Combo with "Endocrine NCLEX" and 2 others

Which client complaint would alert the nurse to a possible hypoglycemic reaction?

Tremors

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which of the following?

"Are you rotating the injection site?"

A nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy?

"Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again."

A client with skeletal traction applied to the right leg complains to the nurse about severe right leg pain in spite of being medicated with a prescribed analgesic. Which action should the nurse take? 1. Remove some of the traction weights. 2. Provide pin care. 3. Notify the registered nurse. 4. Find out when the next dose of the prescribed analgesic can be given.

3. Notify the registered nurse.

A client is being discharged home after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client states to: 1. Avoid getting the cast wet. 2. Cover the casted leg with warm blankets. 3. Use the fingertips to lift and move the leg. 4. Use a padded coat hanger end to scratch under the cast.

1. Avoid getting the cast wet.

A nurse is caring for a client who had a total knee replacement. Postoperatively, the nurse monitors for which highest priority item? 1. Calf pain 2. Heel breakdown 3. Bladder distention 4. Extremity shortening

1. Calf pain

A nurse is caring for a client following total hip replacement who has a Hemovac wound suction drain in place. At the end of the 8-hour shift, the nurse empties 45 mL of drainage from the wound-suction device. Based on this amount of drainage, which action is appropriate? 1. Document the findings. 2. Place the leg in a flat position. 3. Check the client's blood pressure. 4. Immediately notify the health care provider.

1. Document the findings.

A nurse is caring for a client with fresh application of a plaster leg cast. The nurse plans to prevent the development of compartment syndrome by: 1. Elevating the limb and applying ice to the affected leg 2. Elevating the limb and covering the limb with bath blankets 3. Keeping the leg horizontal and applying ice to the affected leg 4. Placing the leg in a slightly dependent position and applying ice

1. Elevating the limb and applying ice to the affected leg

A nurse is caring for the client who is going to have an arthrogram using a contrast medium. Which of the following data collected by the nurse would be of highest priority? 1. Allergy to iodine or shellfish 2. Whether the client needs to void before the procedure 3. Ability of the client to remain still during the procedure 4. Whether the client has any remaining questions about the procedure

1. Allergy to iodine or shellfish

A nurse in the emergency department is caring for a client with a fractured arm. The nurse understands that which item is not necessary before reduction of the fracture in the casting room? 1. Anesthesia consent 2. Consent for the procedure 3. Administration of an analgesic 4. Explanation of the procedure to the client

1. Anesthesia consent

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for rest of the inflamed joints? 1. Large pillows 2. Footboards 3. Small pillows 4. Soft mattress

3. Small pillows

A client has had surgery to repair a fractured left hip. The nurse plans to use which of the following important items when repositioning the client from side to side in the bed? 1. Bed pillow 2. Abductor splint 3. Adductor splint 4. Overhead trapeze

2. Abductor splint

A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse should be especially concerned with which of the following findings? 1. Complaints of discomfort during repositioning 2. An oral temperature of 101° F orally 3. Old bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep breathing exercises

2. An oral temperature of 101° F orally

A nurse is preparing to administer an injection of regular insulin. The vial of the regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. The nurse should:

Discard the insulin and obtain another vial.

A client in skeletal leg traction with an overbed frame is not allowed to turn from side to side. Which action by the nurse would be most useful in trying to provide good skin care to the client? 1. Having another nurse tilt the client to the side 2. Asking the client to pull up on a trapeze to lift the hips off the bed 3. Pushing down on the mattress of the bed while administering care 4. Asking the client to lift up by digging into the mattress with the unaffected leg

2. Asking the client to pull up on a trapeze to lift the hips off the bed

A nurse is caring for a client diagnosed with Paget's disease. The nurse understands that this condition usually affects which bones? 1. Anterior rib cage and sternum 2. Axial skeleton including vertebrae 3. Bones of hands and feet 4. Shoulder and humerus

2. Axial skeleton including vertebrae

During admission data collection, a nurse asks the client to run the heel of one foot down the lower anterior surface of the other leg. The nurse notices rhythmic tremors of the leg being tested and concludes that the client has interference in the area of: 1. Muscle strength and flexibility 2. Balance and coordination 3. Bowel and bladder control 4. Sensation and reflexes

2. Balance and coordination

A client is complaining of low back pain, with radiation down the left posterior thigh. The nurse continues to collect data from the client to see if the pain is worsened or aggravated by: 1. Bedrest 2. Bending or lifting 3. Ibuprofen (Motrin) 4. Application of heat

2. Bending or lifting

A nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. The nurse's response is based on the understanding that: 1. A bone fragment has injured the nerve supply in the area. 2. Bleeding and swelling cause increased pressure in an area that cannot expand. 3. An injured artery causes impaired arterial perfusion through the compartment. 4. The fascia expands with injury, causing pressure on underlying nerves and muscles.

2. Bleeding and swelling cause increased pressure in an area that cannot expand.

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which of the following in an effort to relieve the spasm? 1. Heat 2. Cold 3. Analgesics 4. Prescribed intermittent traction

2. Cold

A nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse should make which response to the client? 1. "No, it is not painful." 2. "A local anesthetic will be given." 3. "You will receive general anesthesia." 4. "You will be heavily medicated before the procedure."

2. "A local anesthetic will be given."

A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further skin care instructions are required when the client states: 1. "I will soak the skin and then wash it gently." 2. "I need to scrub the skin vigorously with soap and water." 3. "I need to apply an emollient lotion to enhance softening." 4. "I need to use a sunscreen on the skin if it's exposed for a period of time."

2. "I need to scrub the skin vigorously with soap and water."

A client with possible rib fracture has never had a chest x-ray. The nurse would plan to tell the client which of the following items about the procedure? 1. "The x-ray stimulates a small amount of pain." 2. "It is necessary to remove jewelry and any other metal objects." 3. "The client will be asked to breathe in and out during the x-ray." 4. "The x-ray technologist will stand next to the client during the x-ray."

2. "It is necessary to remove jewelry and any other metal objects."

A nurse is planning to provide instructions to the client about how to stand on crutches. In the instructions, the nurse plans to tell the client to place the crutches: 1. 3 inches to the front and side of the client's toes 2. 8 inches to the front and side of the client's toes 3. 20 inches to the front and side of the client's toes 4. 15 inches to the front and side of the client's toes

2. 8 inches to the front and side of the client's toes Rationale: The classic tripod position is taught to the client before giving instructions on gait. The crutches are placed anywhere from 6 to 10 inches in front and to the side of the client, depending on the client's body size. This provides a wide enough base of support to the client and improves balance.

An client is brought to the emergency department via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse should anticipate which of the following on inspection of the client's leg? 1. Lengthening, adduction, and external rotation 2. Shortening, abduction, and internal rotation 3. Shortening, adduction, and external rotation 4. Lengthening, abduction, and internal rotation

3. Shortening, adduction, and external rotation

A postoperative client received a spinal anesthetic during the repair of a right hip fracture. The client has not experienced pain because the anesthetic has not yet worn off. The nurse will monitor the client closely for pain and provide the client with which instruction? 1. "I will be bringing your pain medication at ten o'clock PM." 2. "You will not feel pain because of the spinal anesthesia." 3. "You will need to let me know when you start to get feeling back in your legs." 4. "You will not be able to take pain medication until you have been up to the bathroom."

3. "You will need to let me know when you start to get feeling back in your legs."

A nurse is preparing to collect data from a client who has sustained a pelvic fracture following a motor vehicle accident. The nurse reviews the health care provider's (HCP) prescriptions and notes that the HCP has prescribed a pelvic (skin) sling. The nurse prepares to place the client in which device? Refer to figure. 1. 1 2. 2 3. 3 4. 4

3. 3

A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. The nurse should: 1. Put the client's knee through full passive range of motion. 2. Immobilize the knee temporarily. 3. Administer an analgesic. 4. Notify the health care provider immediately.

3. Administer an analgesic.

A nurse is providing care of the client following a bone biopsy. Which action by the nurse is unnecessary in the care of this client? 1. Elevating the limb for 24 hours 2. Monitoring vital signs every 4 hours 3. Administering intramuscular opioid analgesics 4. Monitoring the site for swelling, bleeding, hematoma

3. Administering intramuscular opioid analgesics

A client with a left arm fracture complains of severe, diffuse pain that is unrelieved with pain medication. On further data collection, the nurse notes that the client experiences more pain during passive motion of the left arm as compared with active motion. Based on these findings, the nurse should take which action? 1. Check to see whether it is time for more pain medication. 2. Encourage the client to continue with active range-of-motion exercises to the left arm. 3. Notify the registered nurse. 4. Reassess the client in 30 minutes.

3. Notify the registered nurse.

Which statement by the client who has received home care instruction following an arthroscopy of the knee indicates a need for further education? 1. "I should elevate my knee while sitting." 2. "I should avoid excessive use of the joint for several days." 3. "I can apply heat to my knee if it becomes uncomfortable." 4. "I should return to the health care provider in about 7 days for followup."

3. "I can apply heat to my knee if it becomes uncomfortable."

