MS A & B

A nurse is assisting the charge nurse with developing an in-service about caring for clients who have internal sealed radiation implants. Which of the following information should the nurse include?

Dispose of radiation implants in a lead container.

A nurse in a health clinic is reinforcing teaching with a client who has tuberculosis (TB) about transmission of the disease. Which of the following client statements indicates an understanding of the teaching?

"I inhaled the infection droplets that were in the air."

A nurse is reinforcing teaching with a client who has a new diagnosis of genital herpes. Which of the following information should the nurse include in the teaching?

"The virus can be transmitted without lesions present."

A nurse is collecting data from a client who has an obstructive pulmonary disorder. The nurse should document the sound as which of the following?

Wheezes (high-pitches, musical sounds that occur as air passes through narrowed airways, such as when a client is experiencing an asthma attack.)

A nurse is caring for a client and administers penicillin IM. The client begins exhibiting hives and has severe difficulty breathing. After establishing a patent airway, which of the following actions should the nurse take next?

Administer epinephrine.

A nurse is caring for a client who reports shortness of breath and has an oxygen saturation of 90%. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is reviewing the laboratory reports of a client who reports chest pain. Which of the following laboratory results indicates the client is experiencing a myocardial infarction?

Elevated troponin

A nurse is caring for a client who has dementia due to Alzheimer's disease. Which of the following actions should the nurse take to reduce the client's confusion?

Encourage reminiscence of past experiences.

A nurse is contributing to the plan of care for a client who has multiple sclerosis and is taking dantrolene to manage muscle spasms. Which of the following interventions should the nurse include?

Encourage the client to complete ADLs.

A nurse is contributing to the plan of care for a client who has a new prescription for nystatin suspension for oral candidiasis. Which of the following interventions should the nurse include in the plan?

Instruct the client to swish the medication in her mouth.

A nurse is caring for a client who has acute pancreatitis. While providing care, the nurse observes ecchymosis around the umbilicus. The nurse should identify that this is a manifestation of which of the following?

Intra-abdominal bleeding

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation. The nurse notes decreased output from the urethral catheter. Which of the following provider prescriptions should the nurse expect?

Irrigate the urethral catheter with 0.9% sodium chloride.

A nurse is caring for a client who is preoperative and is receiving an IV infusion of cefazolin. Ten minutes after beginning the infusion, the client reports intense itching. Which of the following actions should the nurse take first?

Stop the medication infusion.

A nurse is collecting data from a client who has 30% body surface area partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?

Urine output is 50 mL/hr.

A nurse is contributing to the plan of care for a client who has a head injury and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse include in the plan?

Use a turn sheet to reposition the client.

A nurse is assisting in the plan of care for a client who had a recent left hemispheric stroke. Which of the following actions should the nurse include in the plan?

Use simple verbal cues when directing tasks.

A nurse is preparing to suction a client who has a tracheostomy. Which of the following actions should the nurse take first?

Ventilate with 100% oxygen.

A nurse is preparing for a client for a cardiac catheterization. Which of the following actions should the nurse take first?

Verify the client has given informed consent.

A nurse is caring for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?

Visitors must don a gown and gloves prior to entering the client's room.

A nurse is reviewing the medical record of a client who is postoperative. Which of the following findings should the nurse identify as a complication of surgery?

WBC count of 15,000/mm3

A nurse is reinforcing teaching to a client about preventing osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will limit my coffee intake"

A nurse is reinforcing teaching with a client who has chronic kidney disease about disease management. Which of the following statements by the client indicates an understanding of the teaching?

"I will limit my daily intake of protein."

A nurse is reinforcing discharge teaching with a client who has leukemia and is receiving chemotherapy. Which of the following statements should the nurse include in the teaching?

"You should place your toothbrush in hydrogen peroxide overnight."

A nurse is contributing to the plan of care for a client who has chronic obstructive pulmonary disease (COPD) and is dyspneic. Which of the following interventions should the nurse include in the plan?

Encourage abdominal breathing.

A nurse is caring for a client who has restricted movement of the chest due to a burn injury. The nurse should anticipate preparing the client for which of the following procedures?

