ATI practice exam
A nurse is caring for a client who is 3 hr postoperative and exhibiting signs of hypovolemia. Which of the following findings should the nurse identify as a manifestation of hypovolemia? a.Distended neck veins b.Rapid pulse rate c.Urine output 45 mL/hr d.Decreased respiratory rate
b.Rapid pulse rate
A nurse is providing teaching for a client who has constipation-predominant irritable bowel syndrome (IBS-C). Which of the following statements should the nurse include in the teaching? a. "Take a dose of loperamide each morning." b. "Increase your fluid intake to 1,000 milliliters per day." c. "Take psyllium in the evening." d. "Consume a diet that is low in protein."
"Take psyllium in the evening." A client who has IBS-C should take a bulk-forming laxative, such as psyllium, to increase the bulk of the stool, reduce constipation, and promote regular bowel movements.
A nurse is preparing to administer enoxaparin 0.75 mg/kg subcutaneously to a client who weighs 154 lb. The amount available is enoxaparin 60 mg/0.6 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
0.5
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication? a. Coronary artery disease b. Retinopathy c. Cerebrovascular accident d. Hypertension
b.Retinopathy
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take? a.Use an infusion pump to deliver the dialysate at a safe rate. b.Report cloudy dialysate drainage to the provider. c.Warm the dialysate solution using a low power level on a microwave oven. d.Allow the dialysate to drain over 1 to 4 hr.
b.Report cloudy dialysate drainage to the provider
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance? a.Breakdown of fatty acids b.Retention of carbon dioxide c.Hyperventilation in response to hypoxia d.Ingestion of large amounts of bicarbonate
b.Retention of carbon dioxide
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
100
A nurse is caring for a client who had abdominal surgery. The client tells the nurse that "something gave way." The nurse removes the dressing and sees the wound has eviscerated. Identify the correct sequence of steps the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Place the client in a low Fowler's position with the knees bent. 2. Cover the client's wound with a sterile saline-soaked dressing. 3. Notify the surgeon about the finding. 4. prepare the client for transfer to surgery.
3. Notify the surgeon about the finding 2. Cover the client's wound with a sterile saline soaked dressing 1. Place the client in a low Fowler's position with the knees bent 4. Prepare the client for transfer to surgery
A nurse is assessing a client who has hypocalcemia. In which of the following areas should the nurse tap on the client's face to detect the presence of Chvostek's sign? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A. Tap the client's cheek just in front of the ear and below the zygomatic arch
A nurse is assessing a client who has an exacerbation of diverticular disease. In which of the following quadrants should the nurse anticipate the client to be experiencing abdominal pain? a. Left upper quadrant b. Left lower quadrant c. Right lower quadrant d. Right upper quadrant
b. Left lower quadrant
A nurse is assessing a client who has Cushing's syndrome. Which of the following findings should the nurse expect? a.Vitiligo b.Osteoporosis c.Myxedema d.Heat intolerance
b.Osteoporosis
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client's weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take? (Click on the "Exhibit" button below for additional information about the client. There are three tabs that contain separate categories of data.) According to the titration table, when the aPTT is greater than 95, the nurse should stop the infusion for 1 hr, then restart the infusion with a decrease of 3 units/kg/hr, which is a decrease of 240 units/hr for a client who weighs 80 kg (176.4 lb). Increase the rate of the infusion by 160 units/hr. An aPTT greater than 95 seconds is outside the expected reference range of 60 to 70 seconds. Therefore, increasing the rate of the heparin infusion places the client at risk for hemorrhage. The nurse should monitor for manifestations of bleeding. Administer heparin 2,400 unit IV bolus. An aPTT greater than 95 seconds is outside the expected reference range. Therefore, administering heparin 2,400 unit IV bolus places the client at risk for hemorrhage. The nurse should monitor for manifestations of bleeding. Continue the infusion without change. An aPTT greater than 95 seconds is outside the expected reference range. Therefore, continuing the infusion at the current rate places the client at risk for hemorrhage. The nurse should monitor for manifestations of bleeding.
