Med/Surge 2019
Posterior Tibial pulse
Left side of ankle/foot
A nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which of the following findings should the nurse report to the provider?
WBC 2300/mm3 This WBC finding is below the expected reference range. Chemotherapy treatment can cause leukopenia; the nurse should report this finding to the provider and implement precautions to protect the client from infection.
A nurse is caring for a client with myasthenia gravis. Which manifestations should the nurse monitor for?
Weakness Generalized weakness of the diaphragmatic and intercostal muscles may produce respiratory distress or predispose the client to respiratory infections.
A charge nurse is anticipating the admission of 4 clients and planning their room assignments. Which client should be close to the nurse's station?
A client who sustained a head injury and is having periods of confusion. client who sustained a head injury and is confused is at risk for seizures. The nurse should place this client in a room near the nurses' station so that he can be closely monitored to prevent injury if a seizure occurs.
A nurse is instructing a group of clients regarding nutrition. The teaching should state that which of the following food groups contains the highest level of carbohydrates?
Rice, potatoes, and oranges
A nurse is discussing the norming stage of the development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
Consensus evolves in this stage Consensus occurs and cooperation develops during the norming stage of the group development process.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
Dysmenorrhea that is unresponsive to NSAIDs Endometriosis is a condition in which the type of tissue that lines the uterus implants in locations outside the uterus. This typically causes pelvic pain around the time of the menstrual period but can cause pain at other times in the cycle. THe discomfort is often unrelieved by the use of NSAIDs.
A nurse in the ED is implementing a plan of care for a conscious client who has a suspected cervical cord injury. Which of the following immediate interventions should the nurse implement?
Hypotension, absence bowel sounds, weakened gag reflex Hypotension is correct. Lack of sympathetic input can cause a decrease in blood pressure. The nurse should maintain the client's SBP at 90 mm Hg or above to adequately perfuse the spinal cord. Absence of bowel sounds is correct. Spinal shock leads to decreased peristalsis, which could cause the client to develop a paralytic ileus. Weakened gag reflex is correct. The nurse should monitor the client for difficulty swallowing, or coughing and drooling noted with oral intake.
A nurse is teaching an assistive personnel about using personal protective equipment while caring for clients. Which of the following statements should the nurse identify as an indication that that AP understands?
"I will wear gloves and a gown when bathing a client who has open skin lesions." The AP should wear personal protective equipment when in direct contact with a client's bodily fluids, such as gloves and a gown when coming in contact with wound exudate is possible.
A charge nurse is planning a room assignment for a client who has a productive cough, a questionable chest x-ray, and positive Mantoux test. Room 208 is private, negative-pressure airflow room; room 212 is semi private, positive-pressure air flow room; 214 is a negative-pressure, semi-private room; and room 216 is a private, positive-pressure airflow room. To which of the following rooms should the nurse assign the client?
208 A client who has or might have tuberculosis requires airborne precautions. That means a private room with negative-pressure airflow. Room 208 is the only one of these options that fits these requirements.
A nurse is preparing to infuse a 250 mL of packed RBCs over 2 hours. The drop factor of the manual IV tubing is 15 gtts/mL. The nurse should adjust the flow rate to deliver how many drops per minute?
31 gtt/min
Instill 840ml of enteral nutrition via gastrostomy tube over 24 hour using an infusion pump. How many mL
35
Isolation for active pulmonary tuberculosis
A protective mask is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering the room requires respiratory protection, in the form of an appropriate filtration mask. A closed door is correct. Clients who have active pulmonary tuberculosis require airborne precautions. Everyone entering or leaving the room should close the door behind them. A puncture-proof sharps container is correct. Nurses must always dispose of needles and sharp instruments in puncture-proof sharps containers. Hand hygiene is correct. Hand hygiene is essential before and after all contact with clients.
A nurse is providing instructions about bowl cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which info should the nurse include
Abdominal bloating may occur. While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.