A client has Buck's extension traction applied to the right leg. The nurse should plan which intervention to prevent complications of the device? 1. Giving pin care once a shift 2. Massaging the skin of the right leg with lotion every 8 hours 3. Inspecting the skin on the right leg at least once every 8 hours 4. Releasing the weights on the right leg for range-of-motion exercises daily

3. Inspecting the skin on the right leg at least once every 8 hours

A nurse is caring for a client diagnosed with Paget's disease. The nurse plans care, knowing that this condition usually affects which bones? 1. Shoulder and humerus 2. Bones of the hands and feet 3. Anterior rib cage and sternum 4. Axial skeleton including the vertebrae

4. Axial skeleton including the vertebrae Rationale: Paget's disease usually affects the axial skeleton, especially the vertebrae and skull. Besides the vertebrae and skull, the pelvis, femur, and tibia are other common sites of the disease. Skull involvement and deformed facial bones frequently occur.

A nurse is evaluating goal achievement for a client in traction with impaired physical mobility. The nurse determines that the client has not successfully met all of the goals formulated if which of the following outcomes was noted? 1. Equal calf measurements bilaterally 2. Active range of motion (ROM) of uninvolved joints 3. Intact skin surfaces 4. Bowel movement every 5 days

4. Bowel movement every 5 days

Which of the following clients is at risk for developing thyrotoxicosis?

A client with Graves' disease who is having surgery

A nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder?

Polyuria

A nurse is reinforcing instructions to a client newly diagnosed with diabetes mellitus regarding insulin administration. The health care provider has prescribed a mixture of NPH and regular insulin. The nurse should stress that the first step is to:

Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

A client with hypoparathyroidism has hypocalcemia. The nurse avoids giving the client the prescribed vitamin and calcium supplement with which of the following liquids?

Milk

A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse focuses on which potential problem for this client?

Dehydration

A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, would the nurse determine as being likely related to the manifestations of this disorder?

Depression

A nurse is reinforcing dietary instructions to a client newly diagnosed with diabetes mellitus. The nurse instructs the client that it is best to:

Eat meals at approximately the same time each day.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis?

Elevated blood glucose and low plasma bicarbonate

When caring for a client diagnosed with pheochromocytoma, what information should the nurse know when assisting with planning care?

Excessive catecholamines are released.

A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem?

Fear about impending surgery

A comatose client with an admitting diagnosis of diabetic ketoacidosis (DKA) has a blood glucose of 368 mg/dL, arterial pH of 7.2, arterial bicarbonate of 14 mEq/L, and a positive for serum ketones. The diagnosis is supported by which noted data?

Fruity breath odor

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a health care provider's prescription?

IV infusion containing 5% dextrose

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic syndrome (HHNS) is made. The nurse who is assisting to care for the client obtains which of the following immediately in preparation for the treatment of this syndrome?

IV infusion of normal saline

A client has been taking prednisone for 3 years to treat symptoms of lupus erythematosa. She is scheduled for abdominal hysterectomy because of menorrhagia. The nurse plans care realizing that postoperatively the client is at risk for which condition?

Increased likelihood of surgical site infection

A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which of the following to perform the procedure properly?

Let the arm hang dependently and milk the digit.

A nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize?

Monitor blood glucose levels frequently.

A nurse reviews a plan of care for a postoperative client following a thyroidectomy and notes that the client is at risk for breathing difficulty. Which of the following nursing interventions will the nurse suggest to include in the plan of care?

Monitor neck circumference frequently.

Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma?

Monitor the client's blood pressure.

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem?

Obtaining dark glasses for the client

A nurse is caring for a client with a diagnosis of myasthenia gravis. The health care provider plans to perform an Enlon test on the client to determine the presence of cholinergic crisis. In addition to planning care for the client during this testing, which of the following will the nurse ensure is at the bedside?

Oxygen equipment

A nurse is caring for a postoperative client who is being monitored by pulse oximetry. Which of the following is an expected measurement determined by the pulse oximeter?

Oxygen saturation 95% to 100%

A nurse is caring for a client with a diagnosis of hypoparathyroidism. The nurse reviews the laboratory results drawn on the client and notes that the calcium level is extremely low. The nurse would expect to note which of the following on data collection of the client?

Positive Trousseau's sign

The anticipated intended effect of fludrocortisone acetate (Florinef) for the treatment of Addison's disease is to:

Promote electrolyte balance.

A nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which of the following actions should the nurse plan to take first?

Recheck the vital signs in 15 minutes.

A client is in metabolic acidosis caused by diabetic ketoacidosis (DKA). The nurse prepares for the administration of which of the following medications as a primary treatment for this problem?

Regular insulin

A nurse is preparing a client for surgery. Which of the following would be a component of the plan of care?

Review the results of the preoperative laboratory studies.

A health care provider has prescribed propylthiouracil (PTU) for a client with hyperthyroidism, and the nurse assists in developing a plan of care for the client. A priority nursing measure to be included in the plan regarding this medication is to monitor the client for:

Signs and symptoms of hypothyroidism

A nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care, knowing that which problem has the highest priority for this client?

The possibility of injury as a result of decreased sensation in the legs and feet

A nurse is reviewing the preoperative orders of a client with a colon tumor who is scheduled for abdominal perineal resection. The nurse notes that the health care provider has prescribed neomycin sulfate (Mycifradin) for the client. The nurse determines that this medication has been prescribed:

To decrease the bacteria in the bowel

Glucagon hydrochloride injection would most likely be prescribed for which disorder?

Type 1 diabetes mellitus

A nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to most carefully monitor which of the following parameters during the next hour?

Urinary output of 20 mL/hr

During routine postoperative assessment of a client who has undergone hypophysectomy, the client complains of thirst and frequent urination. Knowing the expected complications of this surgery, the nurse would next check the:

Urine specific gravity

A nurse has reinforced dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse instructs the client to include which of the following items in the diet?

Vegetables

A nurse is caring for a client with pheochromocytoma. The client is scheduled for an adrenalectomy. During the preoperative period, the priority nursing action would be to monitor the:

Vital signs

A nurse is caring for a client immediately following a total abdominal hysterectomy. The nurse anticipates that which of the following will be the priority in the first 24 hours following surgery?

pain

A client has just been admitted with a diagnosis of myxedema coma. If all of the following interventions were prescribed, the nurse would place highest priority on completing which of the following first?

Administering oxygen

A nurse is reviewing the prescriptions of a client diagnosed with diabetes mellitus who was admitted because of an infected foot ulcer. Which health care provider's prescription supports the treatment of this condition?

An increased amount of NPH daily insulin

A client has an intravenous infusion (IV) started before surgery for a right below-the-knee amputation. In addition to the intravenous infusion, blood is drawn and a surgical skin preparation is done. The nurse anticipates that the client is likely to experience which psychosocial problem in the preoperative period?

Anxiety

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which of the following is the appropriate nursing action?

Apply Montgomery ties.

A nurse is reviewing the postoperative prescriptions for a client who had a transsphenoidal hypophysectomy. Which health care provider's prescription, if noted on the record, indicates the need for clarification?

Apply a loose dressing if any clear drainage is noted.

A nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care?

Apply a moisturizing lotion to dry feet, but not between the toes.

A nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which of the following is the initial action?

Apply a sterile dressing soaked with normal saline to the wound.

A nurse is assisting in providing surgical instructions to a preoperative client. Which instruction would be most appropriate to include in the preoperative plan of care?

Coughing and deep breathing exercises

A client is admitted to the surgical unit postoperatively with a wound drain (Hemovac) in place. Which of the following nursing actions would the nurse avoid in the care of the drain?

Curl the drain tightly and tape it firmly to the body.

A nurse is caring for a client with pheochromocytoma. The client asks for a snack and something warm to drink. The appropriate choice for this client to meet nutritional needs would be which of the following?

Graham crackers and warm milk

A client with Addison's disease asks the nurse how a newly prescribed medication, fludrocortisone acetate (Florinef), will improve the condition. When formulating a response, the nurse should incorporate that a key action of this medication is to:

Help restore electrolyte balance.

In planning nutrition for the client with hypoparathyroidism, which diet would be appropriate?

High in calcium and low phosphorous

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which of the following findings would the nurse note as being consistent with this diagnosis?

High serum glucose level and low serum bicarbonate level

A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse understands that which of the following diets would likely be prescribed for this client?

High-sodium diet

A nurse is reviewing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?

"I can eat foods that contain potassium."

When the nurse is teaching a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective?

"I will notify my health care provider if my blood glucose level is greater than 250 mg/dL."

Which of the following statements made by the nursing student demonstrates an understanding of the hormone oxytocin?

"It causes contractions of the uterus during birth."

A client who currently underwent abdominal surgery experiences an evisceration. Which statement made by the client supports this diagnosis?

"It felt like something just slit me wide open."

A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband?

"It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."

A nurse is planning to instruct a client with diabetes mellitus who has hypertension about "sick day management." Which of the following does the nurse avoid putting on a list of easily consumed carbohydrate-containing beverages for use when the client cannot tolerate food orally?

