MEDSURG FINAL EXAM?

The nurse is caring for four clients who will undergo surgery today. Which client does the nurse recognize as at highest risk for surgical complication? Select one: a. 64-year-old who has just received pre-surgical prophylactic antibiotics b. 58-year-old who has well-controlled Type II diabetes c. 52-year-old who takes aspirin daily d. 69-year-old who will be discharged after surgery to an extended care facility

c. 52-year-old who takes aspirin daily

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? Select all that apply. a. Instruct the client that thyroid replacement therapy will be needed. b. Provide a warm environment for the client. c. A thyroid-releasing inhibitor will be prescribed. d. Encourage the client to consume a well-balanced diet. e. Instruct the client to consume a low-fat diet. f. Instruct the client that episodes of chest pain are expected to occur.

c. A thyroid-releasing inhibitor will be prescribed. d. Encourage the client to consume a well-balanced diet.

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? a. A beta-blocker b. An antibiotic c. An anticoagulant d. A calcium channel blocker

c. An anticoagulant

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of kidney disease. What action should the nurse take first? a. Ask the client if any labs have ever been done to examine renal function. b. Check the client's daily laboratory results. c. Contact the health care provider (HCP). d. Hang the solution.

c. Contact the health care provider (HCP).

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? a. IV fluid intake b. Urinary output c. Daily weight d. NG tube intake

c. Daily weight

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? a. Regular insulin b. Metformin c. Glucagon d. Glyburide

c. Glucagon

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? a. Dilates the major bronchi b. Increases surfactant production c. Maintains inflation of the alveoli d. Enhances ciliary action in the tracheobronchial tree

c. Maintains inflation of the alveoli

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? a. Respiratory acidosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory alkalosis

c. Metabolic alkalosis

The nurse has delegated taking orthostatic vital signs to the unlicensed assistive personnel (UAP). The UAP reports the following vital signs. Which client should the nurse assess as the priority? a. Lying BP: 122/86 mmHg; standing BP 116/78 mmHg b. Lying BP: 144/94 mm Hg; standing BP 136/88 mmHg c. Lying BP: 136/96 mmHg; standing BP 134/76 mmHg d.Lying BP: 118/76 mmHg; standing BP 128/88 mmHg

c.) Lying BP: 136/96 mmHg; standing BP 134/76 mmHg

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? a.Age b.Hypertension c.Glucose Intolerance d.Hyperlipidemia

c.Glucose Intolerance

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? a. Keep a loose seal between the lips and the mouthpiece. b. Inhale as rapidly as possible. c. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. d. After maximum inspiration, hold the breath for 15 seconds and exhale.

c.The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

The nurse educator is teaching the new registered nurse (RN) how to care for clients with a decrease in blood pressure. Which statement by the new RN indicates the need for further instruction? a. "Decreased contractility occurs." b. "Increased resistance to electrical stimulation often occurs." c. "Decreased heart rate is not a side effect." d. "Decreased myocardial blood flow is not a concern."

d. "Decreased myocardial blood flow is not a concern."

The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? a. "Low calcium levels cause high blood pressure." b. "Calcium has no effect on the risk for stroke." c. "Calcium has no effect on urinary stone formation." d. "Low calcium levels can lead to cardiac arrest."

d. "Low calcium levels can lead to cardiac arrest."

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? a. The client will lose consciousness. b. The client will complain of facial numbness and tingling. c. The client's sodium and chloride levels will rise. d. The client's arterial blood gas results will reflect acidosis.

d. The client's arterial blood gas results will reflect acidosis.

The physician orders a patient in septic shock to receive a large IV fluid bolus. How would the nurse know if this treatment was successful for this patient? a. Patient's CVP 2 mmHg b. Patient's urinary output is 20 mL/hr. c. Patient's skin is warm and flushed. d. The patient's blood pressure changes from 75/48 to 110/82.

d. The patient's blood pressure changes from 75/48 to 110/82.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? a. Air flows by gravity. b. Air is flowing against a pressure gradient. c. The respiratory muscles contract. d. The respiratory muscles relax.

d. The respiratory muscles relax.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? a. Negative Trousseau's sign b. Hypoactive bowel sounds c. Hypoactive deep tendon reflexes d. Twitching

d. Twitching

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? Select one: a. Blood pressure of 100/70 mm Hg b. Serous drainage on the surgical dressing c. Temperature of 37.6°C (99.6°F) d. Urinary output of 20 mL/hour

d. Urinary output of 20 mL/hour

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply. a. peas b. cauliflower c. potatoes d. cantaloupe e. Bananas

c. potatoes d. cantaloupe e. Bananas

A client with a complete heart block has had a permanent demand ventricular pacemaker inserted. The nurse assesses for proper pacemaker function by examining the electrocardiogram (ECG) strip for the presence of pacemaker spikes at what point? a. Just after each T wave b. Before each QRS complex c. Before each P wave d. Just after each P wave

b. Before each QRS complex

Which finding in a postoperative client would be of concern to the nurse? a. Temperature of 37.6°C (99.6°F) b. Blood pressure of 88/52 mm Hg c. Urinary output of 40 mL/hr d. Moderate drainage on the surgical dressing

b. Blood pressure of 88/52 mm Hg

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? a. Serous b. Bloody c. Serosanguineous d. Bloody, with frequent small clots

b. Bloody

A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? a. Crackles throughout the lung fields b. Crackles in the bases c. Wheezes d. Rhonchi

b. Crackles in the bases

A nurse teaches a patient who is prescribed an unsealed radioactive isotope. Which statements will the nurse include in this patient's education? (Select all that apply.) Select one or more: a. "You can play with your grandchildren for 1 hour each day." b. "Take a laxative 2 days after therapy to excrete the radiation." c. "Wash your clothing separate from others in the household." d. "Do not share utensils, plates, and cups with anyone else."