Stop the heparin infusion for 1 hour
A nurse is completing an admission assessment for a client who has bacterial meningitis. Which of the following personal protective equipment should the nurse use while caring for the client? a. N95 respirator b. goggles c. disposable mask d. surgical mask
Surgical mask
A nurse is assessing a client who has a central venous catheter (CVC) with intravenous (IV) fluids infusing. The client suddenly develops shortness of breath, and the nurse notes that the IV tubing and needleless connector device are disconnected. Which of the following actions should the nurse take first? a. Close the pinch clamp on the CVC. b. Obtain a prescription for stat ABGs. c. Place the client in left Trendelenburg position. d. Check the tubing for placement of a locking adaptor.
a. Close the pinch clamp on the CVC
A nurse is caring for a group of clients. In which of the following scenarios is the nurse acting as a client advocate? a. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services. b. The nurse provides wound care to a client at the time promised to the client. c. The nurse declines to inform a client's neighbor about the client's prognosis. d. The nurse files an incident report regarding a medication error.
a. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the client's skin? a.A pearly, waxy nodule b.An irregular border on a variegated-colored lesion c.A firm, nodular, crusty, or ulcerated lesion d.A weeping vesicle
a.A pearly, waxy nodule
A nurse is planning care for a client who is receiving intermittent IV fluids via a peripherally inserted central catheter (PICC). Which of the following information should the nurse include in the client's plan of care? a.Assess the PICC infusion system systematically. b.Use a 3-mL syringe to flush the PICC following infusions. c.Change the needleless connector device on the IV tubing after each infusion. d.Provide daily dressing changes to the PICC insertion site.
a.Assess the PICC infusion system systematically
A nurse is assessing a client who has suspected appendicitis. Which of the following manifestations should the nurse expect? (Select all that apply.) a.Elevated WBC count b.Elevated amylase level c.Rebound tenderness d.Ascites e.Anorexia
a.Elevated WBC c.Rebound tenderness e.Anorexia
A nurse is assessing a client who recently had a myocardial infarction. Which of the following findings indicates that the client might be developing pulmonary edema? (Select all that apply.) a. Excessive somnolence b. Epistaxis c. Pink, frothy sputum d. Tachypnea e. Urinary frequency
a.Excessive somnolence b.Pink, frothy sputum d.Tachypnea
A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. "I am aware that my diabetes is caused by an autoimmune disorder." b."I know that my diabetes developed slowly over several years." c."If I lose weight, I may be able to stop taking insulin." d."I have developed a resistance to insulin."
a.I am aware that my diabetes is caused by an autoimmune disorder
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change? a."I changed the floor plan of our home to accommodate my father's wheelchair." b."I'm so stressed out that it makes it difficult for me to manage everything." c."At times, I get so frustrated with how to care for my parents." d."I am learning to take care of my parents as I go."
a.I changed the floor plan of our home to accommodate my father's wheel chair
A nurse is providing teaching for a client who has neutropenia and is receiving chemotherapy. Which of the following client statements indicates an understanding of the teaching? (Select all that apply.) a."I will avoid crowds." b."I will wash my toothbrush weekly." c."I will change my cat's litter box twice weekly." d."I will take my temperature daily." e."I will eat plenty of fresh fruits and vegetables."
a.I will avoid crowds d.I will take my temp daily
A nurse is assessing a client who has a new diagnosis of diabetes mellitus. The nurse should identify that which of the following findings is a manifestation of hyperglycemia? a. Increased thirst b. Decreased urine output c. Dry skin d. Tremors
a.Increased thirst
A nurse is caring for a client who has a small bowel obstruction and an NG tube in place. Which of the following actions should the nurse take? a.Maintain low intermittent suction. b.Assess patency and irrigate the NG tube every 12 hr. c.Record gastric output every 8 hr. d.Fasten the end of the tube to the client's pillow case.
