Final PrepU
The nurse is providing education to a patient with iron deficiency anemia who has been prescribed iron supplements. What statement should the nurse include in patient education?
"Iron will likely cause your stools to darken in color."
A nurse working at a pediatric clinic is teaching a group of parents. A parent asks the nurse if it is okay to let the young child recover from a sore throat naturally, rather than bringing the child to the clinic for diagnosis and treatment. What is the nurse's best response?
"It may be streptococcal sore throat. Rheumatic heart disease can be prevented with early treatment."
The client asks the nurse what urine output has to do with cardiac function. What is the best response by the nurse?
"Poor urine output may indicate inadequate blood flow to the kidneys."
After an extensive diagnostic workup, a 64-year-old man has received a diagnosis of chronic obstructive pulmonary disease (COPD). He is eager to learn as much as possible about his new diagnosis and has asked the nurse numerous questions about his course of treatment and his prognosis. Which of the nurse's following statements is most accurate?
"There is no cure for COPD but there are several measures that can help you maintain your quality of life."
The nurse is caring for a client who is being discharged after insertion of a permanent pacemaker. The client, an avid tennis player, is scheduled to play in a tournament in 1 week. What is the best advice the nurse can give related to this activity?
"You will need to cancel this activity; you must restrict arm movement above your head for 2 weeks."
The nurse is monitoring a patient who is on heparin anticoagulant therapy. What should the nurse determine the therapeutic range of the international normalized ratio (INR) should be?
2.0-3.0
A nurse is caring for four patients. Which patient is most likely at a greater risk for the development of blindness?
A 58-year-old Caucasian woman with macular degeneration
Which of the following is accurate regarding status asthmaticus?
A severe asthma episode that is refractory to initial therapy
The nurse caring for a client with Ménière's disease needs to assist with what when the client is experiencing an attack?
ADLs
On auscultation, which finding suggests a right pneumothorax?
Absence of breath sounds in the right thorax
Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?
Acute pain related to sickle cell crisis
Which action should the nurse take first in caring for a client during an acute asthma attack?
Administer bronchodilator as ordered
A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:
An abnormal distention of the air spaces with destruction of the alveolar walls
Which term refers to chest pain brought on by physical or emotional stress and relieved by rest or medication?
Angina pectoris
A nurse is preparing a client for cardiac catheterization. The nurse knows that which nursing intervention must be provided when the client returns to the room after the procedure?
Assess the puncture site frequently for hematoma formation or bleeding
A patient has had cataract extractions and the nurse is providing discharge instructions. What should the nurse encourage the patient to do at home?
Avoid bending the head below the waist
A patient is seen in the emergency department (ED) with heart failure secondary to dilated cardiomyopathy. What key diagnostic test does the nurse assess to determine the severity of the patient's heart failure?
B-type natriuretic peptide (BNP)
A nurse caring for a patient with severe neutropenia would be primarily concerned about the patient's susceptibility to which of the following?
Bacterial infections
Which type of chest configuration is typical of a client with COPD?
Barrel chest
Which assessment finding would be most consistent with advanced emphysema?
Barrel-shaped chest
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?
Beans, dried fruits, and leafy, green vegetables
A nurse is completing a focused respiratory assessment of a child with asthma. What assessment finding is most closely associated with the characteristic signs and symptoms of asthma?
Bilateral wheezes
A patient has been admitted with endocarditis. The patient asks the nurse how the health care provider knows what medicines to order to kill the bacteria. The nurse knows that to find the most appropriate antibiotic treatment, what test would be the most helpful?
Blood cultures
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
Blood gases
A client diagnosed with a cataract comes into the clinic. What assessments should the nurse observe in this client?
Blurred or cloudy visual image
Which common problem of the upper extremity results from entrapment of the median nerve at the wrist?
Carpal tunnel syndrome
The nurse is caring for a client who has just returned from the cardiac catheterization laboratory following a coronary angioplasty. What is the nurse's priority assessment?
Check the temperature, color, and capillary refill of the affected extremity
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?
Chest pain and dyspnea
Analysis of the results of tonometry has resulted in a diagnosis of glaucoma, and the patient has been prescribed a regimen of therapeutic medications. The nurse is aware that the primary goal of these medications is to:
Decrease intraocular pressure (IOP)
The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic?
Diminished or absent pulses
Which assessment parameter is important for the client diagnosed with congestive heart failure?
Distended veins
The perioperative nurse is writing a care plan for a client who has returned from surgery 2 hours ago. Which measure should the nurse implement to most decrease the client's risk of developing pulmonary emboli (PE)?
Early ambulation
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency?
Elevate the legs periodically for at least 15 to 20 minutes
A nurse is evaluating the diagnostic study data of a client with suspected cystic fibrosis (CF). Which of the following test results is associated with a diagnosis of cystic fibrosis?
Elevated sweat chloride concentration
A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?
Elevated uric acid levels
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
Encouraging increased fluid intake
A nurse is caring for a client who has an MRI scheduled. What is the priority safety action prior to this diagnostic procedure?
Ensuring that there are no metal objects on or in the client
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases?
Extreme fatigue
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication?
Fat embolism syndrome
Which of the following eye disorders is caused by an elevated intraocular pressure (IOP)?
Glaucoma
When planning the care of a client with an implanted pacemaker, what assessment should the nurse prioritize?
Heart rate and rhythm
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia hypoventilation and hypoxemia
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock
A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?
Impaired gas exchange related to airflow obstruction
A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regime?
Improve venous return
A nurse is developing a nursing care plan for a client with peripheral arterial disease. Which of the following will be the priority nursing diagnosis?
Ineffective peripheral tissue perfusion
A client is diagnosed with deep vein thrombosis (DVT). Which nursing diagnosis should receive highest priority at this time?