"Do not share utensils, plates, and cups with anyone else.", "Wash your clothing separate from others in the household." , "Take a laxative 2 days after therapy to excrete the radiation."

A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? Select one: a. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." b. "You'll need thyroid pills for life because your thyroid won't start working again." c. "When blood tests indicate normal thyroid function, you can stop the medication." d. "You will need to take the thyroid medication until the goiter is completely gone."

"You'll need thyroid pills for life because your thyroid won't start working again."

True or False: Septic shock causes system wide vasodilation which leads to an increase in systemic vascular resistance. In addition, septic shock causes increased capillary permeability and clot formation in the microcirculation throughout the body. a. FALSE b. TRUE

A. FALSE

A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.) Select one or more: a. Petechiae b. Weight loss c. Moon face d. Hypotension e. Muscle atrophy

A. Petechiea C. Moon face E. Muscle atrophy

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? a. An increased pH and compensatory increase in HCO3 b. An increased pH and compensatory decreased HCO3- c. An increased pH and a compensatory decreased PaCO2 d. A decreased pH and a compensatory increased PaCO2

An increased pH and compensatory decreased HCO3-

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth (NPO) status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? a. Presence of a swallow reflex b. Appetite c. Presence of bowel sounds d. Absence of nausea

Appetite

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? a. Osteoporosis b. Pacemaker c. Alcohol Abuse d. Peptic Ulcer Disease

C. Alcohol abuse

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. a. Exercise b.Non-steroidal anti-inflammatories c. Cold air d. Hot air e. An upper respiratory infection (URI)

a. Exercise b.Non-steroidal anti-inflammatories c. Cold air e. An upper respiratory infection (URI)

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. a. Fever b. Confusion c. Tremors d. Nausea e. Lethargy f. Bradycardia

a. Fever b. Confusion c. Tremors d. Nausea

A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator (TPA). What assessment finding should the nurse identify as an indicator that the client is experiencing complications of this therapy? a. Tar-like stools b. orange-colored urine c. decreased urine output d. Nausea and vomiting

a. Tar-like stools

The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? a. Have the client practice postoperative breathing exercises. b. Verify that the client has not eaten for the past 24 hours. c. Administer all the daily medications. d. Ensure that the client has voided.

D. Ensure that the client has voided

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg (90 mm Hg), and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? a. Metabolic acidosis without compensation b. Respiratory acidosis without compensation c. Metabolic acidosis with compensation d. Respiratory acidosis with compensation

b. Respiratory acidosis without compensation

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? a. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. b. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. c. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. d. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels.

It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a. Requires nasogastric suction b. Uric acid level of 9.4 mg/dL (high) c. Has a history of Addison's disease d. Sustained tissue damage

Requires nasogastric suction

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. Side-lying in bed b. Sitting up and leaning on an overbed table c. Sitting in a recliner chair d. Sitting up in bed

b. Sitting up and leaning on an overbed table

A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) Select one or more: a. Specific gravity is increased. b. Urine output is increased. c. Specific gravity is decreased. d. Urine osmolality is increased. e. Urine output is decreased. f. Urine osmolality is decreased.

Urine output is decreased. , Specific gravity is increased., Urine osmolality is increased.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. a. Decreased oxygen saturation with mild exercise b. A low arterial PCo2 level c. A hyperinflated chest noted on the chest x-ray d. A widened diaphragm noted on the chest x-ray e. Pulmonary function tests that demonstrate increased vital capacity

a. Decreased oxygen saturation with mild exercise c. A hyperinflated chest noted on the chest x-ray

The nurse is assisting in administering immunizations as well as providing education to the clients who receive them at a health care clinic. Which statement by a client indicates that teaching was successful? a. "Immunizations are a way to acquire immunity to a specific disease." b. "Immunizations can provide innate immunity." c. "Immunizations can provide natural immunity." d. "Immunizations protect against all diseases."

a. "Immunizations are a way to acquire immunity to a specific disease."

A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has capillary blood glucose of 33 mg/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? Select one: a. Administer 1 mg of intramuscular glucagon. b. Administer 25 mL dextrose 50% (D50) IV push. c. Insert a new intravenous access line. d. Encourage the patient to drink orange juice.

a. Administer 1 mg of intramuscular glucagon.

A client with a history of asthma comes to the emergency department complaining of itchy skin and shortness of breath after starting a new antibiotic. What is the first action the nurse should take? a. Assess for anaphylaxis and prepare for emergency treatment. b. Place the client on 100% oxygen and prepare for intubation. c. Obtain an arterial blood gas and immunoglobulin E (IgE) blood level. d. Teach the client about the relationship between asthma and allergies.

a. Assess for anaphylaxis and prepare for emergency treatment.

Your patient, who is post-op from a gastrointestinal surgery, is presenting with a temperature of 103.6 'F, heart rate 120, blood pressure 72/42, increased white blood cell count, and respirations of 21. An IV fluid bolus is ordered STAT. Which findings below indicate that the patient is progressing to septic shock? Select all that apply: a. Blood pressure of 70/34 after the fluid bolus b. Central venous pressure (CVP) of 18 [HIGH] c. Serum lactate less than 2 mmol/L [LOW] d. Patient needs Norepinephrine [vasopressor] to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement

a. Blood pressure of 70/34 after the fluid bolus d. Patient needs Norepinephrine [vasopressor] to maintain a mean arterial pressure (MAP) greater than 65 mmHg despite fluid replacement

A patient with a severe infection has developed septic shock. The patient's blood pressure is 72/44, heart rate 130, respiration 22, oxygen saturation 96% on high-flow oxygen, and temperature 103.6 'F. The patient's mean arterial pressure (MAP) is 53 mmHg. Based on these findings, you know this patient is experiencing diminished tissue perfusion and needs treatment to improve tissue perfusion to prevent organ dysfunction. In regards to the pathophysiology of septic shock, what is occurring in the body that is leading to this decrease in tissue perfusion? Select all that apply: a. Clot formation in microcirculation b. Vasodilation c. Increased systemic vascular resistance d. Increased capillary permeability e. A significantly decreased cardiac output

a. Clot formation in microcirculation b. Vasodilation d. increased capillary permeability

