Med Surg Exam 3
A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best A 5% normal saline B Dextrose 50% C Lactated Ringer's solution
B
While assessing a client with Graves' disease, the nurse notes that the client's temperature has risen 1° F. Which action should the nurse take first A Turn the lights down and shut the client's door. B Call for an immediate electrocardiogram (ECG). C Calculate the client's apical-radial pulse deficit. D Administer a dose of acetaminophen (Tylenol).
A
A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated" What response by the nurse is best A "Breathing so quickly can be dehydrating." B "Everyone with pneumonia is dehydrated." C "This is really just to administer your antibiotics." D "Why do you think you are so dehydrated"
A
A client has Crohn's disease. What type of anemia is this client most at risk for developing A Folic acid deficiency B Fanconi's anemia C Hemolytic anemia D Vitamin B12 anemia
A
A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority A Calling the Rapid Response Team B Delegating taking a set of vital signs C Instituting bleeding precautions D Placing the client on bedrest
A
A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition A Bence-Jones protein in urine B Epstein-Barr virus: positive C Hemoglobin: 18 mg/dL D Red blood cell count: 8.2/mm3
A
A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority A Educating the client on adherence to the treatment regimen B Encouraging the client to eat a well-balanced diet C Informing the client about follow-up sputum cultures D Teaching the client ways to balance rest with activity
A
A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best A Ask the spouse to explain the fear of visiting in further detail. B Inform the spouse the precautions are meant to keep other clients safe. C Show the spouse how to follow the isolation precautions to avoid illness. D Tell the spouse that he or she has already been exposed, so it's safe to visit.
A
A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate A Community social worker for Meals on Wheels B Occupational therapy for job retraining C Physical therapy for homebound therapy services D Visiting Nurses for directly observed therapy
D
A nurse is preparing to administer a blood transfusion. What action is most important A Correctly identifying client using two identifiers B Ensuring informed consent is obtained if required C Hanging the blood product with Ringer's lactate D Staying with the client for the entire transfusion
B
A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority A Genetic testing B Infection prevention C Sperm banking DTreatment options
C
A nurse plans care for a client with hypothyroidism. Which priority problem should the nurse plan to address first for this client A Heat intolerance B Body image problems C Depression and withdrawal D Obesity and water retention
C
A nurse cares for a client with chronic hypercortisolism. Which action should the nurse take A Wash hands when entering the room. B Keep the client in airborne isolation. C Observe the client for signs of infection. D Assess the client's daily chest x-ray.
A
A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care A Assistance with activities of daily living B Physical therapy activities every day C Oxygen therapy at 2 liters per nasal cannula D Complete bedrest with frequent repositioning
A
An emergency nurse cares for a client who is experiencing an acute adrenal crisis. Which action should the nurse take first A Obtain intravenous access. B Administer hydrocortisone succinate (Solu-Cortef). C Assess blood glucose. D Administer insulin and dextrose.
A
The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met A Antibiotics started before admission B Blood cultures obtained within 20 minutes C Chest x-ray obtained within 30 minutes D Pulse oximetry obtained on all clients
A
A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement (Select all that apply.) A Assess vital signs more often. B Hold other IV fluids running. C Premedicate to prevent reactions. D Transfuse smaller bags of blood. E Transfuse each unit over 8 hours.