a.Maintain low intermittent suction
A nurse is caring for a client who is experiencing anxiety as well as numbness and tingling of the lips and fingers. The client's ABGs are: pH 7.48, PCO2 30 mm Hg, HCO3- 24 mEq/L, PaO2 85 mm Hg. Which of the following acid-base imbalances should the nurse identify that the client is experiencing? a.Respiratory alkalosis b.Respiratory acidosis c.Metabolic alkalosis d.Metabolic acidosis
a.Respiratory alkalosis
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective? a. The client's daily peak expiratory flow (PEF) measures 85% above personal best. b. The client's ABGs shows a pH level of 7.32. c. The client's forced expiratory volume is decreased after treatment with medication. d. The client's wheezing is limited to expiratory.
a.The client's daily peak expiratory flow measures 85% above personal best
A nurse is caring for a client who has chronic venous insufficiency. Which of following areas should the nurse assess for the presence of a venous ulcer? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.) a. The nurse should assess the medial malleolus (ankle) b. The nurse should assess the tip of the toe and between the toes c. The nurse should assess the ball of the foot
a.The nurse should assess the medial malleolus of the ankle
A nurse is providing teaching to a group of clients about the prevention of coronary artery disease. Which of the following information should the nurse include in the teaching? a.Walk 30 min daily at a comfortable pace. b.Limit saturated fat intake to 10% of total daily calories. c.Maintain a BMI of 30. d.Consume at least 2,000 mg of sodium per day.
a.Walk 30 min daily at a comfortable pace
A nurse is providing teaching to a client who is scheduled for a bronchoscopy. Which of the following statements should the nurse include in the teaching? a."You will not be able to eat or drink after the procedure until you are able to cough." b."You will drink a contrast solution 30 minutes prior to the procedure." c."The purpose of this procedure is to remove excess fluid from your lungs." d."You will need to lie on your back for 4 to 6 hours following the procedure."
a.You will not be able to eat or drink after the procedure until you are able to cough
A home health nurse is assisting a client with planning care for a family member who has Alzheimer's disease. Which of the following instructions should the nurse include? a. remove clutter from rooms and hallways b. place a monthly calendar in the clients room c. use confrontation to manage the clients behavior d. review the daily schedule with the client every morning
a.remove clutter from room and hallways
A nurse is assessing a client who has a new diagnosis of pericarditis. Which of the following findings should the nurse identify as a manifestation of cardiac tamponade? a. Fever b. Atrial fibrillation c. Paradoxical pulse d. Pericardial friction rub
b. A-fib
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad? a.Increase in temperature from 37.5º C (99.5º F) to 38.3º C (101º F) b.Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg c.Increase in urine output from 30 mL/hr to 100 mL/hr e.Increase in heart rate from 70/min to 90/min
b. Increase in blood pressure from 130/80 to 180/100
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse implement to decrease the client's risk for ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Wear a protective gown when suctioning the client's airway. b. Monitor for oral secretions every 2 hr. c. Provide oral care every 2 hr. d. Maintain the client in a supine position. e. Assess the client daily for readiness of extubation.
b. Monitor for oral secretions every 2 hr c. Provide oral care every 2 hr e. Assess client daily for readiness of extubation
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take? a. Schedule the client for the last surgery of the day. b. Place monitoring cords and tubes in a stockinette. c. Choose rubber injection ports for fluid administration. d. Have phenytoin IV readily available.
b. Place monitoring cords and tubes in a stockinette
A nurse in a long-term care facility is caring for a client who has dementia. Which of the following actions should the nurse take? a. Give detailed directions when addressing the client. b. Provide finger food at mealtime. c. Use written signs to redirect the client. d. Seat the client at a large table for meals.
b. Provide finger food at meal time
A nurse is providing preoperative teaching about stool consistency to a client who will undergo a colectomy with the placement of an ileostomy. Which of the following information about stool consistency should the nurse include in the teaching. a.The stool will have a tarry color. b.The stool will have a high volume of liquid. c.The stool will be solid and well-formed. d.The stool will appear bloody with clots.
b. The stool will have a high volume of liquid
A nurse is providing discharge teaching about infection control at home for a client who has tuberculosis. Which of the following statements by the client indicates an understanding of the teaching? a. "I will have to move out of my family's home until I am no longer contagious." b. "I will place my used tissues in a plastic bag." c. "I will cover my mouth with my hands when I have to cough." d. "I will not go in public areas until I am cured."
b."I will place my used tissues in a plastic bag."
