Hurst Module 2

The nurse is assessing a client admitted with a diagnosis of chronic renal failure. Which finding would the nurse expect to see in the client? 1. Anemia 2. Fluid volume deficit 3. Pruritis 4. Dependent edema 5. Hypokalemia

1. Anemia 3. Pruritis 4. Dependent edema

What information should the pre-operative nurse include when educating a client about preventing a deep vein thrombus (dvt) formation after abdominal surgery? 1. Anticoagulant medication may be prescribed. 2. Caffeinated beverages will be allowed once able to drink in order to promote hydration. 3. Bed rest will be required for at least 5 days. 4. Move feet in a circle 10 times an hour. 5. A sequential compression device (SCD) will be wrapped around the legs.

1. Anticoagulant medication may be prescribed. 4. Move feet in a circle 10 times an hour. 5. A sequential compression device (SCD) will be wrapped around the legs.

What food should the nurse instruct a client to avoid when prescribed digoxin? 1. Black licorice 2. Coenzyme Q-10 3. Grapefruit 4. Grapes 5. Wheat bran

1. Black licorice 5. Wheat bran

The nurse is planning to teach a client about home peritoneal dialysis. What information should the nurse include? 1. After washing hands with soap and water, put on clean gloves to clean catheter site. 2. Apply a prescription antibiotic cream to the skin around the catheter with fingers. 3. Leave crust formed around the insertion site alone. 4. Gently rub the skin dry around the site dry after cleaning. 5. Wash the skin around the catheter site with antibacterial soap.

1. After washing hands with soap and water, put on clean gloves to clean catheter site. 3. Leave crust formed around the insertion site alone. 5. Wash the skin around the catheter site with antibacterial soap.

A nurse is caring for a client post heart catheterization with a left femoral stick. What signs and symptoms would indicate to the nurse that the primary healthcare provider should be notified? 1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4 5. Temperature of 99.9º F (37.72º C)

1. Capillary refill of 6 seconds to left toes. 2. Epigastric discomfort 3. Paresthesia to left leg 4. Left pedal pulse 0/4; Right pedal pulse 2+/4

A nurse is attempting planning care for a client who has self-care difficulty due to left-sided hemiparesis. Which intervention should the nurse include? 1. Offer to take the client to the toilet every two hours. 2. Instruct client to use disposable razors once to prevent infection. 3. Encourage family members to comb hair for client. 4. Provide the client with a button hook for dressing. 5. Teach the client to rely on furniture for support when walking.

1. Offer to take the client to the toilet every two hours. 4. Provide the client with a button hook for dressing.

The nurse is monitoring the client's heart rhythm. The monitor shows sinus tachycardia. What is expected with this assessment finding? 1. Regular rhythm 2. Rate of 101-200 3. Absent P wave 4. P-R interval not measurable 5. QRS complex greater than 0.20 seconds

1. Regular rhythm 2. Rate of 101-200

A manufacturing worker comes into the occupational health nurse's clinic reporting a squeezing pain in the chest. What additional signs and symptoms should the nurse monitor for in the client? 1. Dyspnea 2. Dry, flushed skin 3. Indigestion 4. Restlessness 5. Tachycardia

1. Dyspnea 3. Indigestion 4. Restlessness 5. Tachycardia

What teaching points should the nurse include when teaching a client how to prevent a venous stasis ulcer? 1. Maintain a healthy weight. 2. Wear compression stockings. 3. Go for a daily walk. 4. Crossing of the legs should be limited to 30 minutes at a time. 5. Elevate legs when resting.

1. Maintain a healthy weight. 2. Wear compression stockings. 3. Go for a daily walk. 5. Elevate legs when resting.

The nurse is teaching a male client how to perform intermittent self-catheterization. In what order should this procedure be taught?

Clean the meatus Lubricate several inches of the catheter tip Hold your penis on both sides just behind the head Insert the catheter 6 inches (15.24 cm) into the urethra Gently, but firmly push past the sphincter muscle 2-3 inches(5-7.6 cm) Allow urine to drain completely

The nurse is planning to educate a client who has a diagnosis of right sided heart failure? What information should the nurse include? 1. Blood backs up in the left upper chamber of the heart. 2. Your feet, legs, and ankles will likely swell because blood is backing up in your veins. 3. Activity will increase your heart rate. 4. You might find that you go to the bathroom more often at night. 5. Weigh yourself daily to monitor for rapid weight gain.

2. Your feet, legs, and ankles will likely swell because blood is backing up in your veins. 3. Activity will increase your heart rate. 4. You might find that you go to the bathroom more often at night. 5. Weigh yourself daily to monitor for rapid weight gain.