A B
A hospital nurse is participating in a drill during which many clients with inhalation anthrax are being admitted. What drugs should the nurse anticipate administering (Select all that apply.) A Amoxicillin (Amoxil) B Ciprofloxacin (Cipro) C Doxycycline (Vibramycin) D Ethambutol (Myambutol) E Sulfamethoxazole-trimethoprim (SMX-TMP) (Septra
A B C
A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client (Select all that apply.) A Assisting with chest tube insertion B Facilitating pleural fluid sampling C Performing frequent respiratory assessment D Providing antipyretics as needed E Suctioning deeply every 4 hours
A B C D
A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach (Select all that apply.) A Argatroban (Argatroban) B Bivalirudin (Angiomax) C Clopidogrel (Plavix) D Lepirudin (Refludan) E Methylprednisolone (Solu-Medrol)
A B D
A nurse assesses a client with hypothyroidism who is admitted with acute appendicitis. The nurse notes that the client's level of consciousness has decreased. Which actions should the nurse take (Select all that apply.) A Infuse intravenous fluids. B Cover the client with warm blankets. C Monitor blood pressure every 4 hours. D Maintain a patent airway. E Administer oral glucose as prescribed
A B D
A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for adrenal insufficiency (Select all that apply.) A A 22-year-old female with metastatic cancer B A 43-year-old male with tuberculosis C A 51-year-old female with asthma D A 65-year-old male with gram-negative sepsis E A 70-year-old female with hypertension
A B D
A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate (Select all that apply.) A Hanging the blood product using normal saline and a filtered tubing set B Taking a full set of vital signs prior to starting the blood transfusion C Telling the client someone will remain at the bedside for the first 5 minutes D Using gloves to start the client's IV if needed and to handle the blood product E Verifying the client's identity, and checking blood compatibility and expiration time
A B D
A nurse evaluates the following laboratory results for a client who has hypoparathyroidism: Calcium Sodium 144 mEq/L Magnesium Potassium Based on these results which medication should the nurse anticipate administering A Oral potassium chloride B Intravenous calcium chloride C 3% normal saline IV solution D 50% magnesium sulfate E Oral calcitriol (Rocaltrol)
A C
A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care (Select all that apply.) A Encourage deep breathing and coughing. B Implement an air mattress overlay. C Ambulate the client three times each day. D Provide a diet high in protein and vitamins. E Administer acetaminophen (Tylenol) twice daily.
A C D
A nurse assesses clients with potential endocrine disorders. Which clients are at high risk for hypopituitarism (Select all that apply.) A A 20-year-old female with benign pituitary tumors B A 32-year-old male with diplopia C A 41-year-old female with anorexia nervosa D A 55-year-old male with hypertension E A 60-year-old female who is experiencing shock F A 68-year-old male who has gained weight recently
A C D E
A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination (Select all that apply.) A 22-year-old client with asthma B Client who had a cholecystectomy last year C Client with well-controlled diabetes D Healthy 72-year-old client E Client who is taking medication for hypertension
A C D E
A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid (Select all that apply.) A Dehydration B Exercise C Extreme stress D High altitudes E Pregnancy
A C D E
A nurse assesses a client with anterior pituitary hyperfunction. Which clinical manifestations should the nurse expect (Select all that apply.) A Protrusion of the lower jaw B High-pitched voice C Enlarged hands and feet D Kyphosis E Barrel-shaped chest F Excessive sweating
A C D E F
A nurse assesses a client who potentially has hyperaldosteronism. Which serum laboratory values should the nurse associate with this disorder (Select all that apply.) A Sodium: 150 mEq/L B Sodium: 130 mEq/L C Potassium: 2.5 mEq/L D Potassium: 5.0 mEq/L E pH: 7.28 F pH: 7.50
A C E
A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's teaching (Select all that apply.) A Increased carbohydrates B Decreased fats C Increased calorie intake D Supplemental vitamins E Increased proteins
A C E
A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include (Select all that apply.) A Chemical exposure B Genetically modified foods C Ionizing radiation exposure D Vaccinations E Viral infections
A C E
A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication (Select all that apply.) A Visual hallucinations B Tachycardia C Decreased cravings D Impaired judgment E Increased thirst
A D
A student nurse is learning about blood transfusion compatibilities. What information does this include (Select all that apply.) A Donor blood type A can donate to recipient blood type AB. B Donor blood type B can donate to recipient blood type O. C Donor blood type AB can donate to anyone. D Donor blood type O can donate to anyone. E Donor blood type A can donate to recipient blood type B.
A D
A nurse assesses a client with Cushing's disease. Which assessment findings should the nurse correlate with this disorder (Select all that apply.) A Moon face B Weight loss C Hypotension D Petechiae E Muscle atrophy
A D E
A client is in the family practice clinic reporting a severe cough that has lasted for 5 weeks. The client is so exhausted after coughing that work has become impossible. What action by the nurse is most appropriate A Arrange for immediate hospitalization. B Facilitate polymerase chain reaction testing. C Have the client produce a sputum sample. D Obtain two sets of blood cultures
B
A nurse assesses a client with hyperthyroidism who is prescribed lithium carbonate. Which assessment finding should alert the nurse to a side effect of this therapy A Blurred and double vision B Increased thirst and urination C Profuse nausea and diarrhea D Decreased attention and insomnia
B
A nurse assesses clients for potential endocrine disorders. Which client is at greatest risk for hyperparathyroidism A A 29-year-old female with pregnancy-induced hypertension B A 41-year-old male receiving dialysis for end-stage kidney disease C A 66-year-old female with moderate heart failure D A 72-year-old male who is prescribed home oxygen therapy
B
A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone A A 36-year-old female who has used oral contraceptives for 5 years B A 42-year-old male who experienced head trauma 3 years ago CA 55-year-old female with a severe allergy to shellfish and iodine D A 64-year-old male with adult-onset diabetes mellitus
B
A nurse plans care for a client with a growth hormone deficiency. Which action should the nurse include in this client's plan of care A Avoid intramuscular medications. B Place the client in protective isolation. C Use a lift sheet to re-position the client. D Assist the client to dangle before rising.
