Exam b

nurse is reviewing the medical record of a client who is receiving total parenteral nutrition for a malabsorption disorder. Which of the following findings should the nurse identify as an indication that the client's nutritional status is improving?

1 kg (2.2 lb) weight gain over the past 2 days

nurse is caring for a client who has renal calculi and is taking oxybutynin for pain. Which of the following findings should the nurse identify as an adverse effect of the medication?

: Distended bladder

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as being at risk for developing respiratory acidosis?

A client who has abdominal ascite

A nurse is teaching a client who recently lost his partner to a terminal illness. The client aska how his 4-year-old son is expected to react to the death of his partner. WHich of the following information should the nurse include in the teaching?

A preschooler often believes that death is reversible.

nurse is providing teaching about foot care to a client who has diabetes mellitus. Which of the following client statements indicates an understanding of the teaching?

A: "I'll wash my feet every day with soap and lukewarm wate

82. A nurse is evaluating a client's understanding of dietary teaching to treat hyperlipidemia. Which of the following menu choices indicates an understanding of the teaching?

A: A black bean burger on a whole grain bun

A nurse is admitting a clent who has pepetic ulcer disease and an upper gastrointestinal bleed. Which of the following manifestations should the nurse expect?

A: Dark, tarry stools

nurse in a community health clinic is reviewing data from the medical records of four clients. Which of the following communicable diseases requires reporting by the nurse?

A: Gonorrhea

nurse in an emergency department is assessing a client who displays manifestations of a small bowel obstruction. Which of the following findings should the nurse expect

Abdominal distention Rational: A client who has a small bowel obstruction will manifest abdominal distention from the buildup of intestinal contents that are unable to advance through the intestines D: Vomiting Rational: A client who has a small bowel obstruction can experience nausea and vomiting. Emesis might contain fecal contents. E: Hyperactive bowel sounds Rational: A client who has a small bowel obstruction will initially manifest increased bowel sounds, also known as borborygmi, as peristalsis heightens in an attempt to move the blocked intestinal contents forward

nurse is assessing a newly admitted client who has an intense fear of heights. Which of the following clinical names for this fear should the nurse document in the client's medical record?

Acrophobia

A nurse is reviewing the laboratory records of a client who has AIDS. Which of the following laboratory results should the nurse review to determine if the client is a risk for malnutrition?

Albumin level

nurse is caring for a school-age child who was admitted to the emergency department for acute asthma exacerbation. Which of the following actions should the nurse take first?

Apply humidified oxygen with a simple mask.

64. A nurse is reviewing the laboratory report of a client who is taking atorvastatin. Which of the following findings should the nurse identify as an indication that the medication is having an adverse effect?

Aspartate aminotransferase (AST) 45 units/L

87. A nurse is assessing a preschool-age child who has chickenpox. The parent asks the nurse how to treat the child's fever. Which of the following responses should the nurse make?

Avoid giving aspirin to your child."

A nurse is providing discharge teaching for a client who has a new diagnosis of COPD. Which of the following client statements indicates an understanding of the teaching?

B: "I will breathe out slowly through pursed lips if I feel short of breath

nurse is admitting an infant who has pertussis. Which of the following actions should the nurse take?

B: Initiate droplet precautions for the infant.

nurse is caring for a client who has a deep-vein thrombosis and is receiving heparin via continuous IV infusion. The client has a positive fecal occult blood test and abdominal tenderness upon palpation. Which of the following prescriptions should the nurse expect the provider to prescribe?

B: Protamine sulfate

67. A nurse is developing a plan of care for a client who is scheduled to have an induction of labor due to a fetal demise. Which of the following actions should the nurse include?

Bathe, diaper, and dress the child before bringing the newborn to the client.

nurse in a provider's office is assessing a client who is taking warfarin to treat atrial fibrillation. Which of the following findings should the nurse identify as an adverse effect that should be reported to the provider?

Black, tarry stools

nurse is assessing a client who has hypermagnesemia. Which of the following manifestations should the nurse expect?

Bradycardia

nurse is providing dietary teaching for a client who has GERD. The nurse should instruct the client to avoid which of the following items?