Your patient has arthritis that affects the weight-bearing joints such as the hands, knees, hips, and spine. This type of arthritis is most likely: a. Osteoarthritis b. Rheumatoid arthritis

a. Osteoarthritis

Two nurses are leaving the room of a client whose care required them to wear a gown, mask, and gloves. Which action by these nurses could lead to the spread of infection? a. Removing the gown without rolling it from inside out b. Removing the gloves and then removing the gown using the neck ties c. Taking off the gloves first before removing the gown d. Washing the hands after the entire procedure has been completed

a. Removing the gown without rolling it from inside out

The home health nurse makes a home visit to a client who has an implanted cardioverter-defibrillator (ICD) and reviews the instructions concerning pacemakers and dysrhythmias with the client. Which client statement indicates that further teaching is necessary? a. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker." b. "My wife knows how to call the emergency medical services (EMS) if I need it." c. "If I feel an internal defibrillator shock, I should sit down." d. "I won't be able to have a magnetic resonance imaging test (MRI)."

a. "I can stop taking my antidysrhythmic medicine now because I have a pacemaker."

The nursing student conducted a clinical conference on the role of B lymphocytes in the immune system. Which statement by a fellow nursing student indicates successful teaching? a. "They attack and kill the target cell directly." b. "They initiate phagocytosis." c. "They produce antibodies." d. "They activate T cells."

a. "They attack and kill the target cell directly."

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? a. A client with an ileostomy b. A client receiving frequent wound irrigations c. A client on long-term corticosteroid therapy d. A client with heart failure

a. A client with an ileostomy

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? a. Adjust the oxygen depending on SpO2. b. Do not exceed 1 L/min. c. Adjust the oxygen depending on respiratory rate. d. Do not exceed 2 L/min.

a. Adjust the oxygen depending on SpO2.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? a. Administer the prescribed bronchodilator. b. Place the client in low Fowler's position. c. Instruct the client to limit fluid intake. d. Place a continuous pulse oximeter on the client.

a. Administer the prescribed bronchodilator.

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? a. An arterial ulcer b. A stage 1 pressure ulcer c. A vascular ulcer d. A venous stasis ulcer

a. An arterial ulcer

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? a. An increased amount of NPH insulin daily insulin b. A decreased amount of NPH insulin daily insulin c. An increased-calorie diet d. A decreased-calorie diet

a. An increased amount of NPH insulin daily insulin

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? Select all that apply. a. Application of moist heat to the right leg b. Ambulation in around the nursing unit every hour c. Monitoring for signs of pulmonary embolism d. Elevation of the right leg e. Administration of acetaminophen

a. Application of moist heat to the right leg c. Monitoring for signs of pulmonary embolism d. Elevation of the right leg e. Administration of acetaminophen

When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? a. Apply a sterile dressing soaked with normal saline. b. Apply a sterile dressing soaked in povidone-iodine. c. Irrigate the wound and apply a sterile dry dressing. d. Leave the incision open to the air to dry the area.

a. Apply a sterile dressing soaked with normal saline.

The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. a. Assess extremities for edema. b. Maintain a high-sodium diet. c. Monitor daily weight. d. Maintain a low-potassium diet. e. Monitor intake and output.

a. Assess extremities for edema. c. Monitor daily weight. e. Monitor intake and output.

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? a. Assess the client for signs of dizziness and hypotension. b. Assist the client to move quickly from the lying position to the sitting position. c. Elevate the head of the bed quickly to assist the client to a sitting position. d. Allow the client to rise from the bed to a standing position unassisted.

a. Assess the client for signs of dizziness and hypotension.

A client is scheduled for a cardiac catheterization to diagnose the extent of coronary artery disease. The nurse places highest priority on telling the client to report which sensation during the procedure? a. Chest pain b. Warm, flushed feeling c. Urge to cough d. Pressure at insertion site

a. Chest pain

The nurse suspects that a patient is deficient in thyroid-stimulating hormone. What assessment findings would correlate to this condition? (Select all that apply.) Select one or more: a. Decreased libido b. Alopecia c. Hyperactivity d. Weight gain

a. Decreased libido b. alopecia d. weight gain

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? a. IV fluids containing dextrose b. NPH insulin subcutaneously c. An ampule of 50% dextrose d. Phenytoin for the prevention of seizures

a. IV fluids containing dextrose

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? a. Inability to clear the airway related to inability to expectorate sputum b. Altered breathing pattern secondary to increased work of breathing c. Gas exchange alteration related to ventilation-perfusion mismatch d. Low cardiac output secondary to cor pulmonale (right-sided heart failure)

a. Inability to clear the airway related to inability to expectorate sputum

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? a. Inadequate fluid volume b. Compromised family coping c. Inadequate consumption of nutrients d. Lack of Knowledge

a. Inadequate fluid volume

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. a. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. b. Encourage the client to consume fluids and high-fiber foods in the diet. c. Instruct the client about thyroid replacement therapy. d. Inform the client that iodine preparations will be prescribed to treat the disorder. e. Provide a cool environment for the client. f. Instruct the client to consume a high-fat diet.

a. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. b. Encourage the client to consume fluids and high-fiber foods in the diet. c. Instruct the client about thyroid replacement therapy.

