<3 + pretest+ immune
The nurse is assessing a client who has small groups of vesicles over his chest and upper abdominal area. They are located only on the right side of his body. The client states his pain level is 8/10, and describes the pain as burning in nature. Which question is most appropriate to include in the data collection?
"Did you have chicken pox as a child?"--The client has the symptoms of herpes zoster, or shingles, which is caused by the same organism as chicken pox.
A nurse provides instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
"I should avoid sitting in one position for long periods of time."
A nurse has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?
"I should routinely use polyunsaturated oils in my diet."
Amantadine hydrochloride (Symmetrel) 100 mg orally twice daily has been prescribed for a client with Parkinson's disease, and the nurse teaches the client about the medication. Which statement by the client indicates that further teaching is necessary?
"I'll take this medication early in the morning and just before I go to bed.
A postpartum client asks a nurse when she can resume sexual activity. The appropriate nursing response is which of the following?
"Sexual activity can be resumed in about 3 weeks once the episiotomy has healed and the lochia has stopped."
A client calls the emergency department and tells the nurse that he has been cleaning a wooded area and that he came into direct contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse makes which statement to the client?
"Take a shower immediately, and lather and rinse several times."-- Calamine lotion is a treatment that is used when dermatitis develops. It is not necessary for the client to be seen in the emergency department at this time.
A nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which of the following questions?
"Where is the pain located?"
A client who is human immunodeficiency virus (HIV) positive has had a Mantoux skin test. The results show a 7-mm area of induration. The nurse evaluates that this result is:
(+) ---->The client with HIV is considered to have positive results on Mantoux skin testing with an area of 5 mm of induration or greater. The client without HIV is positive with induration greater than 10 or 15 mm
A nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client?
-Cut down on the amount of fats consumed in the diet. -Walk each day to increase circulation to the legs. -Be careful not to injure the legs or feet. -Eat a well-balanced diet every day.
While collecting data related to the cardiac system on a client diagnosed with an incompetent heart valve, the nurse auscultates a murmur. Which of the following best describes the sound of a heart murmur?
Gentle, blowing or swooshing noise
A client experiences an episode of Bell's palsy and complains about increasing clumsiness. The nurse should prepare the client for which diagnostic study (studies) to determine the cause of the complaints?
Cerebral angiography Computed tomography Lumbar puncture (LP)
A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse would first:
Check the client status and lead placement.
A client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which commonly is reported initially?
Chest pain that occurs suddenly
A client is admitted to the psychiatric unit with a diagnosis of bipolar affective disorder and mania. The nurse would prioritize that which of the following symptoms or behaviors requires immediate intervention?
Constant physical activity and poor oral intake
A client is seen in the health care clinic with a diagnosis of mild anemia. The anemia is believed to be a result of the menstrual period. The woman asks the nurse how much blood is lost during a menstrual period. The nurse bases the response on which of the following amounts of blood lost during this time?
40 mL--During a menstrual period, a woman loses about 40 mL of blood.
A health care provider instructs a client with rheumatoid arthritis to take ibuprofen (Motrin). The nurse reinforces the instructions, knowing that the normal adult dose for this client is which of the following?
400 mg orally three times a day--For acute or chronic rheumatoid arthritis or osteoarthritis, the normal oral adult dose is 400 to 800 mg three or four times daily.
A client reports to the clinic for followup after a 1-month treatment with acebutolol (Sectral). The nurse determines that a therapeutic effect of the medication has occurred if which of the following is noted?
A blood pressure of 130/84 mm Hg--Acebutolol is a β-adrenergic blocker used primarily to manage mild to moderate hypertension or cardiac dysrhythmias. The expected therapeutic response is a controlled blood pressure within normal limit
A postcardiac surgery client with a blood urea nitrogen (BUN) level of 45 mg/dL and a serum creatinine level of 2.2 mg/dL has a total 2-hour urine output of 25 mL. The nurse understands that the client is at risk for:
Acute renal failure
A nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which of the following would the nurse anticipate to be prescribed by the health care provider?