Mineral water

A nurse is changing an abdominal dressing on a client with an open incision and notes the presence of sanguineous drainage. Which nursing action would be appropriate?

Notify the registered nurse.

A nurse is monitoring the results of periodic serum laboratory studies drawn on a client with diabetic ketoacidosis (DKA) receiving an insulin infusion. The nurse determines that which of the following values needs to be reported?

Potassium 3.1 mEq/L

A nurse is caring for a client experiencing thyroid storm. Which of the following would be a priority concern for this client?

Potential for cardiac disturbances

A client with diabetes mellitus visits the health care clinic. The client previously had been well controlled with glyburide (Diabeta), but recently, the fasting blood glucose has been running 180 to 200 mg/dL. Which of the following medications, if added to the client's regimen, may be contributing to the hyperglycemia?

Prednisone

What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease?

Provide a restful environment.

A nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin-human (Cibacalcin). Which outcome has the highest priority regarding this medication?

Reaching normal serum calcium levels

A nurse is collecting data regarding a client after a thyroidectomy and notes that the client has developed hoarseness and a weak voice. Which nursing action is appropriate?

Reassure the client that this is usually a temporary condition.

A nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which of the following activities in the nursing care plan for the client on the day of surgery?

Report immediately any slight increase in blood pressure or pulse.

A client has returned to the nursing unit following abdominal hysterectomy. To most effectively gather data on the client's postoperative bleeding, the nurse will implement which intervention?

Rolling the client to one side to view bedding

A nurse is caring for a postoperative client who has a drain inserted into the surgical wound. Which of the following actions would the nurse avoid in the care of the drain?

Secure the drain by curling or folding it and taping it firmly to the body.

A nurse is assisting in caring for a client in transfer from the post-anesthesia care unit following nasal surgery. Nasal packing and a mustache dressing are in place. The nurse places the client in which position to best reduce swelling?

Semi-Fowler's

A nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

Shakiness

A nurse is caring for a postoperative adrenalectomy client. Which of the following does the nurse specifically monitor for in this client?

Signs and symptoms of hypovolemia

A nurse is caring for a client with type 1 diabetes mellitus who is hyperglycemic. Which problem would the nurse consider first, when planning care for this client?

Signs of dehydration

A nurse provides preoperative teaching to a client who will wear an abdominal binder postoperatively following abdominal surgery. Which should the nurse include in the preoperative teaching plan?

Sit up for coughing while splinting the incision.

A nurse is caring for a client with hypothyroidism who is overweight. Which food items would the nurse suggest to include in the plan?

Skim milk, apples, whole-grain bread, and cereal

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be:

Slightly higher than the normal value

A nurse is explaining the universal protocol for preventing wrong site, wrong procedure, and wrong person surgery to a group of nursing students. The nurse explains that site marking involves:

The surgeon marking the area of the operative procedure

A nurse is discussing foot care with a diabetic client and spouse. The nurse includes which of the following during this informational session?

The toenails should be cut straight across.

A nurse in the health care provider's office is measuring vital signs on a postoperative client who underwent mastectomy of her right breast 2 weeks ago. The client tells the nurse that she is very concerned because she has numbness in the area of the surgery and along the inner side of the arm from the armpit to the elbow. The nurse should tell the client that:

These sensations dissipate over several months and usually resolve after 1 year.

A nurse is monitoring a client following a thyroidectomy for signs of hypocalcemia. Which of the following signs, if noted in the client, likely indicates the presence of hypocalcemia?

Tingling around the mouth

A nurse is explaining the concept of a time-out in the perioperative area. The purpose of a time-out is:

To allow the surgical team a chance to verbally verify its agreement about the client's name, the surgical procedure, and the site

A nurse is explaining the concept of time-out in the perioperative area to a group of nursing students, knowing that the purpose of time-out is:

To allow the surgical team a chance to verbally verify their agreement on the client's name, surgical procedure, and site

A client who is managing diabetes mellitus with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which of the following diets would be appropriate for the client?

Small frequent meals with protein, fat, and carbohydrates at each meal

A nurse is caring for a postoperative client who has been NPO, and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?

Suction equipment

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet for a postoperative client who has had general anesthesia?

Suction equipment

What equipment should the nurse plan to have at the bedside when initiating a clear liquid diet in a postoperative client who has had general anesthesia?

Suction equipment

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions to the client regarding the program. Which of the following should the nurse include in the teaching plan?

Take a blood glucose test before exercising.

A nurse is preparing to discharge a client who has had a parathyroidectomy. When teaching the client about the prescribed oral calcium supplement, what information should the nurse include?

Take the calcium 30 to 60 minutes following a meal.

A nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse?

Temperature

A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. The nurse should take which action first?

Test the drainage for glucose.

When caring for a client who is having clear drainage from his nares after transsphenoidal hypophysectomy, which action by the nurse is appropriate?

Test the drainage for glucose.

A nurse is teaching a client about the use of an incentive spirometer in the postoperative period. The nurse should include which of the following pieces of information in discussions with the client?

The best results are achieved when sitting at least halfway or fully upright.

A nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client's learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn?

The client complains of fatigue whenever the nurse plans a teaching session.

When positioning for a surgical procedure, the nurse understands that the client's respiratory system is most at risk for dysfunction when in which position?

Lithotomy

A client has been diagnosed with hypoparathyroidism. The nurse teaches the client to include foods in the diet that are:

Low in phosphorus and high in calcium

A nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which of the following actions should the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

A nurse is collecting data on a client with hyperparathyroidism. Which of the following questions would elicit the accurate information about this condition from the client?

"Are you experiencing pain in your joints?"

A preoperative client expresses anxiety to the nurse about the upcoming surgery. Which of the following responses by the nurse is most likely to stimulate further discussion between the client and the nurse?

"Can you share with me what you've been told about your surgery?"

A nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's disease. Which statement by the student indicates an accurate understanding of this disorder?

"Cushing's disease is characterized by an oversecretion of glucocorticoid hormones."

A health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further instruction?

"I can take any medications if I need to before the collection."

A client with arthritis is scheduled for a surgical knee joint replacement. The client will be admitted to the hospital on the day of the surgical procedure, and the nurse is providing instructions to the client regarding preparation for the surgical procedure. Which statement by the client indicates an understanding of the preoperative instructions?

"I cannot drink or eat anything after midnight on the night before surgery."

A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client would indicate an understanding of this occurrence?

"I forgot to take my usual afternoon snack yesterday."

Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?

"I had a radionuclide test done 3 days ago."

A nurse is providing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from a registered nurse to monitor drainage and perform dressing changes. Which statement by the client indicates a need for further instructions?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates the need for further teaching?

"I need to buy special dietetic foods."

A nurse is reinforcing home care instructions to a client with a diagnosis of Cushing's syndrome. Which statement reflects a need for further client education?

"I need to read the labels on any over-the-counter medications I purchase."

A nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for further teaching?

"I need to stop my insulin."

A nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement?

"I should check my blood glucose level before eating each meal, regardless of how much I eat."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of NPH insulin and exercise?

"I should not exercise in the late afternoon."

A nurse has reinforced home care measures to a client diagnosed with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction?

"I should perform my exercise at peak insulin time."

A nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen?

"The medication that I am taking helps release the insulin I already make."

A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which response by the nurse is appropriate?

"Usually, these physical changes slowly improve following treatment."

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which question would assist the nurse in the collection of data regarding the client's problem?

"What have you been eating and drinking since the surgery?"

A client with pheochromocytoma is scheduled for surgery and says to the nurse, "I'm not sure that surgery is the best thing to do." What response by the nurse is appropriate?

"You have concerns about the surgical treatment for your condition."

A nurse is caring for a client newly diagnosed with diabetes mellitus. The client asks the nurse whether eating at a restaurant will affect the diabetic control and whether this is allowed. Which nursing response is appropriate?

"You should order a half-portion meal and have fresh fruit for dessert."

A nurse has reinforced instructions to the client with hyperparathyroidism regarding home care measures related to exercise. Which statement by the client indicates a need for further instruction? Select all that apply.

*"I need to limit playing football to only the weekends." *"I should exercise in the evening to encourage a good sleep pattern."

The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which of the following questions would the nurse ask the client? Select all that apply. (Click on the Question Video button to view a video showing preparation procedures.)

*"What makes your pain better or worse?" *"What does the pain feel like?" *Where is the pain located?" *"How does the pain affect you?"

A nurse is reviewing a plan of care for a client with Addison's disease. The nurse notes that the client is at risk for dehydration and suggests nursing interventions that will prevent this occurrence. Which nursing intervention is an appropriate component of the plan of care? Select all that apply.

*Encouraging fluid intake of at least 3000 mL/day *Monitoring for changes in mental status *Monitoring intake and output

A nurse would expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply.

*Instruct the client about thyroid replacement therapy. *Encourage the client to consume fluids and high-fiber foods in the diet. *Instruct the client to contact the health care provider if episodes of chest pain occur.

A nurse notes in the medical record that a client with Cushing's syndrome is experiencing fluid overload. Which interventions should be included in the plan of care? Select all that apply.