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. a. Irritability b. Nervousness c. Anorexia d. Hot, dry skin e. Tremors

a. Irritability b. Nervousness e. Tremors

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. a. Lightheadedness b. Fruity Breath c. Palpitations d. Shakiness e.Polyuria

a. Lightheadedness c. palpitations d. shakiness

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Listening to lung sounds b. Assessing for jugular vein distention c. Assessing for peripheral and sacral edema d. Palpating for organomegaly (organ enlargement)

a. Listening to lung sounds

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. a. Loss of body hair b. Tremors c. Persistant lethargy d. Weight loss e. Feeling cold

a. Loss of body hair c. Persistant lethargy e. Feeling cold

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? Select all that apply. a. Maintain aseptic technique when emptying the drain. b. Curl the drain tightly, and tape it firmly to the body. c. Check the drain for patency. d. Clamp the drain for 15 minutes every hour. e. Observe for bright red bloody drainage.

a. Maintain aseptic technique when emptying the drain. c. Check the drain for patency. e. Observe for bright red bloody drainage.

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? a. Maintain inflation of the alveoli. b. Dilate the major bronchi. c. Enhance ciliary action in the tracheobronchial tree. d. Increase surfactant production

a. Maintain inflation of the alveoli.

You're explaining to a group of outpatients about the signs and symptoms that may present with osteoarthritis. Select all the signs and symptoms that may present with this condition: a. Morning stiffness for less than 30 minutes b. Crepitus c. Hard and bony joints d. Soft, tender, warm joints e. Anemia f. Herberden's Node g. Bouchard's Node h. Fever

a. Morning stiffness for less than 30 minutes b. Crepitus c. Hard and bony joints f. Herberden's Node g. Bouchard's Node

The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? a. Myocardial infarction. b. Heart failure. c. Ventricular tachycardia. d. Atrial fibrillation.

a. Myocardial infarction.

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action to lessen chance of repeat pneumothorax? a. Perform the Valsalva maneuver. b. Exhale very quickly. c. Inhale and exhale quickly. d. Stay very still.

a. Perform the Valsalva maneuver.

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. a. Respirations that are abnormally deep b. Respirations that are abnormally slow c. Respirations that are shallow d. Respirations that are increased in rate

a. Respirations that are abnormally deep d. Respirations that are increased in rate

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. Respiratory distress b. Hypoglycemia c. Level of hoarseness d. Edema at the surgical site

a. Respiratory distress

Which assessment data finding for a client scheduled for total knee replacement surgery is most important for the nurse to communicate to the surgeon and the anesthesia provider before the procedure? Select all that apply. Select one or more: a. The client took a total of 1300 mg of aspirin yesterday. b. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker. c. The client took a regularly scheduled antihypertensive drug with a sip of water 2 hours ago. d. The oxygen saturation is 97%. e. The serum potassium level is 3.0 mEq/L (3.0 mmol/L). f. The client requests to talk with a registered dietitian about weight loss.

a. The client took a total of 1300 mg of aspirin yesterday. b. After receiving the preoperative medications, the client tells the nurse that he lied on the assessment form and that he really is a current smoker. e. The serum potassium level is 3.0 mEq/L (3.0 mmol/L).

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? a. The client with kidney disease and a 12-year history of diabetes mellitus b. The client taking diuretics and has tenting of the skin c. The client who requires intermittent gastrointestinal suctioning d. The client with an ileostomy from a recent abdominal surgery

a. The client with kidney disease and a 12-year history of diabetes mellitus

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? Select all that apply. a. Walk each day to increase circulation to the legs. b. Cut down on the amount of fats consumed in the diet. c. Soak the feet in hot water daily. d. Be careful not to injure the legs or feet. e. Use a heating pad on the legs to aid vasodilation.

a. Walk each day to increase circulation to the legs. b. Cut down on the amount of fats consumed in the diet. d. Be careful not to injure the legs or feet.

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? a. Weigh self on a daily basis. b. Withhold prescribed digoxin if slight respiratory distress occurs. c. Take a double dose of the diuretic if peripheral edema is noted. d. Sleep with the head of the bed flat.

a. Weigh self on a daily basis.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. a. difficulty breathing b. increased during output c. Neck vein distention in the upright position d. Bounding pulse e. presence of dependent edema

a. difficulty breathing c. Neck vein distention in the upright position d. Bounding pulse e. presence of dependent edema

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. a. Elevated blood glucose b. Deep, rapid breathing c. increased pH d. Decreased urine output

a. elevated blood glucose b. deep rapid breathing

A nurse teaches a patient with hyperthyroidism. Which dietary modifications should the nurse include in this patient's teaching? (Select all that apply.) Select one or more: a. Increased carbohydrates b. Increased proteins c. Decreased fats d. Increased calorie intake

a. increased carbohydrates b. increased proteins d. increased calorie intake

The PACU nurse caring for a client with a nasogastric (NG) tube notes 300 mL of bright red blood has collected. What is the appropriate nursing action? Select one: a. Call the client's surgeon to report the drainage. b. Document as a normal finding. c. Place the client in Trendelenburg position. d. Immediately remove the NG tube.

a.Call the client's surgeon to report the drainage.

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? a. "I need to call the health care provider (HCP) because of these symptoms." b. "I need to stop my insulin." c. "I need to monitor my blood glucose every 3 to 4 hours." d. "I need to increase my fluid intake."

b. "I need to stop my insulin."

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? Select one: a. "Food just doesn't taste good without a lot of salt." b. "I am always tired, even with 12 hours of sleep." c. "My sister has thyroid problems." d. "I seem to feel the heat more than other people."

b. "I am always tired, even with 12 hours of sleep."

The nursing instructor asks a nursing student to identify the components of natural resistance as it relates to the immune system. All of the following are characteristics of natural resistance EXCEPT? a. "It is the immunity with which a person is born." b. "It includes all antigen-specific immunities a person develops during a lifetime." c. "It does not require previous exposure to the antigen." d. "It also is called inherited immunity."

b. "It includes all antigen-specific immunities a person develops during a lifetime."