Administration of a subcutaneous rubella virus vaccine--This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.
The nurse overhears the term "sundowning" used to describe the behavior of a client newly admitted to the nursing unit during the previous evening shift. The nurse interprets that this client most likely has a diagnosis of:
Alzheimer's disease
Which of the following individuals is least likely at risk for the development of Kaposi's sarcoma?
An individual working in an environment where exposure to asbestos exists
The nurse is assigned to care for a client with systemic lupus erythematosus (SLE). The nurse plans care knowing that this disorder is:
An inflammatory disease of collagen contained in connective tissue
A client has an inoperable abdominal aortic aneurysm (AAA). The nurse teaches the client about the need for:
Antihypertensives
he health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which of the following laboratory tests would rule out a past streptococcal infection in the child?
Antistreptolysin titer
A client calls the emergency department and tells the nurse that he received a bee sting to the arm while weeding a garden. The client states that he has received bee stings in the past and is not allergic to bees. The client states that the site is painful and asks the nurse for advice to alleviate the pain. The nurse tells the client to first:
Apply ice and elevate the site.
The nurse is assigned to care for a client admitted to the hospital with a diagnosis of systemic lupus erythematosus (SLE). The nurse reviews the health care provider's prescriptions. Which of the following medications would the nurse expect to be prescribed?
Corticosteroid
A nurse is assisting in the care of a client diagnosed with multiple myeloma who has been prescribed an intravenous solution. Which finding would indicate a positive response to this treatment?
Creatinine of 1 mg/dL--Creatinine is the most accurate measure of renal status.
A complete blood cell count is performed on a client with systemic lupus erythematosus (SLE). The nurse would suspect that which of the following findings will be reported from this blood test?
Decrease of all cell types--probably caused by a direct attack of all blood cells or bone marrow by immune complexes.
Streptokinase (Streptase) is being administered to a client following an acute inferior myocardial infarction. The nurse plans care, knowing that the primary purpose of streptokinase is to:
Dissolve the thrombus.--Streptokinase is a thrombolytic medication that causes lysis of blood clots. Anticoagulants prevent further clot formation. β-blockers, nitrates, and calcium-channel blockers are used to reduce myocardial oxygen demand.
A nurse instructs a client at risk for hypokalemia about the foods high in potassium that should be included in the daily diet. The nurse determines that the client needs further instruction if the client states that which food is high in potassium?
Eggs
A nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed:
Eight pads a day
A nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as:
Elevated, signaling the presence of diabetes mellitus, a risk factor of coronary artery disease
A client with cancer is receiving morphine sulfate. When writing the plan of care for this client, the nurse should assign priority to which intervention?
Encourage the client to cough and deep breathe (priority!)-- to prevent complications related to the use of this medication.
A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which of the following that is a sign of this disorder?
Evidence of soiled clothing--Encopresis is defined as fecal incontinence
Cyclobenzaprine (Flexeril) is prescribed for a client to treat muscle spasms, and the nurse is reviewing the client's record. Which of the following disorders, if noted in the client's record, would indicate a need to contact the health care provider regarding the administration of this medication?
GLAUCOMA
A nurse is caring for a client with a health care-associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which of the following protective items will be required to perform this procedure?
Gloves, a gown, and goggles
A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer, expecting to note that the ulcer:
Has a brownish or "brawny" appearance
A nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client's laboratory results, recalling that which electrolyte imbalance could be responsible for this development?
Hypokalemia-- client may experience ventricular dysrhythmias in the presence of hypokalemia because this electrolyte imbalance increases the electrical instability of the heart.
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:
In semi-Fowler's position with the knee gatch slightly raised--This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.
A maternity nurse is providing an inservice educational session to nursing students regarding the process of conception. The nurse determines that a nursing student understands this process if the student states that fertilization of a mature ovum occurs in which of the following areas?