*Monitoring daily weight *Monitoring intake and output *Monitoring extremities for edema *Maintaining a low-sodium diet

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing intervention(s) would the nurse take? Select all that apply.

*Notify the registered nurse. *Document the client's complaint. *Instruct the client to remain quiet. *Prepare the client for wound closure.

A nurse is preparing a list of cast care instructions for a client who just had a plaster cast applied to his right forearm. Which instructions should the nurse include on the list? Select all that apply. 1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.

1. Keep the cast and extremity elevated. 2. The cast needs to be kept clean and dry. 3. Allow the wet cast 24 to 72 hours to dry.

A client with right-sided weakness needs to learn how to use a cane. The nurse plans to teach the client to position the cane by holding it with the: 1. Left hand, and 6 inches lateral to the left foot 2. Right hand, and 6 inches lateral to the right foot 3. Left hand, and placing the cane in front of the left foot 4. Right hand, and placing the cane in front of the right foot

1. Left hand, and 6 inches lateral to the left foot

A nurse is caring for a client who was admitted to the hospital with a fractured right femur sustained from a fall 5 hours ago. The client's plan of care includes interventions related to monitoring for signs of fat embolism. The nurse provides appropriate care by: 1. Monitoring for signs of dyspnea 2. Monitoring the client's temperature regularly 3. Maintaining external rotation of the right leg 4. Educating the client to report paresthesia of the right lower leg

1. Monitoring for signs of dyspnea

A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of: 1. Muscle spasm in the area of the herniated disk 2. Pressure on the spinal cord 3. Pressure on the spinal nerve root 4. Excess cerebrospinal fluid production in the area

1. Muscle spasm in the area of the herniated disk

Which of the following interventions would be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm? 1. Place the left arm in a dependent position for 24 hours. 2. Monitor vital signs every 4 hours. 3. Monitor site for swelling, bleeding, hematoma. 4. Administer oral analgesics as needed.

1. Place the left arm in a dependent position for 24 hours.

A nurse is providing instructions to a client with osteoporosis regarding appropriate food items to include in the diet. The nurse tells the client that which food item would provide the least amount of calcium? 1. Pork 2. Seafood 3. Sardines 4. Plain yogurt

1. Pork

A client who has experienced a brain attack (stroke) has partial hemiplegia of the left leg. The straight-leg cane formerly used by the client is not sufficient any longer. The nurse determines that the client could benefit from the somewhat greater support and stability provided by a: 1. Quad cane 2. Wheelchair 3. Wooden crutch 4. Lofstrand crutch

1. Quad cane

A client has sustained multiple fractures in the left leg and is in skeletal traction. The nurse has obtained an overhead trapeze for the client's use to aid in bed mobility. The nurse would pay particular attention to monitoring for which of the following high-risk areas for pressure and breakdown? 1. Right heel 2. Left heel 3. Scapulae 4. Back of the head

1. Right heel

An older client with advanced Alzheimer's disease is placed in balanced suspension traction, and the health care provider expects to internally fixate the client's femur in 1 week. Based on this information, the nurse determines that the first priority relates to addressing which of the following nursing diagnoses? 1. Risk for constipation 2. Risk for activity intolerance 3. Impaired tissue integrity 4. Disturbed thought processes

1. Risk for constipation

A client with type 1 diabetes mellitus has had a left above-the-knee amputation. The nurse carefully inspects the residual limb for which of the following complications because of the history of diabetes? 1. Separation of wound edges 2. Pain 3. Edema of the stump 4. Hemorrhage

1. Separation of wound edges

A nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. The appropriate nursing action is to: Submit 1. Stay with the victim. 2. Assist the victim out of the automobile. 3. Leave the victim to call an ambulance. 4. Tell the victim to keep moving the leg to maintain circulation.

1. Stay with the victim.

A nurse has reviewed activity restrictions with a client who is being discharged following hip surgery and insertion of a femoral head prosthesis. The nurse determines that the client understands the material presented if the client states that it is acceptable to: 1. Use a raised toilet seat. 2. Bend carefully to put on socks and shoes. 3. Sit in chairs without arms for better mobility. 4. Exercise the leg past the point of 90-degree flexion.

1. Use a raised toilet seat. Rationale: The client who has had an insertion of a femoral head prosthesis should use a raised toilet seat. The client should also maintain the leg in a neutral, straight position when lying, sitting, or walking. The leg should not be adducted, internally rotated, or flexed more than 90 degrees. The client should sit in chairs that have arms so there will be assistance when the client is ready to rise from the sitting position. The client should avoid putting on own socks and shoes for 8 weeks after surgery because it would force the leg into acute flexion. (POSSIBLE MISTAKE ON EXAM)

A nurse has just supervised a newly diagnosed diabetes mellitus client self-inject NPH insulin at 7:30 ᴀᴍ. The nurse reviews the time frames for peak insulin action with the client, telling the client to be especially watchful for a hypoglycemic reaction between:

1:30 ᴘᴍ and 7:30 ᴘᴍ

A nurse is planning to teach the client with a left arm cast about measures to keep the left shoulder from becoming stiff. Which suggestion should the nurse include in the teaching plan? 1. "Use a sling on the left arm." 2. "Lift the left arm up over the head." 3. "Lift the right arm up over the head." 4. "Make a fist with the hand of the casted arm."

2. "Lift the left arm up over the head." Rationale: Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides isometric exercise to maintain muscle strength. Range of motion of the affected fingers is also a useful general measure. Lifting the right arm is of no particular value.

A client is admitted to the nursing unit after a left below-knee amputation following a crush injury to the foot and lower leg. The client tells the nurse, "I think I'm going crazy. I can feel my left foot itching." The nurse interprets the client's statement to be: 1. A normal response and indicates the presence of phantom limb pain 2. A normal response and indicates the presence of phantom limb sensation 3. An abnormal response and indicates that the client is in denial about the limb loss 4. An abnormal response and indicates that the client needs more psychological support

2. A normal response and indicates the presence of phantom limb sensation

A client is complaining of pain underneath a cast in the area of a bony prominence. The nurse interprets that this client may need to have: 1. The cast bivalved 2. A window cut in the cast 3. The cast replaced with an air splint 4. Extra padding put over this area of the cast

2. A window cut in the cast

A nurse is caring for a client following the application of a plaster cast because of a fractured left radius. The nurse monitors the neurovascular status of the client's casted extremity because: 1. The skin under the cast is at high risk for infection. 2. Compartment syndrome may lead to irreversible nerve and muscle tissue injury. 3. Alterations in the neurovascular status of the fingers may be early signs of fat embolism. 4. The client is at high risk of neurovascular compromise until the cast is completely dry.

2. Compartment syndrome may lead to irreversible nerve and muscle tissue injury.

A nurse is caring for a client who has had an open reduction with internal fixation (ORIF) with a posterior approach. The client has been prescribed hip precautions. The nurse plans to implement which of the following in the care of the client? Select all that apply. 1. Ensure the client doesn't bend the hips beyond 120 degrees. 2. Ensure the client doesn't sit or stand for long periods of time. 3. Ensure the client engages in rigorous exercise to maintain strength. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living.

2. Ensure the client doesn't sit or stand for long periods of time. 4. Ensure the client doesn't cross the legs past the midline of the body. 5. Ensure the client uses assistive/adaptive devices with activities of daily living.

A nurse is monitoring a confused older client admitted to the hospital with a hip fracture. Which of the following data obtained by the nurse could place the client at increased risk for disturbed thought processes? 1. Relatives at the bedside 2. Eyeglasses left at home 3. Familiar hospital setting 4. Hearing aid available and in working order

2. Eyeglasses left at home

A nurse has a prescription to place a client with a herniated lumbar intervertebral disk on bedrest to minimize the pain. The nurse plans to put the bed: 1. In high-Fowler's position with the foot of the bed flat 2. In semi-Fowler's position with the knee gatch slightly raised 3. In semi-Fowler's position with the foot of the bed flat 4. Flat with the knee gatch raised

2. In semi-Fowler's position with the knee gatch slightly raised Rationale: Clients with low back pain are often more comfortable when placed in semi-Fowler's position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler's position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Keeping the foot of the bed flat will enhance extension of the spine. Option 4 stretches the lower back.

A nurse is caring for an older client with a diagnosis of osteoarthritis. Which of the following would be least helpful for the client? Submit 1. Gentle regular exercise 2. Increasingly vigorous and high-impact exercise 3. A warm bath or shower early in the day 4. An individualized program of pain medication administration

2. Increasingly vigorous and high-impact exercise

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse's response is based on the understanding that this could result in: 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2. Injury to the brachial plexus nerves

A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which of the following as a high-risk area for pressure and breakdown? 1. Scapulae 2. Left heel 3. Right heel 4. Back of the head

2. Left heel

A nurse is caring for a client with a long bone fracture who is at risk for fat embolism. The nurse specifically monitors for the earliest signs of this complication by checking the client's: Select all that apply. 1. Renal system 2. Mental status 3. Mobility status 4. Respiratory function 5. Cardiovascular system

2. Mental status 4. Respiratory function

A client has undergone fasciotomy to treat compartment syndrome of the leg. The nurse should anticipate that which type of wound care will be prescribed for the fasciotomy site? 1. Dry, sterile dressings 2. Moist, sterile saline dressings 3. Hydrocolloid dressings 4. Half-strength povidone-iodine (Betadine) dressings

2. Moist, sterile saline dressings

A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse would intervene and correct the client if the nurse observed that the client: 1. Holds the cane on the right side 2. Moves the cane when the right leg is moved 3. Leans on the cane when the right leg swings through 4. Keeps the cane 6 inches out to the side of the right foot

2. Moves the cane when the right leg is moved Rationale: The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth great toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through.