A nurse in the ED is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning care, the nurse should identify which risk as priority
Airway obstruction When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take?
Apply to intact skin, cleans the skin prior to procedure, apply medication an hour before procedure begins, use a visual pain rating scale to evaluate effectiveness of the treatment pply to intact skin is correct. The nurse should apply cream over intact skin to reduce the risk for systemic toxicity. The nurse should wear gloves while applying the cream to reduce the risk of absorbing the anesthetic. Apply the medication an hour before the procedure begins is correct. The nurse should allow 30 min to 1 hr for the topical analgesic to take effect. Cleanse the skin prior to procedure is correct. Apply the topical analgesic to clean skin to increase absorption. Use a visual pain rating scale to evaluate effectiveness of the treatment is correct. A child's response and understanding of pain depends on the child's age and stage of development. A preschooler might be unable to describe pain due to a limited vocabulary. Use a visual scale (FACES or OUCHER Scale) with faces or colors to assess evaluate the effectiveness of the treatment.
A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? select all that apply
Assess blood glucose level, neck vein distension, and weigh daily Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose levels. May be helpful to monitow daily weight, I&O, maintain low sodium diet, extremities for edema
An AP reports a client's vital signs as tympanic temp 98.8, pulse 92, respiratory 18, BP 98/58. Which vital signs should the nurse re-measure
BP: 98/58 A nurse who is supervising an AP's work is accountable for the work that the AP completes. Therefore, the nurse should verify anything that seems unusual. The BP the AP reported is low; therefore, the nurse should verify that this result is accurate before taking any other actions.
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which urinary alteration?
Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.
A nurse is caring for a client who has active pulmonary TB and is to be started on IV rifampin therapy. The nurse should instruct the client that this medication can cause which adverse effect.
Body secretions turning a red-orange color
A nurse is caring for a client who has HIV. Which lab value is priority?
CD4-T Cell count 180 cells/mm3 A CD4-T-cell count of less than 180 cells/mm3 indicates that the client is severely immunocompromised and is at high risk for infection. Therefore, this value is the priority for the nurse to report to the provider.
A nurse is caring for a client who is 1 day postoperative following subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles, and around the lips. For which of the following findings should the nurse assess.
Chvostek's sign The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
A nurse is caring for a client who has Parkinson's disease and it taking diphenhydramine 25 mg PO TID. Which of the following therapeutic outcomes should the nurse expect:
Decreased tremors Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling tremors in the early stage of the disease.
A nurse is caring a middle adult female who reports her menstrual periods have become irregular and she has been having hot flashes. The nurse should expect the client to have which of the following manifestations associated with early menopause
Dryness with intercourse Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries stop making estrogen. Because of the changes in the vagina, some women can have dryness, discomfort, or pain during sexual intercourse.
A nurse is planning care for a client who has decreased level of consciousness. The client is receiving continuous enteral feedings via gastroostomy tube due to an inability to swallow. Which is priority action?
Elevate the head of the client's bed 30 -45 degrees A client who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying flat also increases this risk. The priority action by the nurse is to keep the head of the bed elevated 30o to 45o to promote gastric emptying and reduce the risk of aspiration.
A nurse is planning care for a female client who has a T-4 spinal cord injury and is at risk for acquiring UTI. Which of the following actions should the nurse include in care
Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital-acquired) UTI is reduced, even for a client who has a spinal cord injury.
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Establish a plan of care with the client that sets attainable goals. The nurse should develop a plan of care for this client with mutually set goals. This action invests the client in the rehabilitation process, which encourages feelings of ownership for it, and sees the goals as more attainable.
A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice. The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
False imprisonment False imprisonment is detaining a client against her will to seek freedom. The client has the right to refuse treatment against medical advice and leave the hospital.
A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?
Family history Family history is strongly correlated with the formation of urolithiasis. A nurse should assess a client who has kidney stones for familial tendencies toward stone formation.