A registered nurse (RN) is providing instructions to an unlicensed assistive personnel (UAP) assigned to give a bed bath to a client who is on contact precautions. The RN instructs the UAP to use which protective item when giving the bed bath? a. Gloves and shoe protectors b. A gown and gloves c. A gown and goggles d. Gloves and goggles

b. A gown and gloves

Your patient is started on an IV antibiotic to treat a severe infection. During infusion, the patient uses the call light to notify you that she feels a tight sensation in her throat and it's making it hard to breathe. You immediately arrive to the room and assess the patient. While auscultating the lungs you note wheezing. You also notice that the patient is starting to scratch the face and arms, and on closer inspection of the face you note redness and swelling that extends down to the neck and torso. The patient's vital signs are the following: blood pressure 89/62, heart rate 118 bpm, and oxygen saturation 88% on room air. You suspect anaphylactic shock. Select all the appropriate interventions for this patient: a. Slow down the antibiotic infusion b. Call a rapid response c. Prepare for the administration of Epinephrine d. Place the patient on oxygen

b. Call a rapid response c. Prepare for the administration of Epinephrine d. Place the patient on oxygen

An erythrocyte sedimentation rate (ESR) determination is prescribed for a client with a connective tissue disorder. The client asks the nurse about the purpose of the test. What should the nurse tell the client about the purpose of the test? a. Identifies which additional tests need to be performed b. Confirms the presence of inflammation or infection in the body c. Determines the presence of antigens d. Confirms the diagnosis of a connective tissue disorder

b. Confirms the presence of inflammation or infection in the body

A nurse cares for a patient who is recovering from a pituitary gland resection (hypophysectomy). What action would the nurse take first? Select one: a. Apply petroleum jelly to lips to avoid dryness b. Instruct the patient to cough, turn, and deep breathe. c. Report clear or light yellow drainage from the nose. d. Keep the head of the bed flat and the patient supine.

b. Instruct the patient to cough, turn, and deep breathe.

The nurse is assisting in planning care for a client with a diagnosis of immunodeficiency and should incorporate which action as a priority in the plan? a. Identifying factors that decreased the immune function b. Protecting the client from infection c. Providing emotional support to decrease fear d. Encouraging discussion about lifestyle changes

b. Protecting the client from infection

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? a. "I have to cut down on the percentage of carbohydrates in my diet." b. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." c. "Besides smoking, I can't be around second- or thirdhand smoke." d. "I need to avoid alcohol and sedative medications."

b. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute."

The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? a. "I will check my blood glucose level 2 hours after each meal." b. "I will check my blood glucose level before each meal and at bedtime." c. "I will check my blood glucose level every day at 5:00 p.m." d. "I will check my blood glucose level 1 hour after each meal."

b. "I will check my blood glucose level before each meal and at bedtime."

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will decrease my insulin dose during times of illness." b. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." c. "I will adjust my insulin dose according to the level of glucose in my urine." d. "I will stop taking my insulin if I'm too sick to eat."

b. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? a. "Oxygen will prevent the development of any thrombus." b. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." c. "Oxygen has a calming effect." d. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."

b. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? Select one: a. "Early ambulation and administration of blood thinners will prevent pulmonary embolism." b. "Use of an incentive spirometer will help prevent pneumonia." c. "Close monitoring of your oxygen saturation will detect hypoxemia." d. "Administration of intravenous fluids will prevent or treat fluid imbalance."

b. "Use of an incentive spirometer will help prevent pneumonia."

The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? a. "Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves." b. "Ventricular fibrillation does not have P waves or QRS complexes." c. "Ventricular fibrillation appears as irregular beats within a rhythm." d. "Ventricular fibrillation is a regular pattern of wide QRS complexes."

b. "Ventricular fibrillation does not have P waves or QRS complexes."

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NG tube? a. 0.45% sodium chloride b. 0.9% sodium chloride c. Tap Water d. Sterile Water

b. 0.9% sodium chloride

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. a. 0.45% sodium chloride b. 10% dextrose in water c. 0.9% Normal Saline d. 5% dextrose in 0.9% saline e. 5% dextrose in 0.45% saline

b. 10% dextrose in water, d. 5% dextrose in 0.9% saline, e. 5% dextrose in 0.45% saline

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. Excessive bubbling in the water seal chamber b. 50 mL of drainage in the drainage collection chamber c. Drainage system maintained below the client's chest d. Vigorous bubbling in the suction control chamber e. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation f. Occlusive dressing in place over the chest tube insertion site

b. 50 mL of drainage in the drainage collection chamber c. Drainage system maintained below the client's chest e. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation f. Occlusive dressing in place over the chest tube insertion site

The nurse is reviewing the laboratory test results for a client with a diagnosis of Cushing's syndrome. Which laboratory finding would the nurse expect to note in this client? a. A blood glucose level of 110 mg/d b. A potassium (K+) level of 3.0 mEq/L c. A white blood cell (WBC) count of 6.0 d. A platelet count of 200,000 mm3

b. A potassium (K+) level of 3.0 mEq/L

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. Administer 5% dextrose intravenously. b. Administer short-duration insulin intravenously. c. Apply a monitor for an electrocardiogram. d. Correct the acidosis

b. Administer short-duration insulin intravenously.

A client calls the nurse in the emergency department and states that he was just stung by a bumblebee while gardening. The client is afraid of a severe reaction because the client's neighbor experienced such a reaction just 1 week ago. Which action should the nurse take? a. Tell the client not to worry about the sting unless difficulty with breathing occurs. b. Ask the client if he ever sustained a bee sting in the past. c. Tell the client to call an ambulance for transport to the emergency department. d. Advise the client to soak the site in hydrogen peroxide.

b. Ask the client if he ever sustained a bee sting in the past.