C
A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately A Hematocrit: 25% B Hemoglobin: 9.2 mg/dL C Potassium: 3.2 mEq/L D White blood cell count: 38,000/mm3
D
A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism A "My sister has thyroid problems." B "I seem to feel the heat more than other people." C "Food just doesn't taste good without a lot of salt." D "I am always tired, even with 12 hours of sleep."
D
A nurse assesses a client who is recovering from a total thyroidectomy and notes the development of stridor. Which action should the nurse take first A Reassure the client that the voice change is temporary. B Document the finding and assess the client hourly. C Place the client in high-Fowler's position and apply oxygen. D Contact the provider and prepare for intubation.
D
A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain A Average daily fluid intake BNeck circumference C Height and weight D Occupation and hobbies
D
A nurse cares for a client after a pituitary gland stimulation test using insulin. The client's post-stimulation laboratory results indicate elevated levels of growth hormone (GH) and adrenocorticotropic hormone (ACTH). How should the nurse interpret these results A Pituitary hypofunction B Pituitary hyperfunction C Pituitary-induced diabetes mellitus C Normal pituitary response to insulin
D
A nurse cares for a client who is recovering from a parathyroidectomy. When taking the client's blood pressure, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition A Serum potassium: 2.9 mEq/L B Serum magnesium: 1.7 mEq/L C Serum sodium: 122 mEq/L D Serum calcium: 6.9 mg/dL
D
A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best A "Because of immunosuppression, the donor cells take over." B "It's like a transfusion reaction because no perfect matches exist." C "The client's cells are fighting donor cells for dominance." D "The donor's cells are actually attacking the client's cells."
D
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first A Document the findings. B Administer oxygen therapy. C Position the client in high-Fowler's position. D Administer prescribed albuterol.
A
A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful A Assist the client to make "sick day" plans for household responsibilities. B Determine if there are family members or friends who can help the client. C Help the client inform friends and family that they will have to help out. D Refer the client to a social worker in order to investigate respite child care.
A
A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority A Administer oxygen. B Apply an oximetry probe. C Give pain medication. D Start an IV line.
A
A client with hyperaldosteronism is being treated with spironolactone (Aldactone) before surgery. Which precautions does the nurse teach this client A "Read the label before using salt substitutes." B "Do not add salt to your food when you eat." C "Avoid exposure to sunlight." D "Take Tylenol instead of aspirin for pain."
A
A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests (Select all that apply.) A "I held the client's morning bronchodilator medication." B "The client is ready to go down to radiology for this examination." C "Physical therapy states the client can run on a treadmill." D "I advised the client not to smoke for 6 hours prior to the test." E "The client is alert and can follow your commands.
A D E
A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching (Select all that apply.) A "Find an activity that you enjoy and will keep your hands busy." B "Keep snacks like potato chips on hand to nibble on." C "Identify a punishment for yourself in case you backslide." D "Drink at least eight glasses of water each day." E "Make a list of reasons you want to stop smoking."
A D E
A nurse teaches a client who is prescribed an unsealed radioactive isotope. Which statements should the nurse include in this client's education (Select all that apply.) A "Do not share utensils, plates, and cups with anyone else." B "You can play with your grandchildren for 1 hour each day." C "Eat foods high in vitamins such as apples, pears, and oranges." D "Wash your clothing separate from others in the household." E "Take a laxative 2 days after therapy to excrete the radiation."
A D E
While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best (Select all that apply.) A "What response do you have when you eat avocados" B "I will remove any avocados that are on your lunch tray." C "When was the last time you ate foods containing avocados" D "I will document this in your record so all of your providers will know." E "Have you ever been treated for this allergic reaction"
A D E
A nurse cares for a client who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy (Select all that apply.) A Urine output is increased. B Urine output is decreased. C Specific gravity is increased. D Specific gravity is decreased. E Urine osmolality is increased. F Urine osmolality is decreased
A D F
A client is in the family medicine clinic reporting a dry, sore throat. The provider asks the nurse to assess for odynophagia. What assessment technique is most appropriate A Ask the client what foods cause trouble swallowing. B Assess the client for pain when swallowing. C Determine if the client can swallow saliva. D Palpate the client's jaw while swallowing.