A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?
Inability to recognize his family members The right hemisphere is involved with visual and spatial awareness. A client who is unable to recognize faces would have involvement with the right hemisphere.
A nurse is administering tap water enema to constipated client. During, he states having abdominal cramps. which action to relieve discomfort
Lower the height of the solution container f nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed.
A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter. When assessing the client, the nurse notes swelling of the client's arm about the PICC insertion site. What action should the nurse take first
Measure the circumference of both arms The first action the nurse should take using the nursing process is to assess the client. The nurse should measure the arm and compare the result with the circumference of the other arm. If the arm is swollen, the nurse should notify the provider who inserted the PICC line. Swelling could indicate formation of a clot above the site or even catheter rupture.
A nurse is caring for a client following an abdominal surgery. The client has prescription for dressing changes every 4 hours as needed. Which of the following objects should the nurse use to reduce skin irritation around the incision area
Montgomery Straps Montgomery straps are adhesive strips that are applied to the skin on either side of the surgical wound. The strips have holes so the two sides of the dressing can be tied together and re-opened for dressing changes without having to remove the adhesive strips. If Montgomery straps are unavailable, the nurse can place strips of hydrocolloid dressing on either side of the wound and place the tape across the dressing onto the hydrocolloid strips.
A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs?
Move the client to a room closer to the nurse's station This will make it easier for the staff to observe the client, should the client behave in an unsafe manner.
A nurse is caring for a 4 year old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation
Offer the child a choice of taking the medication with juice or water While taking the medicine is not a choice, the child can decide what kind of fluid to take with the medication. This gives the preschool-aged child a sense of control over a stressful situation and increases the child's ability to cope.
A nurse is caring for a client who is on a 2000 calorie American Diabetes Association Diet and substitutes the whole milk on his breakfast tray with skim milk. Because of this substitution, the nurse should know that the client can add which item to oatmeal on his breakfast tray?
One tablespoon low fat margarine Substituting skim (fat-free) milk for whole milk allows the client to add a fat exchange to his breakfast tray. A fat exchange usually varies in serving size, but one tablespoon of low-fat margarine is considered one fat exchange.
A nurse is admitting a client who has acute pancreatitis. Which of the following prescriptions should the nurse anticipate
Pantoprazole 80 mg IV bolus twice daily The nurse should anticipate a provider's prescription for a proton pump inhibitor to decrease gastric acid production, which ultimately decrease pancreatic secretions.
A nurse is teaching a client about nutritional requirements necessary to promote wound healing. which of the following nutrients should the nurse include in the teaching
Protein Protein is the major structural and functional component of every cell. It is required in increased amounts during times when the body needs to heal itself and protein will promote wound healing.
A nurse is preparing a client for outpatient surgery. After the nurse inserts the IV catheter, the client reports pain in the insertion area. Which of the following actions should the nurse take?
Remove the catheter and insert another into a different site It is possible that the catheter is up against a valve or near a nerve and is causing more pain than an IV catheter insertion should. The nurse should remove the source of the pain and establish peripheral IV access elsewhere.
A nurse is assessing a client who sustained a basal skull fracture and notes a think stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
Test the drainage for glucose This is the priority nursing action. Because of the high risk of cerebral spinal fluid (CSF) leak in clients with basal skull fractures, the nurse should realize there is a possibility that the clear fluid coming from the client's nostril is CSF, which will test positive for glucose.
A nurse is working with a LPN to care for a client who is receiving a continuous IV infusion. Which of the following findings reported by the LPN indicates to the nurse client has phlebitis at the IV insertion site?
The area surrounding the insertion site feels warm to the touch. The IV fluid is at room temperature, so the area around the injection site will feel cool, not warm, to the touch when the IV is infiltrated. A warm area around the injection site indicates infection or phlebitis.
A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?