The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? Select all that apply. a. Administer all the daily medications 2 hours before the scheduled time of the surgery. b. Assist the client to void before transfer to the operating room. c. Check all surgeon's prescriptions to ensure they have been carried out. d. Review the client's record for a history and physical report and laboratory reports. e. Teach postoperative breathing exercises before the client is premedicated.

b. Assist the client to void before transfer to the operating room. c. Check all surgeon's prescriptions to ensure they have been carried out. d. Review the client's record for a history and physical report and laboratory reports.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client most likely has which condition? a. Fluid Overload b. Dehydration c. Hypernatremia d. Hypokalemia

b. Dehydration

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. a. Reduce fluid intake to less than 1500 mL/day. b. Encourage alternating activity with rest periods. c. Keep the client in a supine position as much as possible. d. Teach the client techniques of chest physiotherapy. e. Teach diaphragmatic and pursed-lip breathing.

b. Encourage alternating activity with rest periods. d. Teach the client techniques of chest physiotherapy. e. Teach diaphragmatic and pursed-lip breathing.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a. Placing a pillow under the knees b. Encouraging active range-of-motion exercises c. Restricting fluids d. Applying a heating pad to the lower extremities

b. Encouraging active range-of-motion exercises

The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? a. Complaints of headache. b. Hypotension. c. Flat neck veins. d. Complaints of nausea.

b. Hypotension.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? a. Place the client on a nonrebreather mask on 100% FiO2. b. Increase to 3 L/min and titrate until the SpO2 is 92%. c. Maintain at 2 L/min and call respiratory therapy for a breathing treatment. d. Increase to 3 L/min and titrate until the SpO2 is 95%.

b. Increase to 3 L/min and titrate until the SpO2 is 92%.

The charge nurse in a long-term care facility wants to decrease the incidence of fluid volume deficit in the facility's residents (patients). What action by the nurse is best? a. Perform comprehensive assessments for fluid volume deficit. b. Institute "fluid rounds" offering beverages every 2 hours. c. Weigh the residents weekly on the same scale each morning. d. Create a policy mandating monthly urine specific gravity tests.

b. Institute "fluid rounds" offering beverages every 2 hours.

The nurse is reading a health care provider's (HCP's) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? a. The gastrointestinal tract b. Integumentary output c. Wound drainage d. Urinary output

b. Integumentary output

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. a. Increased body temperature b. Muscle retractions c. Clubbed fingers d. Dyspnea at rest e. Prolonged expiratory breathing phase f. Decreased respiratory rate

b. Muscle retractions c. Clubbed fingers d. Dyspnea at rest e. Prolonged expiratory breathing phase

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? Select one: a. Obtain a court order for the surgery. b. Obtain a telephone consent from a family member, following agency policy. c. Send the client to surgery without the consent form being signed. d. Have the charge nurse sign the informed consent immediately.

b. Obtain a telephone consent from a family member, following agency policy.

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? a. Assess the client's pain. b. Obtain the client's vital signs. c. Administer oxygen to the client. d. Check the rate of the intravenous infusion.

b. Obtain the client's vital signs.

What client teaching will the nurse provide regarding postoperative leg exercises, to minimize the risk for development of deep vein thrombosis after surgery? a. Begin exercises by sitting at a 90-degree angle on the side of the bed. b. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs. c. Bend knee, and push heel of foot into the bed until the calf and thigh muscles contract. Repeat several times, then switch legs. d. Only perform each exercise one time to prevent overuse.

b. Point toes of one foot toward bottom of bed, then point toes of same leg toward their face. Repeat several times, then switch legs

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? a. Negative Chvostek's sign b. Positive Trousseau's sign c. Hypoactive bowel sounds d. Unresponsive pupils

b. Positive Trousseau's sign

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? a. Promote oxygen intake. b. Promote carbon dioxide elimination. c. Strengthen the intercostal muscles. d. Strengthen the diaphragm.

b. Promote carbon dioxide elimination.

A nurse assesses a patient with anterior pituitary hyperfunction. Which clinical manifestations would the nurse expect? (Select all that apply.) Select one or more: a. High-pitched voice b. Protrusion of the lower jaw c. Enlarged hands and feet d. Barrel-shaped chest

b. Protrusion of the lower jaw c. Enlarged hands and feet d. Barrel-shaped chest

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? a. The client puffs out the cheeks when breathing out through the mouth. b. The client breathes out slowly through the mouth. c. The client avoids using the abdominal muscles to breathe out. d. The client breathes in through the mouth.

b. The client breathes out slowly through the mouth.

A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? Select one: a. Reassure the patient that the voice change is temporary. b. Contact the provider and prepare for intubation. c. Document the finding and assess the patient hourly. d. Place the patient in high-Fowler's position and apply oxygen

b. contact provider and prepare for intubation

A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? a. Left atrium b. Left ventricle c. Right atrium d. Right ventricle

b. left ventricle

A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first? Select one: a. Consult with the dietitian about increased dietary sodium b. Restrict the patient's fluid intake to 600 mL/day. c. Handle the patient gently by using turn sheets for repositioning. d. Instruct unlicensed assistive personnel to measure intake and output.

b. restrict the patients fluid intake to 600 mL/day

A client is scheduled for surgery at noon. The surgeon is delayed and the surgery is now scheduled for 3:00 PM. How will the nurse plan to administer the preoperative prophylactic antibiotic? a.Give at noon as originally prescribed. b.Adjust the administration time to be given within one hour prior to surgery. c.Cancel orders; preoperative prophylactic antibiotics are given optionally. d.Hold the preoperative antibiotic so it can be administered immediately following surgery.

b.Adjust the administration time to be given within one hour prior to surgery.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? a. "NPH is a basal insulin, so I should exercise in the evening." b. "I should not exercise since I am taking insulin." c. "The best time for me to exercise is after breakfast." d. "The best time for me to exercise is mid- to late afternoon."

c. "The best time for me to exercise is after breakfast."

A client has fluid volume deficit and the provider has prescribed isotonic IV solution at a rate of 100 ml/hour. Which solution does the nurse choose? a. 0.45% sodium chloride (1/2 NS) b. 10% dextrose in water (D10W) c. 0.9% sodium chloride (NS) d. 5% dextrose in water (D5W)

c. 0.9% sodium chloride (NS)

The nursing student conducting a clinical conference on immunity places an emphasis on active immunity. Which statement by fellow nursing students indicates successful teaching? a. "Passive immunity can last for years." b. "Active immunity only lasts from days to months." c. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen." d. "Active immunity provides protection immediately and forever."

c. "Active immunity lasts for years and can be easily reactivated by a booster dose of antigen."