A client with a left arm fracture exhibits loss of sensation in the left fingers, pallor, slow refill, and diminished left radial pulse. The nurse should take which of the following actions? Submit 1. Administer an analgesic. 2. Notify the registered nurse. 3. Check the circulation again in 30 minutes. 4. Provide range-of-motion exercises to the fingers of the left hand.

2. Notify the registered nurse.

Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 1. Decrease in height 2. Overall sclerotic lesions 3. Diminished lean body mass 4. Changes in structural bone tissue

2. Overall sclerotic lesions Rationale: Sclerotic lesions occur as bone resorption increases and results in replacement of original bone with fibrous material. This condition occurs in Paget's disease, an age-related disorder. Options 1, 3, and 4 identify normal age-related changes in the musculoskeletal system.

A client has just undergone spinal fusion after suffering a herniated lumbar disk. The nurse should avoid which of the following to maintain client safety after this procedure? 1. Head of bed flat 2. Overhead trapeze 3. Pillows under the length of the legs 4. Logrolling technique for repositioning

2. Overhead trapeze Rationale: Following spinal fusion, the head of the bed is generally kept in a flat position. The client is logrolled from side to side as prescribed. Pillows may be placed under the entire length of the legs by surgeon preference to relieve tension on the lower back. The use of an overhead trapeze is contraindicated because its use could promote twisting of the spine after surgery.

A client has undergone total hip replacement of the right hip, which was damaged by osteoarthritis. Which of the following should be included in the postoperative plan of care? 1. Assist the client to keep her legs as close together as possible. 2. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively. 3. Remind the client to use a handrail if she is lowering her hips into a 120-degree flexion. 4. Ensure the client receives her daily tablet of enoxaparin (Lovenox).

2. Partial weight bearing on the operative leg is usually permitted 72 hours postoperatively.

A client is complaining of skin irritation from the edges of a cast applied the previous day. The nurse should plan for which of the following actions? 1. Massaging the skin at the rim of the cast 2. Petaling the cast edges with adhesive tape 3. Using a rough file to smooth the cast edges 4. Applying lotion to the skin at the rim of the cast

2. Petaling the cast edges with adhesive tape

A nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse plans to use a: 1. Trochanter roll to prevent abduction while turning 2. Pillow to keep the right leg abducted during turning 3. Pillow to keep the right leg adducted during turning 4. Trochanter roll to prevent external rotation while turning

2. Pillow to keep the right leg abducted during turning

A nurse is caring for a client who sustained multiple fractures in a motor vehicle accident 12 hours ago. The client develops severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. The initial action of the nurse is to: 1. Place the client in a supine position. 2. Place the client in a Fowler's position. 3. Perform a neurological assessment. 4. Reassess the vital signs.

2. Place the client in a Fowler's position. Rationale: Clients with fractures are at risk for fat embolism. If the nurse suspects fat embolism, the nurse should place the client in a sitting (Fowler's) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The health care provider needs to be notified. A neurological assessment needs to be performed, but this would not be the initial nursing action. Vital signs will need to be taken, but this action may delay initial and required interventions.

A nurse is providing postprocedure instructions to a client returning home after arthroscopy of the shoulder. The nurse would encourage the client to: 1. Not eat or drink anything until the following morning. 2. Report to the health care provider the development of fever or redness and heat at the site. 3. Keep the shoulder completely immobilized for the rest of the day. 4. Resume regular full activity the following day.

2. Report to the health care provider the development of fever or redness and heat at the site.

A nurse is caring for a client who had an above-the-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage that has fallen off. The nurse immediately: 1. Calls the health care provider 2. Rewraps the residual limb with an elastic compression bandage 3. Applies ice to the site 4. Applies a dry sterile dressing and elevates it on one pillow

2. Rewraps the residual limb with an elastic compression bandage

A nurse is evaluating the pin sites of a client in skeletal traction. The nurse would be least concerned with which finding? 1. Inflammation 2. Serous drainage 3. Pain at a pin site 4. Purulent drainage

2. Serous drainage

A client who has had spinal fusion and insertion of hardware is extremely concerned about the perceived lengthy rehabilitation period. The client expresses concerns about finances and the ability to return to work. The nurse understands that the client's needs could best be addressed by referral to the: 1. Surgeon 2. Social worker 3. Physical therapist 4. Clinical nurse specialist

2. Social worker

A nurse has given the client instructions regarding crutch safety. The nurse determines that the client needs reinforcement of the instructions if the client states: 1. That use of someone else's crutches is a bad idea 2. That crutch tips will not slip, even when wet 3. That he or she needs to have spare crutches and tips available 4. That crutch tips should be inspected periodically for wear

2. That crutch tips will not slip, even when wet

A nurse is planning to reinforce instructions to the client about proper use of a thoracolumbosacral orthosis (TLSO) after spinal fusion with instrumentation. The nurse plans to include which of the following teaching points in discussion with the client? 1. The brace should be applied directly next to the skin. 2. The device is applied before getting out of bed in the morning. 3. The Velcro closures should be fairly loose to avoid constriction. 4. Areas of skin redness at the edges of the brace indicate a good, snug fit.

2. The device is applied before getting out of bed in the morning.

A client has a newly fractured fibula that is plaster casted in the emergency department. Because the client will need to use crutches, the nurse plans to teach the client which crutch-walking gait before discharge? 1. Four-point alternate gait 2. Three-point gait 3. Two-point gait 4. Swing-through gait

2. Three-point gait

A nurse is caring for a client with a diagnosis of gout. Which laboratory value would the nurse expect to note in the client? 1. Calcium level of 9 mg/dL 2. Uric acid level of 8 mg/dL 3. A uric acid level of 5 mg/dL 4. Phosphorus level of 3 mg/dL

2. Uric acid level of 8 mg/dL

A nurse is collecting data from a client who is being seen in the health care clinic. The client is complaining of unrelieved back pain that has persisted over the past 3 months. The nurse determines that which of the following harmful effects can occur as a result of uncontrolled muscle pain? 1. Anorexia 2. Weakness 3. Weight loss 4. Hypertension

2. Weakness

A licensed practical nurse (LPN) is assisting a high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The LPN tells the adolescents that the normal duration of the menstrual cycle is about:

28 days

A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client: 1. Holds the walker using the handgrips 2. Leans forward slightly when advancing the walker 3. Advances the walker with reciprocal motion 4. Supports body weight on the hands while advancing the weaker leg

3. Advances the walker with reciprocal motion Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks, thus the client would not be supporting the weaker leg with the walker during ambulation.

A client is treated in the health care provider's office after a fall, which sprained an ankle. Radiography has ruled out fracture. Before sending the client home, the nurse would plan to teach the client about which item that is to be avoided in the next 24 hours? 1. Resting the foot 2. Application of an Ace wrap 3. Application of a heating pad 4. Elevating the ankle on a pillow while sitting or lying down

3. Application of a heating pad

A client who has had a right total knee replacement asks the nurse how long the right leg must be kept in the continuous passive motion (CPM) machine. The nurse's response is based on the understanding that the device should be used: 1. Every other hour for 60 minutes 2. For 30 minutes out of every hour 3. As much as the client can tolerate 4. For 3 hours at a time, followed by 1 hour of rest

3. As much as the client can tolerate

A nurse is caring for the client who has had skeletal traction applied to the left leg. The client is complaining of severe left leg pain. Which action should the nurse take first? 1. Provide pin care. 2. Call the health care provider (HCP). 3. Check the client's alignment in bed. 4. Medicate the client with an analgesic.

3. Check the client's alignment in bed.

A client with a fractured femur is placed in skeletal traction. The nurse should do which to monitor for nerve injury? 1. Check the blood pressure. 2. Check the pin sites for drainage. 3. Check the neurovascular status of the affected extremity. 4. Monitor the client's ability to perform active range of motion to the affected extremity.

3. Check the neurovascular status of the affected extremity.

A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data indicates to the nurse favorable resolution of the fat embolus? 1. Arterial oxygen level of 78 mm Hg 2. Minimal dyspnea 3. Clear chest x-ray 4. Oxygen saturation 85%

3. Clear chest x-ray

A client has several fractures of the lower leg and has been placed in an external fixation device. The client is upset about the appearance of the leg, which is very edematous. The nurse determines that the client is experiencing which problem? 1. Feelings of isolation 2. Inability to tolerate activity 3. Concerns about appearance 4. Inability to physically move about

3. Concerns about appearance

A nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed touch-down of the affected leg. The nurse tells the client to advance the: 1. Crutches and then both legs simultaneously 2. Crutches and the right leg, then advance the left leg 3. Crutches and the left leg, then advance the right leg 4. Left leg and right crutch, then right leg and left crutch

3. Crutches and the left leg, then advance the right leg Rationale: A three-point gait requires good balance and arm strength. The crutches are advanced with the affected leg, and then the unaffected leg is moved forward. Option 4 describes a two-point gait. Option 1 describes a swing-to gait. Option 2 describes the three-point gait used for a right leg problem.