In the distal third of the fallopian tube--Fertilization normally occurs in the distal third of the fallopian tube near the ovary. The ovum, fertilized or not, enters the uterus about 3 days after its release from the ovum.
A client is admitted to the hospital with viral hepatitis and is complaining of a loss of appetite. In order to provide adequate nutrition, the nurse encourages the client to:
Increase intake of fluids.
A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse anticipates that which of the following interventions should be included in the plan of care?
Maintaining bed rest Applying warm compresses to the affected area as prescribed Elevating the affected extremity
emphasis of the center is on group and social interaction, and that rules and expectations are mediated by peer pressure..
Milieu therapy
A nurse instructs a client to increase the amount of riboflavin in the diet. The nurse tells the client to select which food item that is high in riboflavin?
Milk--Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.
A nurse has given instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further instructions if the client states that:
Moving to a warmer climate should help.
A nurse is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is:
Normal, caused by increased blood flow through the leg--An expected outcome of surgery is warmth, redness, and edema in the surgical extremity cause by increased blood flow.
The nurse interprets that the client who is prescribed zalcitabine (Hivid) is experiencing an adverse effect of this medication when which event is reported by the client?
Numbness in the legs
A nurse is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The nurse bases the response on which of the following?
Oxygen supply to the heart cells that is deficient results in angina pectoris pain.
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The nurse understands that a life-threatening complication of this condition is:
Pulmonary embolism--Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. Chest pain is the most common symptom
A nurse assisting in caring for a client hospitalized with acute pericarditis is monitoring the client for signs of cardiac tamponade. The nurse determines that which finding is unrelated to possible cardiac tamponade?
Pulse rate of 58 beats per minute--findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure, accompanied by pulsus paradoxus (a drop in inspiratory blood pressure by greater than 10 mm Hg).
A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe?
Restricting the client's potassium intake --Clients with acute pulmonary edema are on a sodium-restricted diet, not potassium restricted. Restricting potassium makes the client more prone to digoxin toxicity.
A nurse is assisting in caring for a client with a respiratory tract infection who is receiving intravenous tobramycin sulfate (Tobrex). which of the following findings is indicative of an adverse effect of this medication?
Ringing in the ears and vertigo are two symptoms that may indicate dysfunction of cranial nerve VIII.
A nurse is administering gentamicin sulfate (Garamycin) ophthalmic ointment to a client. After instilling the ointment, the nurse instructs the client to close the eye and:
Roll the eyeball in all directions.
A nurse is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?
ST-segment depression
A nurse is caring for a client diagnosed with catatonic stupor. The client is lying on the bed, with the body pulled into a fetal position. The appropriate nursing intervention is which of the following?
Sit beside the client in silence and verbalize occasional open-ended questions.--Clients with catatonic stupor may be immobile and mute and may require consistent, repeated approaches. The nurse facilitates communication with the client by sitting in silence, asking open-ended questions, and pausing to provide opportunities for the client to respond.
When preparing a client for a pericardiocentesis, how does the nurse position the client?
Supine with the head of bed elevated at a 45- to 60-degree angle
A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and collecting initial data, the nurse places a sign above the bed stating that the client should remain on bedrest:
With the head of the bed elevated no more than 15 degrees
A nurse is preparing to collect client data by examining the abdomen. The nurse should assist the client into which of the following positions initially?
Supine with the head raised slightly and the knees slightly flexed
A nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is in the client's hospital room?
Surgical tourniquet--the wound and any drains are monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation. Therefore a surgical tourniquet is kept at the bedside in case of acute bleeding.
A nurse is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?
Tall, peaked T waves
A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the expected outcome of care has not yet been achieved?
The client limits fluid intake.
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:
The client may bear weight on the cast in 30 minutes.--A plaster cast can tolerate weight bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.
A health care provider prescribes 3000 mL of 0.9% normal saline to run over 24 hours. The drop (gtt) factor is 15 gtts/mL. The nurse plans to adjust the flow rate at how many gtts per minute? (Round answer to the nearest whole number.)