Caffeinated coffee

A nurse is assessing a 6-month-old infant who has gastroenteritis with mild dehydration. Which of th

Capillary refill greater than 2 seconds

nurse is assessing a client who has a new diagnosis of hypothyroidism. Which of the following manifestations should the nurse expect?

Cold intolerance

nurse is providing teaching about home care to the parent of a child who has pediculosis capitis. Which of the following information should the nurse include?

Comb the child's hair daily with an extra fine-tooth comb

A nurse is assessing a client who is receiving intravenous medications. Which of the following findings should the nurse identify as a manifestation of respiratory acidosis?

Confusion

92. A nurse on a pediatric unit is preparing an in-service for coworkers about failure to thrive in infants. Which of the following risk factors should the nurse include?

Congenital heart disease

A nurse is providing discharge teaching to a client about managing diverticulitis. Which of the following statements should the nurse include in the teaching?

Consume a clear liquid diet until symptoms resolve."

A nurse is caring for a client who has severe hypothermia. Which of the following actions should the nurse take?

Contact a specialized team to place the client on cardiopulmonary bypass

nurse is reviewing the laboratory results of a client who is receiving gentamicin for the treatment of an infection related to renal calculi. Which of the following findings should the nurse report immediately to the provider?

Creatinine 2.5 mg/dL

A nurse is teaching a client who has COPD about preventing pneumonia. Which of the following client statements indicates an understanding of the teaching?

D: "I will wash my hands whenever I come home from the grocery

1. A nurse is assessing a client for manifestations of left-sided heart failure. Which of the following findings should the nurse

D: Cool extremities

106. A nurse is counseling a client who recently lost her partner in a motor-vehicle crash. Which of the following reactions should the nurse identify as a part of the second stage of the grieving process?

D: Feeling anger toward family members

99. A nurse is caring for a client who has pneumonia. Which of the following actions is the priority for the nurse to take?

D: Observe the client perform incentive spirometry.

nurse is assessing a client who has peripheral arterial disease. Which of the following findings should the nurse expect?

Dependent rubor

A nurse is reviewing the medical record of a client who has decreased urinary output. Which of the following findings should the nurse identify as a risk factor for the development of pyelonephritis?

Diabetes mellitus

A nurse is planning discharge teaching for the parent of a newborn. Which of the following information should the nurse include?

Do not bathe your newborn immediately after she eats."

nurse is providing discharge teaching to the parents of a newborn about crib use. Which of the following statements should the nurse make?

Dressing your baby in a one-piece sleeper for bedtime will replace the need to use a blanket or a sheet."

A nurse is providing dietary teaching to a client who is a 13 week of gestation and has hyperemesis gravidarum. Which of the following statements should the nurse make?

Drink fluids between, rather than with, meals."

A nurse is developing a plan of care for a client who is 1 hr postoperative following open carpal tunnel release to treat a musculoskeletal injury. Which of the following interventions should the nurse include in the plan?

Elevate the client's arm above the heart.

A nurse is caring for a client who has developed cellulitis in a lower extremity. Which of the following actions should the nurse take?

Elevate the extremity 7.6 to 15.2 cm (3 to 6 in) above heart level.

nurse is assessing for adverse medication reactions with a client who reports taking more than the recommended dose of acetaminophen for the management of chronic pain. Which of the following findings should the nurse identify as an adverse effect of acetaminophen?

Elevated aspartate aminotransferase levels

A nurse is assessing an infant whose guardian reports, "My baby has been crying nonstop, has a fever, and has been pulling at her ear." Which of the following manifestations should the nurse expect for an infant who might have otitis media?

Enlarged postauricular lymph nodes

A nurse is caring for a client who has respiratory acidosis due to opioid oversedation. Which of the following actions should the nurse take first?

Ensure a patent airway using a chin-lift maneuver

nurse is caring for a client who has generalized anxiety disorder. Which of the following medications should the nurse plan to administer?

Escitalopram

A nurse is assessing a client who has acute cholecystitis. Which of the following findings should the nurse expect

Fever is correct. Rational: The nurse should expect to find a fever in the client who has acute cholecystitis due to the inflammatory process. B: Dyspepsia is correct. Rational: The nurse should expect to find dyspepsia or indigestion in the client who has acute cholecystitis due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder. E: Eructation is correct. Rational: The nurse should expect the client who has acute cholecystitis to exhibit eructation, or belching, due to the biliary stasis from conditions affecting the filling or emptying of the gallbladder.