The nurse is assessing a male client suspected of having a myocardial infarction (MI). What signs/symptoms would the nurse expect the client to exhibit? 1. Bradycardia 2. Chest pressure 3. Cough 4. Flu like symptoms 5. Vomiting

2. Chest pressure 3. Cough 5. Vomiting

A client is admitted with arterial disease of the lower extremities. Which client teachings would the nurse initiate? 1. Elevate extremities above the level of the heart. 2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

2. Discourage use of caffeine. 3. Protect extremities from cold exposure. 4. Maintain a warm environment at home. 5. Encourage isometric exercise.

The nurse is planning care for a client diagnosed with pyelonephritis. What interventions should a nurse include? 1. Advise that urine may turn blue with administration of nitrofurantoin. 2. Encourage voiding every 2 hours. 3. Educate the client that phenazopyridine is an antibiotic used to treat pyelonephritis. 4. Palpate the bladder every 4 hours. 5. Provide client with at least 1500 mL of water to drink daily.

2. Encourage voiding every 2 hours. 4. Palpate the bladder every 4 hours.

A client has been admitted with advanced cirrhosis. The nurse's assessment verifies an increase weight of 6 lbs. (2.71 kg) since yesterday's weight and an abdominal girth increase of 5 inches (12.7 cm). What is the priority assessment? 1. Urinary Output 2. Daily weight 3. Blood pressure 4. LOC

3. Blood pressure

A small community has experienced a mudslide that hit a restaurant causing mass casualties. What would the nurse do first? 1. Assess the immediate area for electrical wires on the ground. 2. Attend to victim injuries as they are encountered. 3. Activate the community emergency response team. 4. Triage and tag victims according to injury.

3. Activate the community emergency response team.

The nurse sees the following rhythm on the cardiac monitor for a client recovering from a myocardial infarction. What would be the nurse's first action upon entering the client's room? 1. Attempt defibrillation 2. Begin CPR 3. Assess for carotid pulse 4. Administer lidocaine

3. Assess for carotid pulse

When an explosion occurs at a local shopping center, an off-duty nurse quickly begins to triage those injured. The nurse knows which client needs immediate attention? 1. An elderly adult with a traumatic left eye enucleation. 2. A child with an open, compound fracture of the femur. 3. An adult with a head laceration bleeding profusely. 4. An adolescent with a rigid, board-like lower abdomen.

4. An adolescent with a rigid, board-like lower abdomen.

A client returns to the unit after having extracorporeal lithotripsy. Which would be the best indicator that the treatment has been effective? 1. The client is relieved of the pain. 2. The urine is free of red blood cells. 3. The urinary output has increased since return to the unit. 4. There is sediment in the urinary catheter drainage bag.

4. There is sediment in the urinary catheter drainage bag.

What should a nurse include when planning an educational program for a group of women on how to prevent a urinary tract infection (UTI)? 1. Empty bladder at least every 8 hours while awake 2. Take showers rather than prolonged baths 3. Use spemicidal jelly during intercourse 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

2. Take showers rather than prolonged baths 4. Use tampons rather than sanitary napkins 5. Wear cotton underwear

A client arrives to the emergency department with reports of palpitations, chest discomfort, and light-headedness. The nurse connects the client to a cardiac monitor and notes a weak, thready pulse, and a BP of 90/50. What actions should the nurse take? 1. Administer Atropine 0.5 mg intravenous push (IVP). 2. Prepare for immediate synchronized cardioversion. 3. Provide 100 percent oxygen. 4. Start large bore intravenous access. 5. Set up for endotracheal intubation.

2. Prepare for immediate synchronized cardioversion. 4. Start large bore intravenous access.

As a member of the emergency preparedness planning team at the hospital, which action should the nurse encourage the team to implement? 1. Develope a response plan for each potential disaster. 2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

2. Provide education to employees on the response plan. 3. Practice the response plan on a regular basis. 4. Evaluate the hospital's level of preparedness. 5. Coordinate with neighboring hospitals regarding different emergency response plans.

What potential contributing factors for transient urinary incontinence should a nurse assess in an elderly female client? 1. Chronic urinary retention 2. Fecal impaction 3. Menopause 4. Restricted mobility 5. Stroke

2. Fecal impaction 4. Restricted mobility

During the admission examination of a client diagnosed with acute pyelonephritis, what signs or symptoms would the nurse expect to find? 1. Dysnea 2. Hematuria 3. Pubic pain 4. Tachycardia 5. Weight gain

2. Hematuria 4. Tachycardia 5. Weight gain

A community health nurse is presenting a seminar to a group of senior citizens on ways to reduce the risks of peripheral artery disease (PAD). What topics should the nurse include? 1. Daily strenuous exercise 2. How to read food labels 3. Maintaining a BMI less than 30 kg/m2 4. Managing diabetes 5. Use of anti-embolic stockings

2. How to read food labels 4. Managing diabetes