The prescribed 3000 mL is to be infused over 24 hours. Follow the formula and multiply 3000 mL by 15 (gtt factor). Then divide the result by 1440 minutes (24 hours × 60 minutes). The infusion is to run at 31.2 or 31 gtts/minute.
A client has been examined in the clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. The nurse tells the client that endometriosis is:
The presence of tissue outside the uterus that resembles the endometrium
A nurse attempts to relieve an airway obstruction on a 6-year-old conscious child. The nurse performs this maneuver by placing the hands between:
The umbilicus and the xiphoid process
A member of the class asks the LPN to identify the correct location for the placement of conductive gel pads to treat ventricular fibrillation. The LPN tells the class that the conductive gel pads are placed in which of the following locations on the client's chest?
Under the right clavicle and to the left of the precordium
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The nurse responds that this procedure may stimulate the:
Vagus nerve to slow the heart rate
The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse would initially check the:
Vital signs--Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised.
A client has experienced several episodes of sickle cell crisis. Which instruction should be included in the client's teaching plan to prevent recurrence?
Wear shoes and socks when walking outside to prevent damage to the feet. --Wearing socks and shoes will prevent wounds to the legs and feet, which heal slowly and frequently become infected in clients with sickle cell disease.
A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply.
Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client
A client is receiving a continuous intravenous (IV) infusion of heparin in the treatment of deep vein thrombosis. The nurse is told that the client's activated partial thromboplastin time (aPTT) level is 65 seconds and that the client's baseline before the initiation of therapy was 30 seconds. The nurse identifies these results as:
Within the therapeutic range--The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal.
A nurse is reinforcing discharge instructions with a client who is being discharged following a fenestration procedure for the treatment of otosclerosis. Which of the following should be included in the list of instructions prepared for the client?
You need to avoid air travel."--Clients must be instructed to avoid drinking with a straw for 2 to 3 weeks, avoid air travel, and avoid coughing excessively.
A nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which of the following to effectively accomplish this goal?
Provide a quiet and low-stimulus environment.
A nurse is performing cardiopulmonary resuscitation (CPR) on an adult. The nurse delivers how many breaths per minute to the client?
10--Each rescue breath is delivered over 1 second at a rate of 1 breath every 6 to 8 seconds (8 to 10 ventilations per minute)
A client with human immunodeficiency virus (HIV) who has contracted tuberculosis (TB) asks the nurse how long the medication therapy lasts. The nurse responds that the duration of therapy would likely be for at least:
9 total months and at least 6 months after cultures convert to negative
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The nurse should take which action first?
Assist the client to sit or lie down.
A nurse is reviewing the health care provider's prescription sheet for the preoperative client, which states that the client must be on nothing per mouth (NPO) status after midnight. The nurse would clarify whether which of the following medications should be given to the client and not withheld?
Atenolol (Tenormin)--Atenolol is a β-blocker. β-Blockers should not be stopped abruptly, and the health care provider should be contacted about the administration of this medication prior to surgery
A nurse is providing instructions to a client with angina pectoris about measures to reduce recurrence of chest pain. The nurse should stress to the client the importance of doing which of the following?
Avoiding exposure to either very hot or very cold weather
An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notes documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action in the care of the client?
Place the client on a cardiac monitor.
A nurse preparing a client for surgery reviews the client's medication record. The client is to be nothing per mouth (NPO) after midnight. Which of the following medications, if noted on the client's record, should the nurse question?
Prednisone
The home care nurse is collecting data from a client who has been diagnosed with an allergy to latex. In determining the client's risk factors associated with the allergy, the nurse questions the client about an allergy to which food item?
Bananas--Individuals who are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts are at risk for developing a latex allergy. This is thought to be due to a possible cross-reaction between the food and the latex allergen.