A nurse is teaching a client who has a new diagnosis of peripheral neuropathy about foot care. Which of the following statements should the nurse include?

File your toenails straight across to prevent ingrown toenails."

A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following finding should the nurse monitor?

Flushed, dry skin

nurse is assessing a client who has generalized anxiety disorder and is experiencing a moderate level of anxiety. Which of the following manifestations should the nurse expect?

Focuses on the source of the anxiety

nurse is providing teaching to the parent of a school-age child who has a severe bee allergy and a new prescription for an epinephrine auto-injector. Which of the following instructions should the nurse include?

Give a second injection if the first fails to reverse your child's symptoms."

nurse is assessing a client for manifestations of GERD. Which of the following findings indicates to the nurse that the client might have GERD?

Globus

A nurse is reviewing the laboratory results of an adult male client who has hyperlipidemia and is making lifestyle changes to improve his cholesterol levels. Which of the following findings indicates to the nurse that the client has a

HDL 50 mg/dL

nurse is conducting a visual assessment for a client who is at risk for developing glaucoma. Which of the following should the nurse identify as a risk factor for this condition?

Heredity

nurse is participating in a health fair by providing screenings for osteoporosis. Which of the following should the nurse recognize as a risk factor for the disease?

Hip fracture 6 months ago

88. A nurse is preparing to administer medication to a client who has a history of hypertension. The nurse should identify that which of the following is administered for antihypertensive therapy?

Hydrochlorothiazide

A nurse is reviewing the medical record of a client who has age-related macular degeneration (AMD). Which of the following findings should the nurse identify as a risk factor for the visual impairment?

Hypertension

A nurse is caring for a client who is experiencing a hyperglycemic-hyperosmolar state related to complication of diabetes mellitus. Which of the following findings should the nurse expect?

Hypotension

nurse is providing teaching for a client who has peripheral neuropathy of the lower extremities. Which of the following client statements indicates an understanding of the teaching?

I should limit wearing the same shoes 2 days in a row.

nurse is teaching about ezetimibe with a client who has hyperlipidemia. Which of the following client statements indicates an understanding of the teaching?

I will return to have my cholesterol levels checked in 2 weeks."

31. A nurse is providing teaching about home care with an adolescent client who has a skin infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which of the following client statements indicates an understanding of the teaching?

I will soak in a bathtub filled one-fourth full of water with one-half cup of bleach."

nurse is assessing a school-age child who has asthma and shortness of breath. Which of the following assessment findings should the nurse identify as the priority?

Inaudible lung sounds

70. A nurse is assessing a client who has gestational diabetes and ketoacidosis. Which of the following manifestations should the nurse expect?

Increased urination

nurse is preparing to mix NPH insulin and insulin aspart in a single syringe for a client who has type 2 diabetes mellitus. Identify the sequence the nurse should follow.

Inject air into the vial equal to the amount of NPH insulin prescribed. D: Inject air into the vial equal to the amount of insulin aspart prescribed A: Withdraw the prescribed volume of insulin aspart into the syringe. C: Withdraw the prescribed volume of NPH insulin into the syringe.

A nurse is planning discharge for a postpartum client. The client tells the nurse she is having a subdermal implant placed for contraception at her 6 week follow-up examination and ask about the adverse effects of the implant. Which of the following manifestations should the nurse include?

Irregular bleeding

103. A nurse is assessing a client for manifestations of right-sided heart failure. Which of the following findings should the nurse expect?

Jugular vein distention

71. A nurse is providing teaching to a client about preventing hearing loss from trauma. Which of the following instructions should the nurse include in the teaching?

Keep your mouth open when sneezing."

nurse is reviewing a client's home medication list during admission to a long-term care facility. The nurse should identify that the client takes which of the following medications to manage osteoarthritis

Lidocaine 5% patches

nurse is providing teaching to a client who has calcium oxalate renal calculi. Which of the following statements should the nurse include in the teaching?