The client who has a nasogastric (NG) tube to suction Hypokalemia is a low serum potassium value. An NG tube is used to decompress the stomach. When attached to suction, an NG tube will remove gastric contents, which are high in electrolytes, especially potassium, and this loss places the client at risk for hypokalemia.
A nurse is caring for a client who has fallen while getting out of bed and states "Im okay! I should have called for help to use the bathroom. After assessing the client, the nurse notifies the provider. Which documentation should be in the medical record.
The provider was notified Nursing interventions that support factual information should be documented in the health record.
A nurse in a clinic is reviewing the lab values of a client who has primary hypothyroidism. the nurse should anticipate an elevation of which of the following lab values?
Thyroid stimulating hormone (TSH) : will be elevated
A nurse is caring for a client who has chemotherapy induced peripheral neuropathy. The nurse should expect the client to report having experienced which of the following symptoms?
Tingling feeling in the extremities Peripheral neuropathy is a neurological disorder resulting from damage to the peripheral nerves. It may be caused by diseases of the nerves, systemic illnesses, or it may be a side-effect from chemotherapy. If a sensory nerve is damaged, the client is likely to experience pain, numbness, tingling, burning, or a loss of feeling in the extremities.
A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?
Turn the client on his side before starting oral care helps fluid run out of his mouth by gravity, thus preventing aspiration and choking.
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?
Veracity: is the duty to tell the truth. The nurse violated the ethical principle of veracity when choosing not to report the error instead of being truthful.
A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?
Yellow-green drainage on the surgical incision Thick yellow-green drainage is indicative of an infection and should be reported immediately.
A nurse is instructing a client who has new diagnosis of Raynaud's disease about preventing onset of manifestations. Which of the following client statements should indicate to the nurse the need for additional teaching?
"I will take my medications at the first sign of an attack." Taking medications at the onset of an episode of Raynaud's disease may help to reduce the severity of the manifestations, but it will not prevent the onset of vasoconstriction.
A nurse is providing teaching to an AP about caring for clients with restraints. What indicates understanding?
"I will tie a restrain to the portion of the bed that moves when the head of the bed is moved." This statement by the AP indicates an understanding of the teaching. Restraints should be tied to the portion of the bed that moves when the head of the bed is raised or lowered.
A nurse is caring for a client who is being treated with a cesium implant. The client tells the nurse, "I feel so isolated and alone in this room." After acknowledging her feelings, what response?
"Do you have a cell phone you can talk to friends and family on?" A client who has a radiation implant must remain in radiation isolation. Time and distance are the factors that reduce exposure to the source. After acknowledging the client's feelings of loneliness and recognizing the sense of social isolation, this solution provides an appropriate, safe means of meeting the client's need for contact.
A nurse is reviewing lab results for a client who has a history of atherosclerosis and notes elevated cholesterol levels. Which of the following statements by client indicates the nurse should plan follow up teaching on low-cholesterol diet
"I eat two eggs for breakfast each morning." Clients should limit egg yolks to two to three per week.
A nurse is providing dietary teaching to a client who has calcium oxylate kidney. Which indicates understanding
"I may eat a banana with my breakfast." Excessive dietary intake of oxalate can increase the risk of calcium oxalate stone. Bananas are not high in oxalate. Therefore, this food choice indicates an understanding of teaching.
A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. Which statement indicates understanding
"I should avoid eating liver and other organ meats." The nurse should encourage the client who has gout to avoid organ meats, such as liver, due to high levels of purine.
A nurse is teaching a client about which foods she should include in her low-fiber diet. Which statement indicates understanding
"I should choose white rice as a side dish." White rice is a refined grain and has less fiber than whole or unrefined grains. The client can include white rice as part of a low-fiber diet.
A nurse is teaching a client who has diabetes about which dietary source should provide the greatest percentage of calories. Which of the following statements indicates the client understands the teaching?