A nurse is providing teaching to a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following statements by the client indicates an understanding of the teaching? a."Once my weight is back to normal, I can gradually reduce and then stop the medication." b. "If my heart starts racing, my provider might need to adjust my dosage." c."I will keep a journal of my daily food intake to show the provider." d. "I'm not forgetful, so I do not need a pill reminder system."
b."If my heart starts racing, my provider might need to adjust my dosage
A nurse is assessing a client's ECG strip and notes an irregular heart rate of 98/min with no clear P waves. Which of the following cardiac dysrhythmias should the nurse document? a.First-degree heart block b.Atrial fibrillation c.Complete heart block d.Ventricular tachycardia
b.A-fib
A nurse in an emergency department is caring for a client who is confused, has a temperature of 40° C (104° F), a BP of 74/52 mm Hg, and a diagnosis of exertional heat stroke. Which of the following actions should the nurse take first? a.Measure the client's urine specific gravity. b.Administer oxygen using a high-concentration mask. c.Initiate gastric lavage with ice water. d.Immerse the client in cold water.
b.Administer oxygen using a high concentration mask
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery? a.oral temp 37.2C (99F) b.clear drainage on the dressings c.drain output 75mL in 4hr d.decreased bowel sounds in all quadrants of the abdome
b.Clear drainage on the dressings
A nurse is assessing a client who has a chest tube connected to a closed water-seal drainage system. Which of the following findings should the nurse report to the provider? a.Fluctuation of the water level in the chamber as the client breathes b.Constant bubbling in the water seal chamber c.Numerous small blood clots in the drainage tubing d.Water seal chamber contains 1 cm (0.39 in) of water
b.Constant bubbling in the water seal chamber
A nurse is providing discharge teaching to a client who has COPD. Which of the following instructions should the nurse include in the teaching? a."Schedule controlled coughing exercises after meals." b."Consume a diet that is high in calories." c."Practice breath-holding." d."Perform arm-reaching exercises."
b.Consume a diet high in calories
A nurse is reviewing the health histories of a group of clients. Which of the following findings should the nurse identify as an indication that a client is at an increased risk for urinary tract infections (UTIs)? a. Asthma b. Diabetes mellitus c. Pernicious anemia d. Osteoporosis
b.Diabetes mellitus
A nurse is preparing to discharge a client who is postoperative following a total hip arthroplasty. Which of the following equipment should the nurse ensure that the client has available at home prior to discharge? a. Continuous passive motion device b. Elevated toilet seat c. Trapeze bar d. Compression garment
b.Elevated toilet seat
A nurse is providing teaching about health promotion activities for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? a. "If I can keep my hemoglobin A1C less than 6.5%, I will be cured of diabetes." b. "I will check my blood sugar level before exercising." c. "I should have my eyes checked every 2 years." d. "I should soak my feet daily in warm, soapy water."
b.I will check my blood sugar level before exercising
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome? a. weight gain b. iron-deficiency anemia c. hypercalcemia d. reduced heart rate
b.Iron deficiency anemia
A nurse in an emergency department is assessing a client who is overusing prescribed diuretics and has a sodium level of 127 mEq/L. Which of the following laboratory findings should the nurse expect? a.High lipase b.Low urine specific gravity c.Low hemoglobin d.High creatine kinase-MB (CK-MB)
b.Low urine specific gravity
A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication? a.The client's blood pressure is elevated. b.The client is becoming flushed. c.The client reports blurred vision. d.The client is experiencing polyuria.