A client is brought to the emergency department and is unconscious. From the viewpoint of informed consent, a nurse determines that emergency treatment can be initiated to the unconscious client:
Because emergency treatment can be provided under the emergency doctrine
A nurse is providing information to a client with systemic lupus erythematosus (SLE) about dietary alterations. The nurse should remind the client to avoid which of the following foods?
Beef
A nurse is preparing for the admission of a client with a suspected diagnosis of herpes simplex encephalitis. Which diagnostic test will be prescribed to confirm this diagnosis?
Brain biopsy
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which of the following is noted?
Presence of accelerations--Accelerations are an indication of fetal well-being and an oxygenated fetal central nervous system.
A nurse evaluates the client following treatment for carbon monoxide poisoning. The nurse would document that the treatment has been successful when the:
Carboxyhemoglobin levels are less than 5%.
A nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?
Cat's-eye reflex-- commonly observed by the parent and is described as a whitish "glow" in the pupil.
A clinic nurse periodically cares for a client diagnosed with acquired immunodeficiency syndrome. The nurse assesses for an early manifestation of Pneumocystis jiroveci infection by monitoring for which of the following at each client visit?
Cough
The nurse is assisting in planning care for a client with a diagnosis of immune deficiency. The nurse would incorporate which of the following as a priority in the plan of care?
Protecting the client from infection
A nurse is identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy?
Individuals with spina bifida
A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain. The nurse further collects data on the client to see whether these episodes occur with:
Ingestion of coffee or chocolate--Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain in the fingers. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress.
A nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). The nurse should alter the environment to ensure that it is:
Low stimulus, low stress
A nurse is providing dietary instructions to a client with systemic lupus erythematosus. Which of the following dietary items would the nurse instruct the client to avoid?
Steak--The client with systemic lupus erythematosus is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia
A pericardial friction rub-
described as a scratchy, leathery heart sound.
A nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume in which of the following clients who is at risk for this fluid imbalance?
A client with an ileostomy-- because of increased gastrointestinal tract losses.
The nurse is reinforcing instructions to a new mother about cord care and how to monitor for infection. The nurse tells the mother that which of the following is a sign of infection?
A moist cord with discharge--Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base.
A client has been given a prescription for chloral hydrate (Somnote) for short-term use. The nurse includes which of the following nursing interventions in caring for this client?
Instruct the client to call for help to get out of bed.--Chloral hydrate is a sedative-hypnotic. This medication promotes sleep, and the client is at risk for falls due to sedative effects.
A nurse is caring for a female client who was recently admitted to the hospital for anorexia nervosa. The nurse enters the client's room and notes that the client is doing vigorous push-ups. Which nursing action is appropriate?
Interrupt the client and offer to take her for a walk.
The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate in the plan during the bathing of this client?
Wearing a gown and gloves--required if the nurse anticipates contact with soiled items, such as wound drainage, or while caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy.
A nurse is preparing to auscultate a client's abdomen for bowel sounds. The nurse listens for bowel sounds in which abdominal quadrant first?
When auscultating the abdomen, the nurse begins in the right lower quadrant (RLQ), in the ileocecal valve area, because bowel sounds are always present here normally.
A client returns to the nursing unit after an above-the-knee amputation of the right leg. The nurse positions the client:
With the foot of the bed elevated
A nurse is providing instructions to a client with acquired immunodeficiency syndrome (AIDS) who is experiencing night fever and night sweats. The nurse advises the client to do which of the following to increase comfort while minimizing symptoms?
Keep liquids on the nightstand at home
A nurse is evaluating the effects of care for the client with deep vein thrombosis. Which of the following limb observations would the nurse note as indicating the least success in meeting the outcome criteria for this problem?
Pedal edema that is 3+ Symptoms of deep vein thrombosis include leg warmth, redness, edema, tenderness, and enlarged calf.
A nurse has given simple instructions on preventing some of the complications of bedrest to a client who experienced a myocardial infarction. The nurse would intervene if the client were performing which of these activities, which would be contraindicated?
Isometric exercises of the arms and legs--client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises.