"I should eat more calories from complex carbohydrates than anything else." The client who has diabetes should consume the majority of calories from complex carbohydrates, such as whole grains, fruits, and vegetables.
A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following indicates need for MORE teaching?
"I will ensure my baby's feedings last 10-15 minutes" This statement by a parent indicates a need for further teaching. Feedings should last 20 to 30 minutes.
A nurse is providing teaching about the Mediterranean diet to a client newly who has a diagnosis of hypertension. What indicates need for more teaching
"I will limit my intake of red meat to twice weekly." This statement by the client indicates a need for further teaching. Following the Mediterranean diet, red meat should be limited to two times monthly.
A nurse is teaching a client who has acute kidney disease about fluid restrictions. Which of the following statements by the client should the nurse identify as understanding of the teaching?
"I will make a list of my favorite beverages." The nurse should work with the client to develop a schedule for fluid restrictions, and should attempt to include the client's favorite beverages when possible to promote satisfaction.
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of violation of confidentiality?
"Reporting lab findings to a member of client's family." Confidentiality is the nondisclosure of information except to an authorized person, that is, someone involved in the client's care or someone the client has given permission for informing. Reporting laboratory findings to a family member without the client's permission violates client confidentiality.
A nurse is teaching the partner of a client who has an acute myocardial infarction about the reason blood was drawn from the client. Which of the following statements should the nurse make regarding cardiac enzymes studies?
"These tests help determine the degree of damage to the heart tissues." Cardiac enzyme studies are obtained because the degree of enzyme elevation reflects the degree of damage to the myocardium. The enzymes most commonly measured are CPK and troponin. These enzymes have a characteristic rise and fall pattern after an MI. It may take 4 hr or more after the onset of manifestations for the test to become abnormal and up to 24 hr for the level to peak. Eventually, the levels in the blood fall back to normal. Consequently, serial blood tests must be taken from the client to document and evaluate enzyme levels.
A nurse is caring for an 8 month old infant who screams when the parent leaves the room. The parent begins to cry and says "I don't understand why my child is so upset. I've never seen my child act this way around others before." Which of the following statements should the nurse make?
"This is a normal, expected reaction for a child of this age." The 8-month-old child is exhibiting a normal response to separation from the parent by protesting loudly. Explaining this expected separation anxiety reaction to the parent might help the parent to cope with feelings of guilt when leaving the child's bedside.
A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take.
A primary survey is an organized system to rapidly identify and manage immediate threats to life. The mnemonic "ABCDE" is a reminder of the steps of the primary survey. The first step is "airway," during which the nurse should establish a patent airway using the jaw-thrust maneuver. The second is "breathing," during which the nurse should assess the client's ventilator efforts to determine effectiveness of breaths. During the third step, "circulation," the nurse should establish IV access for fluids and blood administration as needed. The fourth step is "disability," during which the nurse should determine a baseline neurologic status by completing a GSC assessment. And the fifth step is "exposure," during which the nurse should remove the client's clothing to complete a thorough assessment of the client's injuries.
A nurse is admitting a client who has active tuberculosis to a room on a medical-surgical unit. Which of the following room assignments should the nurse make for the client?
A room with air exhaust directly to the outdoor environment room with air exhaust directly to the outside environment eliminates contamination of other client-care areas. This type of ventilation system is referred to as an airborne infection isolation room.
A nurse is teaching a client about snacks that are appropriate on a low-fat, low-sodium, and low cholesterol diet. Which of following food choices indicated need for teaching?
A slice of cheese The client should limit the intake of cheese due to high levels of fat and sodium.
A nurse is reviewing the EKG strip of client who has prolonged vomiting. Which of the following abnormalities should the nurse interpret as sign of hypokalemia
Abnormally prominent U wave Although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strip for a flattened T wave, prolonged PR interval, prominent U wave, or ST depression.
A nurse is caring for a client who has cancer and is receiving total parenteral nutrition (TPN). Which of the following lab values indicates the treatment is effective?