A nurse is talking to a client who underwent a below-the-knee amputation 2 days earlier. The client says to the nurse, "I hate looking at this; I feel that I'm not even myself anymore." The nurse understands that the client is experiencing which problem? 1. Self-care deficit 2. Ineffective coping 3. Disturbed body image 4. Ineffective health maintenance

3. Disturbed body image

A client seeks treatment in the emergency department for a lower leg injury. There is visible deformity to the lower aspect of the leg, and the injured leg appears shorter than the other. The area is painful, swollen, and beginning to become ecchymotic. The nurse interprets that this client has experienced a: 1. Strain 2. Sprain 3. Fracture 4. Contusion

3. Fracture

A nursing instructor asks a nursing student about the risk factors associated with osteoporosis. The instructor tells the student that she needs to read and learn about this disorder if the student states that which of the following is an associated risk factor? 1. Postmenopausal age 2. Family history of osteoporosis 3. High-calcium diet consumption 4. Long-term use of corticosteroids

3. High-calcium diet consumption

A nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the priority? 1. Take a set of vital signs. 2. Call the radiology department. 3. Immobilize the leg before moving the client. 4. Reassure the client that everything will be fine.

3. Immobilize the leg before moving the client.

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by: 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The newness of the fracture

3. Impaired tissue perfusion

A nurse is caring for a comatose client at risk for fat embolism because of a fractured femur and pelvis sustained in a fall. Which of the following findings does the nurse identify as early signs of possible fat embolism? 1. Increased heart rate and increased oxygen saturation 2. Decreased heart rate and decreased respiratory rate 3. Increased heart rate and adventitious breath sounds 4. Decreased heart rate and increased restlessness

3. Increased heart rate and adventitious breath sounds

A nurse is caring for the client who has skeletal traction applied to the left leg. The client complains of severe left leg pain. The nurse checks the client's alignment in bed and notes that proper alignment is maintained. Which action should the nurse take next? 1. Medicate the client. 2. Provide pin care. 3. Notify the registered nurse. 4. Remove 2 pounds of weight from the traction.

3. Notify the registered nurse.

A nurse is checking the casted extremity of a client. The nurse would check for which of the following signs and symptoms indicative of infection? 1. Dependent edema 2. Diminished distal pulse 3. Presence of a "hot spot" on the cast 4. Coolness and pallor of the extremity

3. Presence of a "hot spot" on the cast

A client has been placed in Buck's extension traction. The nurse can provide for countertraction by: 1. Using a footboard 2. Providing an overhead trapeze 3. Slightly elevating the foot of the bed 4. Slightly elevating the head of the bed

3. Slightly elevating the foot of the bed

A nurse provides cast application instructions to a client who is going to have a plaster cast applied. The nurse determines that the client needs further instruction if the client states that: 1. The cast will give off heat as it dries. 2. The cast edges may be trimmed with a cast knife. 3. The client may bear weight on the cast in 30 minutes. 4. A stockinette will be placed over the leg area to be casted.

3. The client may bear weight on the cast in 30 minutes.

A nurse is preparing to teach a client how to safely use crutches. Before initiating the teaching the nurse collects data on the client. The priority data would include which of the following? 1. The client's fear related to the use of the crutches 2. The client's understanding of the need for increased mobility 3. The client's vital signs, muscle strength, and previous activity level of the client 4. The client's feelings about the restricted mobility

3. The client's vital signs, muscle strength, and previous activity level of the client

A nurse is teaching a client who is to have a gallium scan about the procedure. The nurse should include which of the following items as part of the instructions? 1. The client must stand erect during the filming. 2. The procedure takes about 15 minutes to perform. 3. The gallium will be injected intravenously 2 to 3 hours before the procedure. 4. The client should remain on bedrest for the remainder of the day after the scan.

3. The gallium will be injected intravenously 2 to 3 hours before the procedure.

A nurse is providing discharge instructions to a client following surgical treatment for carpal tunnel syndrome. Which statement by the client would indicate a need for further instruction? 1. "I should elevate my arm to reduce the swelling." 2. "I should use a sling to limit movement and keep my arm elevated." 3. "I should return to the health care provider in about ten days to have the sutures removed." 4. "I should perform pronation and supination exercises of my wrist starting twenty-four hours after surgery."

4. "I should perform pronation and supination exercises of my wrist starting twenty-four hours after surgery."

A nurse is assisting in preparing a client for discharge to home. Daily cold therapy has been prescribed for the client, and the nurse provides instructions about this treatment. Which statement by the client indicates adequate understanding of cold therapy treatment? 1. "I need to apply the cold pack for at least 60 minutes." 2. "I should check my pulse before using the ice on my joints." 3. "I can lie on the ice by placing it between the bed and my body." 4. "I should wrap the frozen ice pack in a warm towel to help adjust to the cold."

4. "I should wrap the frozen ice pack in a warm towel to help adjust to the cold."

A nurse has reinforced instructions with the client with a nonplaster (fiberglass) leg cast about cast care at home. The nurse determines that the client needs further instruction if the client makes which statement? 1. "I should avoid walking on wet, slippery floors." 2. "I'm not supposed to scratch the skin underneath the cast." 3. "It's all right to wipe dirt off the top of the cast with a damp cloth." 4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

4. "If the cast gets wet, I can dry it with a hair dryer turned to the warmest setting."

A client who is scheduled for surgery and who is to be placed in skeletal traction says to the nurse, "I'm not sure if I want to have this skeletal traction or if the skin traction would be best to stabilize my fracture." Based on the client's statement, the nurse should make which response to the client? 1. "Your fracture is very unstable. You will die if you don't have this surgery performed." 2. "There is no reason to be concerned. I have seen lots of these procedures." 3. "Skeletal traction is much more effective than skin traction in your situation." 4. "You have concerns about skeletal versus skin traction for your type of fracture?"

4. "You have concerns about skeletal versus skin traction for your type of fracture?"

A nurse has a prescription to get the client out of bed to a chair on the first postoperative day after total knee replacement. The nurse plans to do which of the following to protect the knee joint? 1. Obtain a walker to minimize weight bearing by the client on the affected leg. 2. Apply an Ace wrap around the dressing and put ice on the knee while sitting. 3. Lift the client to the bedside chair, leaving the continuous passive motion (CPM) machine in place. 4. Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting.

4. Apply a knee immobilizer before getting the client up, and elevate the client's surgical leg while sitting. Rationale: The nurse assists the client to get out of bed on the first postoperative day after putting a knee immobilizer on the affected joint for stability. The surgeon prescribes the weight-bearing limits on the affected leg. The leg is elevated while the client is sitting in the chair to minimize edema.

A nurse is caring for a client with a fractured tibia and fibula. Eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. The initial nursing action is to: 1. Contact the health care provider. 2. Elevate the casted leg. 3. Administer another dose of pain medication. 4. Check the neurovascular status of the toes on the casted leg.

4. Check the neurovascular status of the toes on the casted leg.

This morning a client sustained a right proximal fibula and tibia fracture that was casted in a long leg plaster cast. During evening rounds, the nurse notes that the right lower extremity capillary refill is greater than 3 seconds and the toes are edematous and dusky. The client states that the pain medication is not working anymore and that the right foot feels like it is asleep. The nurse analyzes the data and determines that the client's symptoms are indicative of: 1. Fat embolism 2. Volkmann's thrombosis 3. Venous thrombosis 4. Compartment syndrome

4. Compartment syndrome

A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states that he or she will: 1. Report any feelings of nausea or flushing. 2. Eat only small meals for the remainder of the day. 3. Ambulate at least three times before the end of the day. 4. Drink plenty of water for a day or two following the procedure.

4. Drink plenty of water for a day or two following the procedure. Rationale: There are no special restrictions following a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. The minimal amount of radioactivity of the isotope poses no hazards to the client or staff.

A nurse is caring for a client with osteoarthritis. The nurse collects data, knowing that which of the following is a clinical manifestation associated with the disorder? Submit 1. Morning stiffness 2. Positive rheumatoid factor 3. An elevated sedimentation rate 4. Dull aching pain in the affected joints

4. Dull aching pain in the affected joints

A nurse is assigned to care for a client with multiple traumas who is admitted to the hospital. The client has a leg fracture, and a plaster cast has been applied. In positioning the casted leg, the nurse should: 1. Keep the leg in a level position. 2. Elevate the leg for 3 hours, and put it flat for 1 hour. 3. Keep the leg level for 3 hours, and elevate it for 1 hour. 4. Elevate the leg on pillows continuously for 24 to 48 hours.