B
A nurse plans care for a client with Cushing's disease. Which action should the nurse include in this client's plan of care to prevent injury A Pad the siderails of the client's bed. B Assist the client to change positions slowly. C Use a lift sheet to change the client's position. D Keep suctioning equipment at the client's bedside.
C
A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best A Encourage high-protein foods. B Perform a Hemoccult test on the client's stools. C Offer frequent oral care. D Prepare to administer cobalamin (vitamin B12).
B
A client has been taking isoniazid (INH) for tuberculosis for 3 weeks. What laboratory results need to be reported to the health care provider immediately A Albumin: 5.1 g/dL B Alanine aminotransferase (ALT): 180 U/L C Red blood cell (RBC) count: 5.2/mm3 D White blood cell (WBC) count: 12,500/mm3
B
A nurse cares for a client newly diagnosed with Graves' disease. The client's mother asks, "I have diabetes mellitus. Am I responsible for my daughter's disease" How should the nurse respond A "The fact that you have diabetes did not cause your daughter to have Graves' disease. No connection is known between Graves' disease and diabetes." B "An association has been noted between Graves' disease and diabetes, but the fact that you have diabetes did not cause your daughter to have Graves' disease." C "Graves' disease is associated with autoimmune diseases such as rheumatoid arthritis, but not with a disease such as diabetes mellitus." D "Unfortunately, Graves' disease is associated with diabetes, and your diabetes could have led to your daughter having Graves' disease."
B
A nurse cares for a client who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The client's serum sodium level is 114 mEq/L. Which action should the nurse take first A Consult with the dietitian about increased dietary sodium. B Restrict the client's fluid intake to 600 mL/day. C Handle the client gently by using turn sheets for re-positioning. D Instruct unlicensed assistive personnel to measure intake and output.
B
A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication should the nurse anticipate being prescribed to the client A Atropine sulfate B Levothyroxine sodium (Synthroid) C Propranolol (Inderal) D Epinephrine (Adrenalin)
B
A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next A Administer an albuterol treatment. B Notify the Rapid Response Team. C Assess the client's peripheral pulses. D Obtain blood and sputum cultures.
B
A nurse is caring for a client who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The client's symptoms have now resolved and the client asks, "When can I stop taking these medications" How should the nurse respond A "It is possible for the inflammation to recur if you stop the medication." B "Once you start corticosteroids, you have to be weaned off them." C "You must decrease the dose slowly so your hormones will work again." D "The drug suppresses your immune system, which must be built back up."
B
A nurse plans care for a client with hyperparathyroidism. Which intervention should the nurse include in this client's plan of care A Ask the client to ambulate in the hallway twice a day. B Use a lift sheet to assist the client with position changes. C Provide the client with a soft-bristled toothbrush for oral care. D Instruct the unlicensed assistive personnel to strain the client's urine for stones.
B
After teaching a client who is recovering from a complete thyroidectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional instruction A "I may need calcium replacement after surgery." B "After surgery, I won't need to take thyroid medication." C "I'll need to take thyroid hormones for the rest of my life." D "I can receive pain medication if I feel that I need it."
B
After teaching a client who is recovering from an endoscopic trans-nasal hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching A "I will wear dark glasses to prevent sun exposure." B "I'll keep food on upper shelves so I do not have to bend over." C "I must wash the incision with peroxide and redress it daily." D "I shall cough and deep breathe every 2 hours while I am awake."
B
An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best A "Chest x-rays are always ordered when we suspect pneumonia." B "Older people often have vague symptoms, so an x-ray is essential." C "The x-ray can be done and read before laboratory work is reported." D "We are testing for any possible source of infection in the client."
B
The charge nurse on a medical unit is preparing to admit several "clients" who have possible pandemic flu during a preparedness drill. What action by the nurse is best A Admit the "clients" on Contact Precautions. B Cohort the "clients" in the same area of the unit. C Do not allow pregnant caregivers to care for these "clients." D Place the "clients" on enhanced Droplet Precautions.