Albumin 4.2 g/dL Clients who have cancer can receive TPN to provide needed proteins and glucose they are otherwise unable to obtain. An albumin level of 4.2 g/dL is within the expected reference range and indicates the client is receiving adequate amounts of protein.
A nurse is working on an orthopedic unit is caring for 4 clients. Which of the following clients should the nurse identify as being at greatest risk for skin breakdown?
An older adult who has a hip fracture and is in Buck's traction
A client who has a history of MI is prescribed aspirin 325 mg. The nurse recognizes the aspirin is given due to which actions of the medication?
Anti-platelet aggregate Aspirin is used to decrease the likelihood of blood clotting. It also is used to reduce the risk of a second heart attack or stroke by inhibiting platelet aggregation and reducing thrombus formation in an artery, a vein, or the heart.
A nurse is preparing to perform hand hygiene. Which of the following actions should the nurse take?
Apply 4-5mL of liquid soap to hands The nurse should apply 4 to 5 mL of liquid soap to the hands to ensure an adequate amount is available to produce lather and kill microorganisms.
A nurse is completing discharge teaching with a client following arthroscopic knee surgery. Which of the following instructions should the nurse include in the teaching?
Apply ice to affected area Arthroscopy is a surgical procedure used to visualize, diagnose and treat problems inside a joint. Applying ice to the affected area in the immediate postoperative period (first 24 hr) reduces pain and swelling.
A nurse in a clinic is interviewing a client who will undergo diagnostic testing. Nurse should ask about potential allergies during which nursing process phase
Assessment: The assessment phase includes asking the client about her health history, physical concerns and health care expectations. A review of possible allergies is included in the assessment phase.
A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Atelectasis: Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.
A nurse is teaching a client who has has GERD about managing illness. What recommendations?
Avoid eating 3 hours withing bedtime The nurse should instruct the client to eat small, frequent meals but to avoid eating with 3 hr of bedtime.
A nurse is caring for a client who has a prescription for a stool test for guaiac. The nurse understands the purpose of the test is to check the stool for which of the following substances?
Blood A guaiac test detects the presence of occult or hidden blood in the stool. The guaiac test is an extremely useful diagnostic screening test for the presence of colon cancer and gastrointestinal ulcers.
A nurse is providing teaching to a client who has new diagnosis of type 2 diabetes. The nurse should recognize the client understands the teaching when he identifies which hypoglycemia manifestations
Blurred vision, tachycardia, most and clammy skin.
A nurse in a clinic is assessing a client who has AIDS and a significant decreased CD-T-4 cell count. The nurse should recognize that the client is at risk for developing which of the following infectious oral conditions
Candidiasis Although oral candidiasis can affect anyone, it occurs most often in infants, toddlers, older adults, and clients whose immune systems have been compromised by illness, such as AIDS, or medications.
A nurse is caring for a client who is 4 days postoperative following a right radical mastectomy. Which of the following activities should the nurse anticipate being the most difficult for this client to perform with her right hand?
Combing her hair Abduction of the arm is the most difficult, and usually the last, type of movement to be regained by a client following a mastectomy.
The family of an older adult client brings him to the ED after finding him wandering outside. During the initial assessment, the nurse notes the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as an explanation
Confusion Since the client was manifesting signs of confusion before coming to the emergency department and currently seems unable to understand or respond to speech, the nurse should determine that the client has confusion.
A nurse is caring for a client who as emphysema. Which of the following should the nurse expect to assess?
Dyspnea, barrel chest, clubbing of the fingers Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.
A nurse is caring for a client who has active pulmonary tuberculosis. The client requires airborne precautions and is receiving multidrug therapy. Which of the following precautions should the nurse take to transport the client safely to the radiology department for a chest x-ray?
Have the client wear a mask. When a client who has a communicable disease must leave his room, it is important to protect everyone with whom the client comes in contact. Having the client wear a mask protects others from airborne particles should the client cough.