The nurse provides education to the client about the primary purpose of neutrophils. Which statement by the client indicates successful teaching? a. "They close up blood vessels." b. "They increase fluids at the injury site." c. "They engulf any potential foreign materials." d. "They open up blood vessels."

c. "They engulf any potential foreign materials."

A nurse assesses patients for potential endocrine disorders. Which patient is at greatest risk for hyperparathyroidism? Select one: a. A 66-year-old female with moderate heart failure b. A 29-year-old female with pregnancy-induced hypertension c. A 41-year-old male receiving dialysis for end-stage kidney disease d. A 72-year-old male who is prescribed home oxygen therapy

c. A 41-year-old male receiving dialysis for end-stage kidney disease

A patient is in anaphylactic shock. The patient has a severe allergy to peanuts and mistakenly consumed an eggroll containing peanut ingredients during his lunch break. The patient is given Epinephrine intramuscularly. As the nurse, you know this medication will have what effect on the body? a. It will prevent a recurrent attack. b. It will cause vasoconstriction and decrease the blood pressure. c. It will help dilate the airways. d. It will help block the effects of histamine in the body.

c. It will help dilate the airways.

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? Select one: a. Propranolol (Inderal) b. Atropine sulfate c. Levothyroxine sodium (Synthroid) d. Epinephrine (Adrenalin)

c. Levothyroxine sodium (Synthroid)

The nurse is caring for a client with a wound infected with methicillin-resistant Staphylococcus aureus (MRSA). The most appropriate infection control precautions for MRSA include which intervention? a. Mask or respiratory protection device and gown b. Private room with negative-pressure airflow c. Private room, gown, gloves, and face shield d. Room with positive-pressure airflow

c. Private room, gown, gloves, and face shield

The home health nurse is watching the caregiver change the sternotomy dressing on the postoperative client. Which action by the caregiver identifies correct principles of infection control? a. The caregiver selects a previously opened gauze to cover the sternal wound. b. The caregiver dons gloves before removal of the old dressing and then applies the new dressing. c. The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing. d. The caregiver covers her mouth with her hand when she sneezes and then continues with the dressing change.

c. The caregiver washes her hands before removal of the soiled dressing and again before applying the clean dressing.

You're assessing the patient's complete blood count (CBC). Which lab result below demonstrates leukopenia? a. Platelets 500,000 b. Platelets 90,000 c. WBC 3,000 d. WBC 7,000

c. WBC 3,000

The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? a. "Edema will be present in the legs." b. "Blood pressure will decrease." c. "Pulse rate will increase." d. "Crackles in the lungs will be present."

c. "Pulse rate will increase."

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? a. Tracheostomy collar b. Aerosol mask c. Venturi mask d. Face tent

c. Venturi mask

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. Hypotension b. Cyanosis c. Paradoxical chest movement d. Dyspnea, especially on exhalation

c. Paradoxical chest movement

A client is admitted to the hospital with difficulty breathing. Which is the best approach for the nurse to use in obtaining the client's health history? a. Focus only on completing the physical examination. b. Obtain all health history information from family members. c. Plan short sessions with the client to obtain most recent health history data. d. Use the primary health care provider's documented medical history.

c. Plan short sessions with the client to obtain most recent health history data.

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? a. Pedal Edema b. Decreased respiratory rate c. Polyuria d. Diaphoresis

c. Polyuria

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? a. Cover the client with a warm blanket. b. Shake the client gently to arouse. c. Recheck the vital signs in 15 minutes. d. Call the surgeon immediately.

c. Recheck the vital signs in 15 minutes.

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2of 30 mm Hg (30 mm Hg), and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? a. Metabolic acidosis, compensated b. Metabolic alkalosis, uncompensated c. Respiratory alkalosis, compensated d. Respiratory acidosis, uncompensated

c. Respiratory alkalosis, compensated

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? a. Ask the client about sensation of moistness on her perineal pad. b. Check the blood pressure. c. Roll the client to one side and check her perineal pad. d. Check the heart rate.

c. Roll the client to one side and check her perineal pad.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? a. Respiration b. Blood Pressure c. Temperature d. Pulse

c. Temperature

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? a. The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. b. The client requires follow-up teaching regarding the administration of oral antidiabetics. c. The client needs immediate education before discharge. d. The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.

c. The client needs immediate education before discharge.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? a. The client with hyperaldosteronism b. The client with Cushing's syndrome c. The client who is taking diuretics

c. The client who is taking diuretics

The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse should interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? a. The client says the pain began while she was trying to open a stuck dresser drawer. b. The client is not experiencing nausea or vomiting. c. The pain has not been relieved by rest and nitroglycerin tablets. d. The client is not experiencing dyspnea.

c. The pain has not been relieved by rest and nitroglycerin tablets.

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? a. To stimulate release of parathyroid hormone b. To prevent cardiac irritability c. To treat hypocalcemic tetany d. To treat thyroid storm

c. To treat hypocalcemic tetany

A client who has had a myocardial infarction asks the nurse why she should not bear down or strain to ensure having a bowel movement. The nurse provides education to the client based on which physiological concept? a. Sympathetic nerve stimulation causes an increase in heart rate and cardiac contractility. b. Sympathetic nerve stimulation causes a decrease in heart rate and cardiac contractility. c. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility. d. Vagus nerve stimulation causes an increase in heart rate and cardiac contractility.

c. Vagus nerve stimulation causes a decrease in heart rate and cardiac contractility.