b.The client is becoming flushed
A nurse is planning care for a client who had a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? a. Instruct the client to lift no more than 6.8 kg (15 lb) when at home. b. Turn the client by log rolling with a turning sheet. c. Inform the client to shower on the second postoperative day. d. Remove sterile adhesive strips before discharge.
b.Turn the client by log rolling with a turning sheet
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurse's priority? a.WBC count b.Intake and output c.ABGs d.Blood glucose level
c. ABGs
A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard? a.The client's bed has a three-prong plug attached to the electrical cord. b.A protective cover is inserted into an unused outlet. c.An IV pump is plugged into an outlet near a sink. d.An electrical cord is coiled and secured to the floor.
c. An IV pump is plugged into an outlet near a sink
A nurse is teaching a client about preventing the transmission of HIV. Which of the following information should the nurse include? a. Use a natural material condom during oral, genital, and anal intercourse. b. Medication is available that will reduce the risk for HIV transmission. c. Use skin lotion as a lubricant when using a condom. d. A diaphragm will provide protection against HIV transmission.
c. Medication is available that will reduce the risk for HIV transmission
A nurse is caring for a client who is receiving a transfusion of packed RBCs. The nurse notes that the client's blood type is AB positive and the blood infusing is labeled type B negative. Which of the following actions should the nurse take? a. Stop the blood transfusion immediately. b. Prepare to administer antipyretics. c. Monitor the client for any adverse reactions. d. Transfuse the blood over 6 hr.
c. Monitor the client for any adverse reactions. Although the client is a universal recipient and can receive any ABO blood type, the nurse should continue to monitor for any adverse reactions, which is standard procedure for any blood transfusion.
A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy? a. stomatitis b. vomiting c. skin changes d. hematuria
c. Skin changes
A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following medications should the nurse instruct the client to avoid? (Select all that apply.) a. ferrous sulfate b. echinacea c. aspirin d. naproxen
c.Aspirin d.Naproxen
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The client's vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurse's priority? a.Notify the surgeon of the temperature elevation. b.Encourage the client to drink more fluids. c.Assess the surgical incision for signs of infection. d.Monitor vital signs every 4 hr.
c.Assess the surgical incision for signs of infection
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy? a.WBC count 8,000/mm3 b.RBC count 6 million/mm3 c.BUN 24 mg/dL d.Potassium 3.5 mEq/L
c.BUN 24 mg/dl
A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse identify as a manifestation of right-sided heart failure? a.gallop b.weak peripheral pulses c.increased abdominal girth d.wheezing
c.Increased abdominal girth
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes? a. Hypernatremia b. Decreased serum osmolality c. Ketones in the urine d. Hypoglycemia
c.Ketones in the urine
A nurse is teaching a client about self-management of their halo fixator device. Which of the following information should the nurse include in the teaching? a. Apply powder liberally under the chest portion of the halo fixator device. b. Avoid the use of straws when drinking liquids. c. Place a small pillow under the head while lying supine. d. Give each screw a quarter turn daily using the wrench provided.
c.Place a small pillow under the head while lying supine
A nurse is assisting with the care of a client who is scheduled for a thoracentesis. Which of the following interventions should the nurse plan to take? a. Inform the client that they must empty their bladder before the procedure. b. Weigh the client before and after the procedure. c. Place the client leaning forward over the bedside table for the procedure. d. Keep the client on bed rest after the procedure.
c.Place the client leaning forward over the bedside table for the procedure.
A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome? a. audible pleural friction rub b.Tracheal deviation from the midline c.refractory hypoxemia d.bloody expectorant when coughing
c.Refractory hypoxemia
A nurse is providing teaching about dietary options for a client who has cholelithiasis. Which of the following statements should the nurse include in the teaching? a."Cauliflower is a good dietary choice." b."Increase the amount of egg yolks in your diet." c."Select desserts such as angel-food cake." d."Eat choice or prime cuts of meat."