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Heart rate When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as in indication of adequate fluid replacement.
A nurse is assessing a client who has a long history of smoking and is suspected of having laryngeal cancer. The nurse should anticipate that the client will report that her earliest manifestation was?
Hoarseness Laryngeal cancer, a malignant tumor of the larynx, is most often caused by long exposure to tobacco and alcohol. Hoarseness that does not resolve for several weeks is the earliest manifestation of cancer of the larynx because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh and lower in pitch than normal.
A nurse is assessing a client who is admitted for elective surgery and has history of Addison's disease. Which finding should be expected
Hyperpigmentation Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as priority care?
Impaired tissue perfusion When using the airway, breathing, and circulation (ABC) priority-setting framework, the nurse should identify impaired perfusion of tissues as the priority finding. The presence of varicose veins indicates venous reflux is present which inhibits perfusion to all the tissues. The nurse should note the client has signs of chronic venous insufficiency as well which include edema, a feeling of heaviness in the legs, and the presence of venous stasis ulcers.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect?
Increased heart rate, increased B/P, increased respiratory rate Increased heart rate is correct. The nurse should expect the client who has fluid volume excess to have tachycardia and increased cardiac contractility in response to the excess fluid. Increased blood pressure is correct. The nurse should expect the client who has fluid volume excess to have increased blood pressure and bounding pulse in response to the excess fluid. Increased respiratory rate is correct. The nurse should expect the client who has fluid volume excess to have increase in respiratory rate and moist crackles heard in lungs.
A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome
Moon face, purple striations, and buffalo hump Moon face is correct. Moon face, which is manifested by a round, red, full face, is a common manifestation of Cushing's syndrome. Purple striations is correct. Purple striations on the skin of the abdomen, thighs, and breasts are common manifestations of Cushing's syndrome. Buffalo hump is correct. Buffalo hump, which is a collection of fat between the shoulder blades, is a common manifestation of Cushing's syndrome.
A client smoking in his bathroom dropped a cigarette butt into a wastepaper basket, which begins to smolder. Which of the following actions is the nurse's priority?
Move an clients in the immediate vicinity The greatest risk to clients is injury from smoke and fire; therefore, the nurse's first action is to move any clients near the smoke to a safe location. The acronym RACE is a reminder of the order in which to take steps in the event of a fire. The nurse should rescue the clients, activate the fire alarm, confine the fire, and extinguish the fire.
A nurse is completing an admission assessment on an adolescent client who is vegetarian. He eats milk products but does not like beans. Which of the following items should the nurse suggest the client order for lunch to provide the nutrients most likely to be lacking his diet?
PB&J A vegetarian diet may be low in protein, especially if the client does not substitute protein-rich beans for meat protein. Peanut butter is an excellent source of protein. A peanut butter and jelly sandwich, especially if prepared on protein-enriched bread, can provide almost 20 grams of protein.
A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia. Which of the following is the priority action for the nurse to take?
Perform a neurovascular assessment The greatest risk to the client is neurovascular injury. Therefore, the priority action is to perform a neurovascular assessment. This consists of assessing the involved extremity (the lower leg) at the most distal point (the foot) for circulation (color), motion (movement), and sensation, and can be remembered by the acronym "C-M-S check."
A nurse is preparing to administer 3 liquid meds to client with NG tube with intermittent suction. Which action should the nurse take?
Pinch the tube prior to attaching the medication syringe After detaching the NG tube from the suction tubing, the nurse should pinch or kink the tube to prevent distention from air entering the tube.
A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had inter maxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?
Prevent aspiration When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority goal is to prevent the client from aspirating. Because the client's jaws are wired together, aspiration of emesis is a possibility. Therefore, the client should be given medication for nausea, and wire cutters should be kept at the bedside in case of vomiting.
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low stimulus environment. Thyroid crisis can occur in response to a stressor, so the nurse should minimize stressful stimuli in the client's environment.