Ineffective peripheral tissue perfusion related to venous congestion
A patient with acute myeloid leukemia (AML) has a neutrophil count that persists at less than 100/mm3. What should the nurse cautiously monitor this patient for?
Infection
Which term refers to a muscular, cramplike pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest?
Intermittent claudication
A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?
Iron
A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?
Lack of erythropoietin
A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize?
Lifestyle modifications and techniques for preventing thromboembolism
The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care?
Limit foods that are high in sodium
The nurse is caring for a client who is scheduled to undergo mechanical valve replacement. Client education should include which of the following?
Long-term anticoagulant therapy
The nurse would expect which of the following age-related change of the musculoskeletal system?
Loss of bone mass
An older adult patient has noticed a significant amount of vision loss in the last few years. What does the nurse recognize as the most common cause of visual loss in older adults?
Macular degeneration
Which classic symptom will the nurse assess for to detect the development of plantar fasciitis?
Morning heel pain
A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea
The nurse is caring for a client with aortic regurgitation. The nurse knows to expect what symptoms during the physical examination?
Orthopnea and dyspnea
A client being seen in the emergency department has labored respirations. Auscultation reveals inspiratory and expiratory wheezes. Oxygen saturation is 86%. The client was nonresponsive to an albuterol (Ventolin) inhaler and intravenous methylprednisolone (Solu-Medrol). The nurse administers the following prescribed treatment first:
Oxygen therapy through a non-rebreather mask
When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis?
Pain in the calf
The nurse is developing a plan of care for a patient with severe vertigo. What expected outcome statement would be a priority for this patient?
Patient will experience no falls due to balance disorder
Which cells are also known as thrombocytes?
Platelets
A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?
Potassium
The nurse is caring for a patient who has returned to the unit following a bronchoscopy. The patient is asking for something to drink. What criteria will determine when the nurse will allow the patient to drink fluids?
Presence of a cough and gag reflex
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client?
Preventing bone injury
Which medication is an antidote to heparin?
Protamine sulfate
A patient has been admitted to the medical unit because of an exacerbation of heart failure. Over the past hour, the patient has become increasingly restless, tachypneic, and short of breath, and pulse oximetry reveals SaO2 of 78%. Which of the following actions should the nurse prioritize?
Protecting the patient's airway and taking measures to promote gas exchange
Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)?
Pulse oximetry
A client comes to the emergency department with reports of pain in the left ankle. The client states, "I missed a step coming down the stairs, and landed funny." The ankle is swollen and tender to the touch. What will the nurse do to help control the swelling?
Raise the left leg above the level of the heart
Which should a nurse encourage in clients who are at the risk of pneumococcal and influenza infections?
Receiving vaccinations
Which terms describes the backward flow of blood through a heart valve?
Regurgitation
A nurse is creating a health promotion intervention focused on chronic obstructive pulmonary disease (COPD). What should the nurse identify as a complication of COPD?
Respiratory failure
Which nursing diagnosis takes highest priority for a client admitted for evaluation for Ménière's disease?
Risk for injury related to vertigo
A nurse is assessing a pediatric client in a public health clinic. The parent states that the client has been sneezing and rubbing the eyes. The nurses observes the client's eyes and documents objective symptoms of watery and red eyes. When reporting to the physician the assessment findings, which word is appropriate?
Signs and symptoms of conjunctivitis
The nurse uses which term for the normal pacemaker of the heart?
Sinoatrial (SA) node
A client with Meniere's disease has a nursing diagnosis of risk for injury related to gait disturbances and vertigo. Which of the following would be most appropriate to include in this client's plan of care?
Sitting down at the first sign of feeling dizzy
Most cases of osteomyelitis are caused by which microorganism?
Staphylococcus aureus
The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and is experiencing chest tightness. What is the most appropriate initial action for the nurse to take?
Stop the transfusion immediately
For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?
Teaching the client how to perform controlled coughing
The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?
The client with enlarged lymph nodes in the neck
What is hematopoiesis?
The manufacture and development of blood cells
The client has just been diagnosed with a dysrhythmia. The client asks the nurse to explain normal sinus rhythm. What would the nurse explain is the characteristic of normal sinus rhythm?
The sinoatrial (SA) node initiates the impulse
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak
A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?
Vitamin B12 deficiency
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
An elderly patient has been admitted to the emergency department (ED) after accidentally overdosing on warfarin, and the patient's initial blood work reveals a dangerously high international normalized ratio (INR). The ED nurse should anticipate the need to administer:
Vitamin K
A patient with hypertension has a newly diagnosed atrial fibrillation. What medication does the nurse anticipate administering to prevent the complication of atrial thrombi?
Warfarin
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
Withhold the medication and notify the physician of the heart rate
The nurse is caring for a client who is displaying a third-degree AV block on the EKG monitor. What is the priority nursing intervention for the client?
alerting the healthcare provider of the third-degree heart block
Medical management of cardiac failure uses similar methodology whether it is right-sided or left-sided. Measures such as dietary modification, lifestyle changes, medications to reduce dyspnea and relieve anxiety, etc. are all used with one primary intention. The primary goal in the medical management of heart failure is to reduce:
cardiac workload
During the acute phase of a burn, a nurse should assess:
circulatory status
The nurse is teaching a client about hypertension and the effects on the left ventricle. What diagnostic test will the nurse describe?
echocardiography
A client reports light-headedness, chest pain, and shortness of breath. They physician orders tests to ascertain what is causing the client's problems. Which test is used to identify cardiac rhythms?
electrocardiogram
The nurse is screening children for scoliosis. What nursing assessment finding is indicative of scoliosis?
lateral curvature of the spine
A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:
maintaining the client's fluid, electrolyte, and acid-base balance
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as
pleural effusion
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub
A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of:
vitamin B12