4. Elevate the leg on pillows continuously for 24 to 48 hours.

A nurse has provided instructions to a client with a herniated lumbar disk about proper body mechanics and other items pertinent to low back care. The nurse determines that the client needs further instructions if the client verbalizes that he or she will: 1. Increase fiber and fluids in the diet. 2. Bend at the knees to pick up objects. 3. Strengthen the back muscles by swimming or walking. 4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

4. Get out of bed by sitting straight up and swinging the legs over the side of the bed.

A nurse is providing care to a client with this type of cast. (Refer to figure.) The nurse documents that the client has a: 1. Short leg cast 2. Long leg cast 3. Body jacket cast 4. Hip spica cast

4. Hip spica cast

A nurse is collecting physical data of the musculoskeletal system on an assigned client. The nurse should document the presence of which of the following as a normal finding? 1. Presence of fasciculations 2. Atrophy on the client's dominant side 3. Atrophy on the client's nondominant side 4. Hypertrophy on the client's dominant side

4. Hypertrophy on the client's dominant side Rationale: Hypertrophy, or increased muscle size on the client's dominant side of up to 1 cm, is considered normal. Atrophy on either side is considered an abnormal finding. Fasciculations are fine muscle twitches that are not normally present.

A nurse is caring for a client following a total hip replacement. The client has been diagnosed with iron deficiency anemia. The nurse instructs the client to increase intake of which of the following foods? 1. Milk and yogurt 2. Potatoes and carrots 3. Apples and mangos 4. Lean beef and chicken liver

4. Lean beef and chicken liver

A nurse is discussing primary prevention measures to clients regarding osteoporosis. The nurse plans to tell the clients that which of the following is a primary prevention measure? 1. Applying nonskid strips on areas that get wet 2. Selecting shoes that have firm nonskid soles 3. Installing telephones in several rooms of the house 4. Maintaining body weight at or above minimum recommended levels

4. Maintaining body weight at or above minimum recommended levels

A nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states to report which early symptom of compartment syndrome? 1. Pain that is relieved only by an opioid analgesic 2. Pain that increases when the arm is dependent 3. Cold, bluish fingers 4. Numbness and tingling in the fingers

4. Numbness and tingling in the fingers

A nurse is caring for a client with osteoarthritis. The nurse monitors the client, knowing that which of the following is a clinical manifestation associated with the disorder? 1. An elevated platelet count 2. Symmetrical joint discomfort 3. Elevated antinuclear antibody levels 4. Pain that increases with activity and is relieved by rest

4. Pain that increases with activity and is relieved by rest

A nurse has provided instructions regarding specific leg exercises for the client immobilized in right skeletal lower leg traction. The nurse determines that the client needs further instruction if the nurse observes the client: 1. Pulling up on the trapeze 2. Flexing and extending the feet 3. Doing quadriceps-setting and gluteal-setting exercises 4. Performing active range of motion (ROM) to the right ankle and knee

4. Performing active range of motion (ROM) to the right ankle and knee

A nurse is caring for a client who has a cast applied to the left lower leg. On data collection of the client, the nurse notes the presence of skin irritation from the edges of a cast. Which nursing intervention is appropriate? 1. Massage the skin at the edges of the cast. 2. Contact the health care provider. 3. Place a small face cloth in the cast around the edges of the cast. 4. Petal the cast edges with adhesive tape.

4. Petal the cast edges with adhesive tape.

A nurse is preparing a plan of care for a client in skeletal leg traction with an overbed frame. Which nursing intervention should be included in the plan of care to best assist the client with positioning in bed? 1. Encourage the client to pull up by pushing with the unaffected leg on the bed mattress. 2. Use the assistance of four nurses to reposition the client. 3. Place a draw sheet under the client for pulling the client up in bed. 4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

4. Place a trapeze on the bed to provide a means for the client to lift the hips off the bed.

A client with a hip fracture asks the nurse why Buck's extension traction is being applied before surgery. The nurse's response is based on the understanding that Buck's extension traction primarily: 1. Allows bony healing to begin before surgery 2. Provides rigid immobilization of the fracture site 3. Lengthens the fractured leg to prevent severing of blood vessels 4. Provides comfort by reducing muscle spasms and provides fracture immobilization

4. Provides comfort by reducing muscle spasms and provides fracture immobilization Rationale: Buck's extension traction is a type of skin traction often applied after hip fracture, before the fracture is reduced in surgery. It reduces muscle spasms and helps immobilize the fracture. It does not lengthen the leg for the purpose of preventing blood vessel severance. It also does not allow for bony healing to begin.

A nurse has provided instructions to the client returning home after arthroscopy of the knee. The nurse determines that the client understands the instructions if the client states that he or she will: 1. Resume regular exercise the following day. 2. Stay off of the leg entirely for the rest of the day. 3. Refrain from eating food for the remainder of the day. 4. Report fever or site inflammation to the health care provider.

4. Report fever or site inflammation to the health care provider.

A client with diabetes mellitus has had a right below-knee amputation. The nurse would be especially vigilant in monitoring for which of the following because of the client's history of diabetes mellitus? 1. Hemorrhage 2. Edema of residual limb 3. Slight redness of incision 4. Separation of wound edges

4. Separation of wound edges

A client is fearful about having an arm cast removed. Which of the following actions by the nurse would be the most helpful? 1. Telling the client that the saw makes a frightening noise 2. Reassuring the client that no one has had an arm lacerated yet 3. Stating that the hot cutting blades cause burns only very rarely 4. Showing the client the cast cutter and explaining how it works

4. Showing the client the cast cutter and explaining how it works

A nurse is one of several people who witness a vehicle hit a pedestrian at a fairly low speed on a small street. The individual is dazed and tries to get up, and the leg appears fractured. The nurse would plan to: 1. Try to manually reduce the fracture. 2. Assist the person to get up and walk to the sidewalk. 3. Leave the person for a few moments to call an ambulance. 4. Stay with the person and encourage the person to remain still.

4. Stay with the person and encourage the person to remain still.

A client has slight weakness in the right leg. Based on this information, the nurse determines that the client would benefit most from the use of a: 1. Walker 2. Wooden crutch 3. Lofstrand crutch 4. Straight-leg cane

4. Straight-leg cane

A health care provider has given a prescription for dietary iron supplements to the client with osteoporosis who has an iron deficiency anemia. The nurse suggests that the client do which of the following to enhance compliance with therapy? 1. Decrease fluid intake. 2. Decrease dietary fiber. 3. Chew the tablet thoroughly. 4. Take the medication following a meal.

4. Take the medication following a meal.

A client who is learning to use a cane is afraid it will slip with ambulation, causing a fall. The nurse provides the client with the greatest reassurance by telling the client that: 1. Canes prevent falls, not cause them. 2. The physical therapist will determine if the cane is inadequate. 3. The cane would help to break a fall, even if the client does slip. 4. The cane has a flared tip with concentric rings to provide stability.

4. The cane has a flared tip with concentric rings to provide stability.

A nurse plans dietary measures for a client with osteomalacia, knowing that the client is deficient in which of the following? 1. Vitamin A 2. Vitamin B 3. Vitamin C 4. Vitamin D

4. Vitamin D

A client has a fiberglass (nonplaster) cast applied to the lower leg. The client asks the nurse when he will be able to walk on the cast. The nurse replies that the client will be able to bear weight on the cast: 1. In 24 hours 2. In 48 hours 3. In approximately 8 hours 4. Within 20 to 30 minutes of application

4. Within 20 to 30 minutes of application

A nurse is caring for a client who had a below-the-knee amputation of the right leg and has a cast on the residual limb. The client calls the nurse and reports that the cast fell off. The nurse immediately: 1. Replaces the cast with a new one 2. Contacts the surgeon 3. Documents the findings 4. Wraps the residual limb with an elastic compression bandage

4. Wraps the residual limb with an elastic compression bandage

A nurse is caring for a client with Addison's disease. The nurse checks the vital signs and determines that the client has orthostatic hypotension. The nurse determines that this finding relates to which of the following?

A decreased secretion of aldosterone

While collecting data on a client being prepared for an adrenalectomy, the nurse obtains a temperature reading of 100.8° F. The nurse analyzes this temperature reading as:

A finding that needs to be reported immediately

A nurse is monitoring a client receiving glipizide (Glucotrol). Which outcome indicates an ineffective response from the medication?

A glycosylated hemoglobin level of 12%

A nurse receives a client in the surgical unit who was transferred from the postanesthesia care unit. The nurse checks the client for which of the following first?

A patent airway

A nurse is monitoring an adult client for postoperative complications. Which of the following would be the most indicative of a potential postoperative complication that requires further observation?

A urinary output of 20 mL/hour

A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and Regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease?

Adjust insulin according to capillary blood glucose levels.

A nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to plan to prepare to:

Administer intravenous (IV) regular insulin.

When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should plan to do which of the following in the initial care of this wound?

Apply a sterile dressing soaked with normal saline.

A nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which of the following is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?

Apply the safety strap 2 inches above the knees.

A nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client's fears and misconceptions about surgery, the nurse should:

Ask the client to discuss information known about the planned surgery.

The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period?