c.Select desserts such as angel food cake
A nurse is assessing a client who has left-sided heart failure. Which of the following findings should the nurse identify as a manifestation of left-sided heart failure? a.Dependent edema b.Jugular distention c.Weight gain d.Frothy sputum
d.Frothy sputum
A nurse is caring for a client who has a prescription for lactated Ringer's by continuous IV infusion to replace output from an NG tube. Which of the following findings should indicate to the nurse that this therapy is effective? a.Decreased NG tube drainage b.Serum osmolality 350 mOsm/L c.Urine specific gravity 1.020 d.Increased hematocrit
c.Urine specific gravity 1.020
A nurse is teaching a client who is scheduled to receive radioactive iodine therapy for treatment of hyperthyroidism. Which of the following instructions should the nurse include in the teaching? a. Remain 0.3 m (1 ft) away from children. b. Limit the time spent around women who are pregnant to 10 min daily. c. Use disposable utensils for meals. d. Use an absorbent pad if incontinent.
c.Use disposable utensils for meals.
An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus? a. coughing b. flat neck veins c. use of accessory muscles d.presence of coarse crackles
c.Use of accessory muscles
A nurse is providing teaching to a client about strategies to manage menopausal symptoms. Which of the following instructions should the nurse include in the teaching? a."Drink green tea to relieve menopausal hot flashes." b."Take vitamin D supplements to relieve menopausal hot flashes." c."Use water-based lubricant during intercourse to reduce discomfort." d."Apply estrogen cream during intercourse to reduce discomfort."
c.Use water based lubricant during intercourse to reduce discomfort
A nurse is caring for a client who is hemorrhaging and hypotensive from esophageal variceal bleeding. Which of the following actions should the nurse take first? a. Administer vasopressin to the client. b. Request blood from blood bank. c. Verify that the client has adequate IV access. d. Insert an indwelling urinary catheter.
c.Verify that the client has adequate IV access
A nurse is assessing a group of clients. For which of the following clients should the nurse make a referral to palliative care? a. A client who is newly diagnosed with type 1 diabetes mellitus and cannot afford insulin b. A client who has Meniere's disease and cannot safely ambulate due to vertigo c. A client who had a stroke and cannot eat or drink without choking d. A client whose medications to manage Parkinson's disease are no longer effective
d. A client whose medications to manage parkinson's disease are no longer effective
A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching? a. "Use salt substitutes to reduce your sodium intake." b. "Increase your fluid intake to 1,000 mL a day." c. "Include phosphorus-rich foods in your diet." d. "Increase your intake of protein to 1 to 1.5 grams per kilogram per day."
d. Increase your intake of protein to 1-1.5 g/kg/day
A nurse notes that a client's eyes are protruding slightly from their orbits. Which of the following laboratory findings should the nurse expect? a. Decreased calcium levels b. Decreased somatotropin levels c. Increased glucose levels d. Increased T4 levels
d. Increased T4 levels
A nurse is caring for a client who has multiple leg fractures and is 24 hr postoperative following placement of skeletal traction. Which of the following actions should the nurse take? a. Apply petroleum jelly to the pin sites. b. Apply a sterile hydrocolloid dressing every 24 hr. c. Cleanse the pin sites with isopropyl alcohol. d. Inspect the pin sites at least every 8 hr.
d. Inspect the pin site at least every 8 hours
A nurse is planning care for a client who has a lump in their right breast. Which of the following findings increases the client's risk of developing breast cancer? a. Menarche started at age 15 b. First born child was at 20 years of age c. History of a fibrocystic breasts d. Oral contraceptives were taken for the last 6 years
d. Oral contraceptives were taken for the last 6 years
A nurse is caring for a client immediately following intubation with an endotracheal (ET) tube. Which of the following methods should the nurse identify as the most reliable for verifying placement of the ET tube? a. Feel for exhaled air emerging from the endotracheal tube. b. Assess for bilateral breath sounds. c. Observe for symmetric chest movement. d. Check for end-tidal carbon dioxide levels.