A nurse is caring for a client who is undergoing a lumbar puncture. Which of the following is the priority action for the nurse to take to maintain privacy for the client?
Pull the curtains around the client's bed Pulling the curtains around the client's bed assures privacy for the client should someone open the door or enter the room.
A nurse is caring for an adolescent who has hemophilia A and is scheduled for wisdom teeth extractions. Prior to the procedure, the nurse should anticipate that the client will receive which product
Recombinant: The underlying problem of hemophilia is a deficiency of clotting factors. Therefore, clients who have hemophilia are given recombinant to replace the deficient factor as a prophylactic measure before an invasive procedure, surgery, or when actively bleeding.
A nurse is caring for an antepartum client who has iron-deficiency anemia. When teaching the client about nutrition, the nurse should emphasize the need for an increased intake of which of the following foods?
Red meat and organ meat This client has a deficiency in iron and needs instruction about foods that are rich sources of iron. A diet rich in red and organ meat provides iron, which is what the client needs to improve anemia.
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?
Reduce the client's intake of protein Ammonia is formed in the gastrointestinal tract by the action of bacteria on protein. Limiting dietary protein intake can assist with decreasing the client's ammonia level. Protein is necessary for healing, so strict limitation of dietary protein is not recommended.
A nurse is caring for an adolescent who has a long history of diabetes mellitus and is being admitted to ED confused, flushed with acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client.
Regular insulin Regular insulin is classified as a short-acting insulin. It can be given intravenously with an onset of action of less than 30 min. This is the insulin that is most appropriate in emergency situations of severe hyperglycemia or diabetic ketoacidosis.
A nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Review the electrolyte values The greatest risk to this client is injury from impaired function of cardiac or respiratory muscles; therefore, the first action the nurse should take is to review the client's electrolyte values. The client might have low sodium, potassium, and chloride from frequent diarrhea.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Secure the restraints using a quick-release tie The nurse should secure the restraints using a quick-release tie for easy removal in an emergency.
A nurse is reviewing lab values for a client who has systemic lupus erythematosus (SLE). Which of the following values should give the nurse the best indication of the client's renal function?
Serum creatinine A renal function disorder reduces the excretion of creatinine, resulting in increased levels of blood creatinine. Creatinine is a specific and sensitive indicator of renal function.
A nurse is assessing a client and discovers the infusion pump with the client's total parenteral nutrition solution is not infusing. Nurse should monitor for?
Shakiness and diaphoresis When a sudden interruption in the infusion of TPN occurs, the client is at risk for hypoglycemia. Shakiness and diaphoresis are manifestations of hypoglycemia.
A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which action should be taken
Suction 2-3 times with 60 second pause between passes Copious secretions may require several passes of the suction catheter. An interval of 60 seconds should be allowed between passes to prevent hypoxia.
A nurse is administering nasal decongestant drops for a client. Which of the following actions should the nurse take?
Tell the client to blow her nose gently before instillation. Prior to instillation, the nurse should instruct the client to blow her nose gently. This action will help remove any secretions or crusts that could interfere with the distribution and absorption of the medication.
A nurse is auscultation a client's heart sounds and hears and extra heart sound before what should be considered the first heart sounds S1. The nurse should document this finding as which of the following heart sounds?
The fourth heart sound (S4) S4 is an extra sound that is heard late in diastole just before S1. It occurs due to resistance to blood flow in an enlarged ventricle.
A nurse is review the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
pH 7.25, HCO3 19mEq/L, PaCO2 30 mm Hg The nurse should expect a client who has renal failure to have metabolic acidosis, which is characterized by a low HCO3-, a low pH, and a low or normal PaCO2. Expected reference ranges for these laboratory values are as follows: pH 7.35 to 7.45, HCO3- 21 to 28 mEq/L, and PaCO2 35 to 45 mm Hg.