B
A client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition (Select all that apply.) A Blood urea nitrogen (BUN): 19 mg/dL B International normalized ratio (INR): 6.3 C Prothrombin time: 35 seconds D Serum sodium: 130 mEq/L E White blood cell (WBC) count: 72,000/mm3
B C
A client has Hodgkin's lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client (Select all that apply.) A Headaches B Night sweats C Persistent fever D Urinary frequency E Weight loss
B C E
A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen (Select all that apply.) A Azacitidine (Vidaza) B Darbepoetin alfa (Aranesp) C Decitabine (Dacogen) D Epoetin alfa (Epogen) E Methylprednisolone (Solu-Medrol)
B D
A nurse teaches a client with Cushing's disease. Which dietary requirements should the nurse include in this client's teaching (Select all that apply.) A Low calcium B Low carbohydrate C Low protein D Low calories E Low sodium
B D E
A nurse plans care for a client who has hypothyroidism and is admitted for pneumonia. Which priority intervention should the nurse include in this client's plan of care A Monitor the client's intravenous site every shift. B Administer acetaminophen (Tylenol) for fever. C Ensure that working suction equipment is in the room. D Assess the client's vital signs every 4 hours.
C
A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention A Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. B Crackles are heard in bases. - The nurse encourages the client to cough forcefully. C Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. D Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply.
C
A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP) A Apply ice packs to the client's legs. B Elevate the client's legs on pillows. C Keep the lower extremities warm. D Place elastic bandage wraps on the client's legs.
C
A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the client's medication list to determine if the client is taking which drug A Enoxaparin (Lovenox) B Salicylates (aspirin) C Unfractionated heparin D Warfarin (Coumadin)
C
A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition A "I brush and use dental floss every day." B "I chew hard candy for my dry mouth." C "I usually put ice on bumps or bruises." D "Nonslip socks are best when I walk."
C
A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention A Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. B Client's heart rate is 55 beats/min. - Nurse withholds pain medication. C Client has reduced breath sounds. - Nurse calls physician immediately. D Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.
C
A nurse assesses a client who is recovering from a transsphenoidal hypophysectomy. The nurse notes nuchal rigidity. Which action should the nurse take first A Encourage range-of-motion exercises. B Document the finding and monitor the client. C Take vital signs, including temperature. D Assess pain and administer pain medication.
C
A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective A "I need to take extra vitamin C while on INH." B "I should take this medicine with milk or juice." C "I will take this medication on an empty stomach." D "My contact lenses will be permanently stained."
C
A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best A Arrange a visitation schedule among friends and family. B Explain that this process is difficult but must be endured. C Help the client find things to hope for each day of recovery. D Provide plenty of diversionary activities for this time
C
A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP) A Encourage between-meal snacks. B Monitor temperature every 4 hours. C Provide oral care every 4 hours. D Report any new onset of cough.
C
After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching A "I will no longer need to limit my fluid intake after surgery." B "I am glad no visible incision will result from this surgery." C "I hope I can go back to wearing size 8 shoes instead of size 12." D "I will wear slip-on shoes after surgery to limit bending over."
C
A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP) (Select all that apply.) A Assist with oral hygiene using a firm toothbrush. B Give the client an enema if he or she is constipated. C Help the client choose soft foods from the menu. D Shave the male client with an electric razor. E Use a lift sheet when needed to re-position the client.
C D E
A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate (Select all that apply.) A Not allowing any visitors until engraftment B Limiting the protein in the client's diet C Placing the client in protective precautions D Teaching visitors appropriate hand hygiene E Telling visitors not to bring live flowers or plants
C D E
A nurse cares for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. Which actions should the nurse take (Select all that apply.) A Administer levothyroxine (Synthroid). B Administer propranolol (Inderal). C Monitor the apical pulse. D Assess for Trousseau's sign. E Initiate telemetry monitoring.
C E
A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best A Educate the client on oseltamivir (Tamiflu). B Facilitate admission to the hospital. C Instruct the client to have a flu vaccine. D Teach the client to sneeze in the upper sleeve
D
A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client A Bortezomib (Velcade) B Dexamethasone (Decadron) C Thalidomide (Thalomid) D Zoledronic acid (Zometa)
D
A client has been admitted for suspected inhalation anthrax infection. What question by the nurse is most important A "Are any family members also ill" B "Have you traveled recently" C "How long have you been ill" D "What is your occupation"
D
The nurse assesses a client's oral cavity and makes the discovery shown in the photo below: A Encourage the client to have genetic testing. B Instruct the client on high-fiber foods. C Place the client in protective precautions. D Teach the client about cobalamin therapy.
D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need high-fiber foods or protective precautions.