A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next? Select one: a. Administer 10 units of regular insulin subcutaneously. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 1 mg of glucagon intramuscularly. d. Administer another half-cup (120 mL) of orange juice

d. Administer another half-cup (120 mL) of orange juice

What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient? a. Administering Corticosteroids b. Establishing IV access c. Administering Epinephrine d. Assessing, documenting, and avoiding all the patient allergies

d. Assessing, documenting, and avoiding all the patient allergies

A patient is at risk for septic shock when a microorganism invades the body. Which microorganism is the MOST common cause of sepsis? a. Parasite b. Virus c. Fungus d. Bacteria

d. Bacteria

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? Select one: a. Extremity tremors followed by seizure activity b. Oral temperature of 102° F (38.9° C) c. Severe orthostatic hypotension d. Increased rate and depth of respiration

d. Increased rate and depth of respiration

Which statement is FALSE concerning rheumatoid arthritis? a. Rheumatoid arthritis can occur at any age (20-60 year old most commonly). b. Rheumatoid arthritis most commonly affects the fingers and wrist. c. Ankylosis can occur in severe cases of rheumatoid arthritis. d. Rheumatoid arthritis is different from osteoarthritis in that it doesn't affect other systems of the body.

d. Rheumatoid arthritis is different from osteoarthritis in that it doesn't affect other systems of the body.

While assessing a patient with Graves' disease, the nurse notes that the patient's temperature has risen 1° F (1° C). What does the nurse do first? Select one: a. Administer a dose of acetaminophen (Tylenol). b. Calculate the patient's apical-radial pulse deficit. c. Call for an immediate electrocardiogram (ECG). d. Turn the lights down and shut the patient's door.

d. Turn the lights down and shut the patient's door.

A student nurse is giving hand-off report to the registered nurse on four clients who have fluid volume deficit. Which client should the registered nurse assess first? a. 76-year-old client, urine specific gravity 1.028 b. 66 kg client, urine output averages 36ml/hour for the last 4 hours c. 100 kg client, lying BP 128/72 mmHg, standing BP 118/68 mmHg d. 86-year-old client, IV fluids infusing at 100 ml/hour, rales bilaterally

d. 86-year-old client, IV fluids infusing at 100 ml/hour, rales bilaterally

The nurse is assessing four hospitalized clients for fluid volume deficit. Which client should the nurse assess further as the priority? a. 106 kg client; pulse 108 beats per minute b. 79 kg client; cannot obtain fluids c. 102 kg client; urine output 73 ml in 1 hour d. 98 kg client; urine specific gravity 1.042 (high)

d. 98 kg client; urine specific gravity 1.042 (high)

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? a. Elevated blood pressure b. Bilateral crackles in the lungs c. Bradycardia d. Changes in mental status

d. Changes in mental status

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? a. Press the recorder button on the electrocardiogram console. b. Call a code. c. Call the health care provider. d. Check the client's status and lead placement.

d. Check the client's status and lead placement.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? a. Notify the health care provider. b. Check for an air leak. c. Change the chest tube drainage system d. Document the findings.

d. Document the findings.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? a. Increased oxygen saturation with ambulation b. A widened diaphragm documented by chest x-ray c. A shortened expiratory phase of the respiratory cycle d. Hyperinflation of lungs documented by chest x-ray

d. Hyperinflation of lungs documented by chest x-ray

The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? a. Draw up the correct dosage of NPH insulin into the syringe. b. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin. c. Draw up the correct dosage of regular insulin into the syringe. d. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

d. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Administer fluid replacement b. Administer thyroid hormone c. Warm the client d. Maintain a patent airway

d. Maintain a patent airway

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? a. Take the pulse oximetry reading from any finger. b. Check labs, Hgb and Hct. c. Remove one of the artificial nails and then obtain the reading from the finger. d. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. e. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger.

d. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? a. Plan activities with rest periods to conserve oxygen needs. b. Monitor oxygenation (the oxygen saturation [SaO2]) during activity. c. Initiate and maintain supplemental oxygen as prescribed. d. Provide nasotracheal suctioning as needed to remove secretions.

d. Provide nasotracheal suctioning as needed to remove secretions.

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? a. Blood pressure decreased from 140/86 to 112/72 mm Hg. b. Oxygen saturation decreased from 96% to 91%. c. Pulse rate increased from 80 to 104 beats per minute. d. Respiratory rate increased from 16 to 19 breaths per minute.

d. Respiratory rate increased from 16 to 19 breaths per minute.

The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse explains to the client that the normal site in the heart responsible for initiating electrical impulses is which site? a. Bundle of His b. Purkinje fibers c. Atriventricluar (AV) node d. Sinoatrial (SA) node

d. SA node

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy (gall bladder removal). Which intervention would be of highest priority in the preoperative teaching plan? a. Assessing the client's understanding of the surgical procedure b. Teaching leg exercises c. Providing instructions regarding fluid restrictions d. Teaching coughing and deep breathing exercises

d. Teaching coughing and deep breathing exercises

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? a. The client has COPD b. The client has acidotic blood. c. The client is fluid volume overloaded. d. The client is probably hyperventilating.

d. The client is probably hyperventilating.

A nurse evaluates the following laboratory results for a patient who has hypoparathyroidism:Calcium 7.2 mg/dL (1.8 mmol/L)Sodium 144 mEq/L (144 mmol/L)Magnesium 1.2 mEq/L (0.6 mmol/L)Potassium 5.7 mEq/L (5.7 mmol/L)Based on these results, which medications does the nurse anticipate administering? (Select all that apply.) Select one or more: a. Oral potassium chloride b. 3% normal saline IV solution c. Oral calcitriol (Rocaltrol) d. 50% magnesium sulfate e. Intravenous calcium chloride

d.50% magnesium sulfate e. Intravenous calcium chloride

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? Select one: a.Avoid oral hygiene and rinsing with mouthwash. b.Verify that the client has not eaten for the last 24 hours. c.Report immediately any slight increase in blood pressure or pulse. d.Have the client void immediately before going into surgery.

d.Have the client void immediately before going into surgery.