Bleeding

A client is admitted with a diagnosis of pheochromocytoma. The nurse would monitor which of the following to detect the most common sign of pheochromocytoma?

Blood pressure

A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse includes which priority item in the preoperative teaching plan for the client?

Blowing the nose following surgery is prohibited.

A nurse is caring for a postoperative client who had a pelvic exenteration. The health care provider has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks which of the following before administering the clear liquids?

Bowel sounds

A nurse participating in a free health screening at the local mall obtains a random blood glucose level of 200 mg/dL on an otherwise healthy client. The nurse tells the client to do which of the following as a next step?

Call the health care provider to have the value rechecked as soon as possible.

The wife of a client with diabetes mellitus who takes insulin calls the nurse in a health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which of the following should the nurse tell the woman to do first?

Check his blood glucose level.

A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. The nurse would immediately:

Check the client's capillary blood glucose.

A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client's hourly urine output is 25 mL. Based on this finding, the first action of the nurse would be to:

Check the client's overall intake and output record.

Following hypophysectomy, a client complains of being very thirsty and having to urinate frequently. The initial nursing action is to:

Check the urine specific gravity.

An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission?

Chlorpropamide

A nurse working on an endocrine nursing unit understands that which correct concept is used in planning care?

Clients who have hyperparathyroidism should be protected against falls.

A client's preoperative vital signs are temperature 98.6° F orally, apical pulse 80 beats per minute with a regular rhythm, respiration rate 22 breaths per minute, and blood pressure 168/94 mm Hg in the right arm. Based on the interpretation of these findings, which action should the nurse take first?

Compare these values to those recorded previously.

A nurse is caring for a client with pheochromocytoma. Which data would indicate a potential complication associated with this disorder?

Congestion heard on auscultation of the lungs

A nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which of the following nursing actions should be performed?

Continue to monitor the vital signs.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. The appropriate intervention to decrease the client's anxiety would be to:

Convey empathy, trust, and respect toward the client.

A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the surgeon and anticipates that the surgeon will prescribe which of the following?

Discontinue the aspirin 48 hours before the scheduled surgery.

A nurse is providing instructions to a client and family regarding home care following cataract removal from the left eye. The nurse would provide the client with which of the following pieces of information about positioning in the postoperative period?

Do not sleep on the left side.

A nurse is caring for a client following an abdominal hysterectomy performed 1 day ago. An intravenous (IV) line is infusing and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse should appropriately:

Document the finding and continue to check for bowel sounds.

A nurse is caring for a client diagnosed with hyperparathyroidism who is prescribed furosemide (Lasix). The nurse reinforces dietary instructions to the client. Which of the following is an appropriate instruction?

Drink at least 2 to 3 L of fluid daily.

A client has a blood glucose level drawn for suspected hyperglycemia. After interviewing the client, the nurse determines that the client ate lunch approximately 2 hours before the blood specimen was drawn. The laboratory reports that the blood glucose to be 180 mg/dL, and the nurse analyzes this result to be:

Elevated from the normal value

A nurse has admitted a client to the clinical nursing unit following a right mastectomy. The nurse plans to place the right arm in which of the following positions?

Elevated on one or two pillows

A nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the symptoms of hypoglycemia. Which symptoms will the nurse review?

Elevated pulse; shakiness; and cool, clammy skin

A nurse is preparing the client for transfer to the operating room (OR). The nurse should take which of the following actions in the care of this client at this time?

Ensure that the client has voided.

A maternity nursing instructor asks a nursing student to identify the hormones that are produced by the ovaries. Which of the following, if identified by the student, indicates an understanding of the hormones produced by this endocrine gland?

Estrogen and progesterone

A nursing student notes in the medical record that a client with Cushing's syndrome is experiencing body image disturbances. The need for additional education regarding this problem is identified when the nursing student suggests which nursing intervention?

Evaluating the client's understanding that the body changes need to be dealt with

A nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which of the following signs and symptoms, if noted in the client, will alert the nurse to the presence of this crisis? Select all that apply.

Fever Sweating Agitation

A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 ᴀᴍ. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which of the following signs in the late afternoon?

Hunger; shakiness; and cool, clammy skin

A client with type 2 diabetes mellitus has a blood glucose of more than 600 mg/dL and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and would expect to note which of the following diagnoses?

Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

A nurse is caring for a client after thyroidectomy and monitoring for signs of thyroid storm. The nurse understands that which of the following is a manifestation associated with this disorder?

Hypotension

Which clinical manifestation should the nurse expect to note when assessing a client with Addison's disease?

Hypotension

A nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which of the following, if noted in the client, indicates signs and symptoms related to adrenal insufficiency? Select all that apply.

Hypotension Mental status changes Weakness Fever

A nurse is caring for a postoperative parathyroidectomy client. Which of the following would require the nurse's immediate attention?

Laryngeal stridor

A client is diagnosed with hyperparathyroidism. The nurse teaching the client about dietary alterations to manage the disorder tells the client to limit which of the following foods in the diet?

Ice cream

A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication should be included on the list?

Increased thirst

A nurse is assisting in caring for a client immediately following an abdominal surgical procedure who lost a significant amount of blood during surgery. Which finding would indicate a sign of a potential complication?

Increasing restlessness

A nurse is monitoring the status of the postoperative client. The nurse would become most concerned with which of the following signs, which could indicate an evolving complication?

Increasing restlessness

A nurse monitors a postoperative client for signs of complications. Which of the following signs would the nurse determine to be indicative of a potential complication?

Increasing restlessness

A client with Cushing's disease is being admitted to the hospital after a stab wound to the abdomen. The nurse plans care and places highest priority on which potential problem?

Infection

A surgeon is performing an abdominal hysterectomy. Before the surgery is completed, the operating room nurse counts the sponges and notes that the sponge count is not correlating with the preoperative count. Which action by the nurse is important?

Informing the surgeon of the situation

A nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique will provide data necessary to support the admitting diagnosis?

Inspection of facial features

A nurse is providing discharge instructions to a client who had a unilateral adrenalectomy. Which of the following will be a component of the instructions?

Instructions about early signs of a wound infection

A client has an endocrine system dysfunction of the pancreas. The nurse anticipates that the client will exhibit impaired secretion of which of the following substances?

Insulin

A nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. The nurse appropriately tells the client that the hoarseness:

Is normal and will gradually subside

A nurse checks the sternotomy incision of a client on the second postoperative day after cardiac surgery. The incision shows some slight "puffiness" along the edges and is non-reddened with no apparent drainage. The client's temperature is 99° F (37.2° C) orally. The white blood cell (WBC) count is 7500 cells/mm3. The nurse interprets that the incision line:

Is slightly edematous but shows no active signs of infection

A client with newly diagnosed Cushing's syndrome expresses concern about personal appearance, specifically about the "buffalo hump" that has developed at the base of the neck. When counseling the client about this manifestation, the nurse should incorporate the knowledge that:

It may slowly improve with treatment of the disorder.

A male client recently diagnosed with diabetes mellitus requiring insulin tells the clinic nurse that he is traveling by air throughout the next week. The client asks the nurse for any suggestions about managing the disorder while traveling. The nurse tells the client to:

Keep snacks in carry-on luggage to prevent hypoglycemia during the flight.

Which nursing measure would be effective in preventing complications in a client with Addison's disease?

Monitoring the blood glucose

During a surgical procedure a nurse prevents a client's extremities from dangling over the sides of the table, knowing that this action may cause:

Nerve and muscle damage

A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the:

Patency of the airway

When a nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs, what information should the nurse obtain from the client?

Plan of injection rotation

A nurse monitors the postoperative client frequently for the presence of secretions in the lungs, knowing that accumulated secretions can lead to:

Pneumonia

After several diagnostic tests, a client is diagnosed with diabetes insipidus. The nurse understands that which symptom is indicative of this disorder?

Polydipsia

A nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited by the client, would indicate hyperglycemia and thus warrant health care provider notification?

Polyuria

A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care, understanding that which of the following accurately reflects this client's level of knowledge?

The client needs immediate education before discharge.

An older client with a history of hyperparathyroidism and severe osteoporosis is hospitalized. The nurse caring for the client plans first to address which problem?

The possibility of injury

A nurse checks the client's surgical incision for signs of infection. Which of the following would be indicative of a potential infection?

The presence of purulent drainage

A nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves:

The surgeon marking the area of the operative procedure

A nurse caring for a client scheduled for a transsphenoidal hypophysectomy to remove a tumor in the pituitary gland assists to develop a plan of care for the client. The nurse suggests including which specific information in the preoperative teaching plan?

Toothbrushing will not be permitted for at least 2 weeks following surgery.

A preoperative client is scheduled for adrenalectomy to remove a pheochromocytoma. The nurse would most closely monitor which of the following items in the preoperative period?

Vital signs

A client with diabetes mellitus is scheduled to have a fasting blood glucose level determined in the morning. The nurse tells the client not to eat or drink after midnight. When the client asks for further information, the nurse clarifies by stating that which of the following would be acceptable to take before the test?

Water

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the initial nursing action is to check the:

vital signs