d. check for end-tidal carbon dioxide levels
A nurse is providing preoperative teaching to a client who is scheduled for a radical prostatectomy. Which of the following information should the nurse include in the teaching? a.The client will be on bed rest while continuous bladder irrigation is in place. b.Cold compresses will be used to manage bladder spasms. c.The client will have an NG tube in place for 48 hr postoperatively. d. A PCA pump will be used for postoperative pain control.
d.A PCA pump will be used for postoperative pain control
A nurse is preparing to administer propranolol to several clients. For which of the following clients should the nurse clarify the prescription with the provider before administration? a.A client who had a myocardial infarction 24 hr ago b.A client who has a heart rate of 98/min c.A client who has hypertension d.A client who has a history of asthma
d.A client who has history of asthma
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan? a. Maintain the head of the bed greater than 45°. b. Place a donut-shaped cushion under the client's sacrum. c. Massage bony prominences three times daily. d. Apply moisturizer to damp skin after bathing.
d.Apply moisturizer to damp skin after bathing
A nurse is teaching a client how to obtain a specimen at home for a fecal occult blood test. Which of the following actions should the nurse instruct the client to take for 3 days prior to collecting the specimen? a. Take a low-dose aspirin tablet twice daily. b. Avoid eating cooked vegetables. c. Take vitamin C supplements. d. Avoid eating red meat.
d.Avoid eating red meat
A nurse is assessing a client's understanding of a surgical procedure prior to witnessing their signature on the informed consent form. The nurse determines that the client does not understand what the procedure will involve. Which of the following actions should the nurse take? a.Provide teaching about the surgical procedure for the client. b.Instruct the client's spouse to sign the consent form. c.Read the consent form to the client using words the client will understand. d.Contact the provider who will be performing the procedure.
d.Contact the provider who will be performing the procedure
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching? a. "I can resume sexual intercourse in 48 hours." b. "I can expect some heavy vaginal bleeding for 24 hours." c. "I can use tampons when my period comes in a week." d. "I may have mild cramping for several hours."
d.I may have mild cramping for several hours
A nurse is providing teaching to a client who has a new prescription for cephalexin oral suspension. Which of the following statements by the client indicates an understanding of the teaching? a. "I will increase my consumption of foods high in potassium." b. "I will apply lotion to my skin if I feel any itching." c. "I will avoid sun exposure while taking this medication." d. "I will keep the medication refrigerated."
d.I will keep the medication refrigerated
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take? a.Place the affected leg in external rotation. b.Encourage the client to use the incentive spirometer every shift. c.Instruct the client to lean forward when rising from a chair. d.Maintain abduction of the affected extremity.
d.Maintain abduction of the affected extremity
A nurse is caring for a client who has acute kidney a and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect? a. Prominent P waves b. Narrowed QRS complexes c. Shortened PR intervals d. Peaked T waves
d.Peaked T waves
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider? a.tender,bleeding gums b.increase facial hair c.constipation d.skin rash
d.Skin rash
A nurse is assessing a client for fluid volume deficit following lumbar spinal surgery. The nurse should identify which of the following findings as an indication the client is at risk for fluid volume deficit? a.BUN 16 mg/dL b. Urine output 40 mL every hour for 3 hr c. Hct 42% d. Surgical drain output 300 mL during an 8-hr shift
d.Surgical drain output 300 mL during an 8 hour shift
A nurse is performing a risk assessment for a client. Which of the following factors should the nurse identify as increasing the client's risk for falls? a.The client has gastroesophageal reflux disease b.A client who has gastroesophageal reflux disease is not at an increased risk for falls. c.The client is 62 years old. d.The client had cataract surgery 1 day ago.
d.The client had cataract surgery 1 day ago
A nurse is teaching a client who has a new prescription for phenytoin to treat a seizure disorder. Which of the following adverse effects should the nurse instruct the client to report immediately to the provider? a.Increased pigmentation b.Topical glucocorticoid therapy can cause the adverse effect of hypopigmentation. c.Localized hair loss d.Thinning of the skin
d.Thinning of the skin
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client? a.Contact precautions b.Protective environment precautions c.Droplet precautions d.Airborne precautions
d.airborne precautions