Limit the amount of spinach in your diet."

nurse is teaching a group of newly licensed nurses about risk factors for peptic ulcers. Which of the following risk factors should the nurse include in the teaching?

Long-term use of NSAIDs

A nurse is reviewing the medical record of a client who has AIDS and is experiencing anorexia. Which of the following medications should the nurse expect the provider to prescribe to reduce the client's risk of failure to thrive?

Megestrol

nurse is planning discharge teaching for the guardian of a child who had a cardiac catheterization. Which of the following instructions should the nurse include?

Monitor the site daily for drainage.

. A Nurse is assessing a 6-month-old infant who has bacterial pneumonia. Which of the following Manifestations Should the nurse expect?

Nasal flaring

A nurse is assessing a client who has an external fixator to the right lower arm following musculoskeletal trauma. Which of the following findings should indicate to the nurse that the client has developed compartment syndrome?

Numbness to the fingers on the right arm

nurse is caring for a client who has right-sided hemiparesis following a stroke. Which of the following images is an indication that the nurse is correctly assisting the client to ambulate?

Nurse on the right holding gait belt

A nurse is assessing a client for manifestations of heat stroke. Which of the following findings should the nurse expect?

Oliguria

A nurse is assessing a client who has renal calculi. For which of the following findings should the nurse notify the provider immediately?

Oliguria with bladder distention

nurse is assessing an 18-month-old toddler who has gastroenteritis with dehydration. The toddler is able to consume 3 mL of oral rehydration solution every 5 minutes but still has emesis and diarrhea. Which if the following medications should the nurse anticipate administering to the toddler?

Ondansetron

A nurse is teaching a client who has hypokalemia about nutrition management. Which of the following fruits should the nurse recommend as the best source of potassium?

One small orange

A nurse is providing teaching about home care to the parent of an adolescent who has infectious mononucleosis. Which of the following manifestations should the nurse instruct the parent to report to the provider?

Onset of abdominal pain

nurse is assessing a client who is experiencing diarrhea and vomiting and has a sodium level of 124 mEq/L. Which of the following manifestations should the nurse expect?

Orthostatic hypotension

A nurse is assessing a client who has musculoskeletal trauma following a motor-vehicle crash 2 days ago. Which of the following findings should the nurse report to the provider? Exhibit 1: Diagnostic Results Hct 42% Hgb 14 g/dL ECG Sinus tachycardia Exhibit 2: Graphic Record Temperature 38.3°C (100.9°F) Heart rate 106/min Respiratory rate 22/min Blood pressure 144/90 mm Hg Exhibit 3: Nurses' Notes Client reports pain level of 8 on a scale of 0 to 10 in casted left arm IV morphine administered 45 min ago Client is diaphoretic and anxious

Pain report

nurse is caring for a client who is experiencing an asthma attack. Which of the following procedures should the nurse use to assess the client's respiratory status?

Peak expiratory flow meter testing

A nurse is providing teaching about exercise to a client who has osteoarthritis. Which of the following information should the nurse include?

Perform exercise even on days when joints are painful

nurse is providing teaching to a client who has osteoporosis. Which of the following information should the nurse include in the teaching?

Perform exercises to strengthen the abdominal core

nurse is assessing a client in the triage room of an emergency department. Based on the client findings, which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Exhibit 1: Nurses' Notes Medical history of type 2 diabetes mellitus and hypertension. Reports weight loss, lethargy, and night sweats over the last 3 weeks. Cough with hemoptysis. Client traveled overseas 3 months prior. Exhibit 2: Graphic Record Blood pressure 110/62 mm Hg Heart rate 90/min Respiratory rate 24/min SaO2 95% Temperature 38.1° C (100.6° F) Exhibit 3: Diagnostic Results Casual blood glucose 132 mg/dL

Place a surgical mask on the client.

A nurse is teaching a group of newly licensed nurses about hypothermia and the care of a client who has frostbite to the fingers and toes from cold exposure. Which of the following information should the nurse include in the teaching about frostbite?

Place the affected areas of frostbite in a warm water bat

home health nurse is assessing a client who has COPD. The client has a respiratory rate of 22/min and reports shortness of breath. Which of the following actions should the nurse take first?

Place the client in high-Fowler's position.

