Maintain a supine position after meals
D The nurse should instruct the client to lie supine after eating to help slow the rapid emptying of food into the small intestine. A client who has dumping syndrome should decrease the amount of food eaten at once, eat small meals more frequently, and eliminate fluids at mealtime. Fluid shifts occur in the upper gastrointestinal tract when food contents and simple sugars exit the stomach too rapidly, attracting fluid into the upper intestine and decreasing blood volume, which causes the client to experience nausea and vomiting, sweating, syncope, palpitations, increased heart rate, and hypotension.
A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? A. Pulmonary edema B. Tension pneumothorax C. Flail chest D. Respiratory obstruction.
D. Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema. The nurse should notify the rapid response team and plan to administer racemic epinephrine.