7. A nurse is an emergency department is caring for a client who has appendicitis. Which of the following actions should the nurse take?

Place the client in semi-Fowler's position.

nurse is reviewing the laboratory results of an adult client who has metabolic alkalosis. Which of the following findings should the nurse expect?

Potassium 3 mEq/L

nurse is reviewing a client's medical record prior to a laparoscopic appendectomy. Which of the following findings should the nurse report to the provider?

Report of urinating small amounts twice daily

nurse in an emergency department is reviewing the laboratory report of a client who has hyperventilation. The client's ABG results are pH 7.50, PaCo2 29 mmHg, and HCO3 25 following acid-base imbalances?

Respiratory alkalosis

72. A nurse is assessing a client who has a partial obstruction of the large bowel. Which of the following manifestations should the nurse expect?

Ribbon-like stools

77. A nurse in a provider's office is reviewing the medical record of a client who has COPD. Which of the following findings is a priority for the nurse to report to the provider?

Sputum culture shows gram positive bacteria.

nurse is caring for a client who has possible appendicitis. Which of the following actions should the nurse take?

Start IV fluid replacement.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client until manifestations subside

95. A nurse is assessing a client who has deep-vein thrombosis (DVT) in the right lower extremity. Which of the following findings on the affected extremity should the nurse expect?

Swelling

nurse is reviewing the laboratory results of a client who is scheduled for surgery and notes a potassium level of 6 mEq/L. Which of the following ECG findings should the nurse expect?

Tall T waves

A nurse is assessing a client whose parent recently died. The nurse should identify that which of the following findings places the client at risk for maladaptive grieving?

The client lost his house in a house fire 1 month ago

nurse is planning care for a client following collection of admission data. Which of the following findings should the nurse identify as the priority client need?

The client reports coughing and a change of voice whenever he eats.

A nurse is assessing a client who has hyperthyroidism and has been taking methimazole for 6 months. Which of the following findings indicates a therapeutic response to the medication?

The client reports sleeping longer during the nig

A nurse is teaching about clonazepam with a young adult female client who has generalized anxiety disorder. Which of the following statements should the nurse include in the teaching?

This medication could cause you to have thoughts of self-harm."

nurse is performing a focused assessment on a client who has cholelithiasis and reports pain. Which of the following areas should the nurses assess?

Upper Right Quadrant

A nurse is assessing a client who has acute pyelonephritis. Which of the following findings should the nurse expect?

Urinary burning

A nurse is assessing a client who has developed Clostridium defficile as an adverse effect to ciprofloxacin. Which of the following medications should the nurse expect the provider to prescribe the treat the C. defficile?

Vancomycin

A nurse is reviewing the laboratory results of a client who is taking sulfasalazine to treat ulcerative colitis. Which of the following laboratory findings should the nurse identify as an adverse effect of sulfasalazine?

WBC count 4,000/mm3

A hospice nurse is visiting with a client following the death of her partner 1 month ago. The client is tearful and states she does not see how she can ever be happy again. Which of the following responses should the nurse make?

What are some of the best times with your partner that you remember?"

nurse is assessing a client who has generalized anxiety disorder and has been practicing adaptive use of coping mechanisms. Which of the following responses indicates the client's adaptive use of suppression?

avoid thinking about problems that worry me until I have time to focus on a solution."

nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching?

nurse is planning teaching for an adolescent who has exercise-induced asthma and has new prescriptions for cromolyn and albuterol inhalers. Which of the following instructions should the nurse plan to include in the teaching? A: Inhale the second puff of cromolyn 2 min after the first. B: Use the cromolyn following exercise if shortness of breath occurs.

A nurse is providing teaching for a client following cataract surgery. Which of the following statements indicates to the nurse that the client understands the teaching?

should avoid using the vacuum cleaner for several weeks."

nurse is providing teaching about home care with the parent of a child who has scabies. Which of the following statements by the parent indicates an understanding of the teaching?

should wash my child's bed linens and clothing in hot water and detergent."

nurse is providing teaching to a client who has a methicillin-resistant Staphylococcus aureus (MRSA) skin infection. WHich of the following client statements indicates an understanding of the management of antibiotic resistant infections?

will wash all uninfected skin areas with a fresh washcloth