Escharotomy

A nurse is reinforcing teaching about management of constipation with a client who has hypothyroidism. Which of the following should the nurse include in the teaching?

Increase intake of fiber-rich foods.

A nurse is reinforcing teaching with a client who is on a low-sodium diet and asks about how to improve the taste of bland food. Which of the following should the nurse recommend?

Lemon juice

A nurse is caring for a client who has neutropenia. Which of the following nursing interventions should the nurse implement?

Limit visitors to healthy adults.

A nurse is reinforcing teaching with the parent of a toddler who has type 1 diabetes mellitus and whose prescription has been changed from regular insulin to lispro insluin. Which of the following information should the nurse include in the teaching?

Lispro should be given before eating.

A nurse is contributing to the plan of care for a client who has tuberculosis (TB). Which of the following interventions should the nurse include?

Place the client in a negative-pressure airflow room.

A nurse is contributing to the plan of care for a client who is having difficulty eating following a stroke. Which of the following interventions should the nurse plan to implement first?

Recommend a referral for a speech language pathologist.

A nurse is reinforcing teaching about insulin injections with an adult client who weighs 45.4 kg (100 lb). Which of the following statements by the client indicates an understanding of the teaching?

"I should give my shot in my belly tissue."

A nurse is reinforcing teaching with a client who has systemic lupus erythematosus (SLE) and is to begin taking methylprednisolone orally. Which of the following statements should the nurse include in the teaching?

"Limit contact with large groups of people."

A nurse is preparing to insert a double-lumen gastric (Salem) sump tube for a client who has peptic ulcer disease and has developed gastrointestinal bleeding. Which of the following images indicates the tube that the nurse should select?

(In a double-lumen gastric (Salem) sump tube, the clear portion of the tube allows for aspiration of stomach contents. The blue portion of the tube, or the "pig tail", vents the tube to the atmosphere, which prevents the tube from becoming lodged against the wall of the stomach and protects the stomach from damage.)

A nurse is providing information regarding transmission-based precautions for a client who has Clostridium difficile to an assistive personnel (AP). Which of the following instructions should the nurse include?

-"Provide the client with disposable utensils and dishes for meals." -"Leave blood pressure equipment in the client's room" -"Clean contaminated surfaces with a bleach solution"

A nurse is reinforcing teaching with a client about increasing dietary fiber. The nurse should recommend which of the following foods as the best source of fiber?

1/2 cup cooked kidney beans

A nurse is contributing to the plan of care for a client who has just transferred to the medical-surgical unit from the PACU following a right total knee arthroplasty. Which of the following interventions should the nurse include in the plan?

Assist the client to change positions at least every 2 hr.

A nurse is preparing to administer scheduled medications to a client. Which of the following prescriptions should the nurse verify with the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Ceftriaxone

A nurse is caring for a client who is postoperative and has a Jackson-Pratt drain. Which of the following actions should the nurse take?

Compress the bulb reservoir and then close the drainage valve.

A nurse is assisting in the care of a client who has manifestations of sepsis. Which of the following provider prescriptions should the nurse implement first?

Initiate oxygen at 4 L/min via nasal cannula.

A nurse is assisting with the care of a client who had a stroke and is unable to speak. The nurse should identify that the client's injury occurred in which of the following lobes of the brain?

Injury to the frontal lobe can result in alterations to motor function or voluntary movements. This involves the ability to speak and the ability to move purposefully.

A nurse is admitting a client who is suspected of having active tuberculosis (TB). Which of the following actions should the nurse take first?

Institute airborne precautions.

A nurse is collecting data from a client and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma?

Irregular borders

A nurse in an orthopedic clinic is reinforcing teaching with a client who has osteoarthritis. Which of the following instructions should the nurse include to promote comfort?

Sleep on a firm mattress.

A nurse in a long-term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools

A nurse is contributing to the plan of care for a client who had a cerebrovascular accident (CVA). For which of the following interdisciplinary team members should the nurse recommend a referral prior to initiating oral intake for the client?

Speech-language pathologist

A nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication.

A nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which of the following complications of IV therapy?

Thrombophlebitis

A nurse is caring for a client who has Cushing's syndrome and expresses concern regarding body image changes. Which of the following should the nurse recognize as a physical change caused by this disease?

Truncal obesity

A nurse is performing an ECG on a client who is scheduled for surgery the following morning. In which of the following locations should the nurse place the V1 electrode? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

c

A nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals?

olive oil

A nurse is caring for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?

Mask

A nurse is reinforcing teaching with a client who has coronary artery disease and is taking a statin medication to lower cholesterol levels. Which of the following instructions should the nurse include in the teaching?

"Add oily fish to your diet twice weekly."

A nurse is reinforcing discharge teaching with a client who has cirrhosis. Which of the following instructions should the nurse include?

"Consume foods low in sodium."

A nurse is caring for a client who is receiving a continuous tube feeding of 60 mL/hr at 1.2 cal/mL. How many calories will the client receive in 12 hr?

864 cal

A nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?

"Avoid bending your hips more than 90 degrees."

A nurse is reinforcing teaching with a client who has osteoporosis and a new prescription for calcitonin. Which of the following statements should the nurse make to describe the effect of calcitonin in treating osteoporosis?

"Calcitonin will slow the breakdown of bone in your body."

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease. Which of the following statements indicates that the client is adhering to the nurse's instructions?

"I don't cross my legs anymore."

A nurse is reinforcing teaching about nutrition choices with a client who has leukemia and is receiving chemotherapy. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

"I drink bottled water."

A nurse is preparing to administer an influenza vaccine to a client. Which of the following statements by the client should cause the nurse to postpone administration of the vaccine?

"I had a low fever this morning."

A nurse is reinforcing teaching with a client who has gonorrhea. Which of the following information should the nurse include?

"You are at risk for infertility with this infection, regardless of treatment."

A nurse in a clinic is collecting data from a client who has hyperthyroidism and has been taking methimazole for 4 weeks. Which of the following statements by the client indicates a therapeutic response of the medication?

"I have gained 3 pounds since my last appointment."

A nurse is reinforcing teaching with a client who has asthma. Which of the following client statements indicates an understanding of the use of budesonide and albuterol inhalers? (Select all that apply.)

"I never forget to rinse my mouth after using my budesonide inhaler." "Between office visits, I keep a record of how many times I use my albuterol inhaler." "I use my albuterol inhaler before I go swimming."

A nurse is reinforcing teaching with a client who has mitral valve disease. Which of the following statements by the client indicates an understanding of the disease process?

"I should call my doctor if my ankles swell."

A nurse is reinforcing teaching about gastroesophageal reflux disease (GERD) with a client. Which of the following statements by the client indicates an understanding of the teaching?

"I should wait at least 2 hours after eating before going to bed."

A nurse is reinforcing teaching with an adolescent client regarding testicular self-examination. Which of the following statements by the client demonstrates an understanding of the teaching?

"I understand that testicular cancer is painless."

A nurse is reinforcing teaching with a client prior to removal of a leg cast. Which of the following statements should indicate to the nurse that the client understands the teaching?

"I will feel vibrations on my leg from the cast cutter."

A nurse is reinforcing teaching about glycosylated hemoglobin (HbA1c) testing with a client who has diabetes mellitus. Which of the following statements indicates that the client understands the teaching?

"I will have my HbA1c checked twice per year."

A nurse is discussing health screening guidelines with an older adult client. Which of the following statements should the nurse include?

"You should have a pneumococcal immunization every 10 years."

A nurse is reinforcing discharge teaching for a client who had a mechanical mitral valve replacement. Which of the following statements by the client indicates an understanding of the teaching?

"I will notify my dentist about this procedure."

A nurse is reinforcing discharge teaching with a client who has Crohn's disease. Which of the following statements should the nurse include in the teaching?

"Maintain a low-residue diet."

A nurse is collecting data from an older adult client who has several concerns. Which of the following concerns should the nurse recognize as a normal change associated with aging?

"My food tastes bland even after I add seasoning."

A nurse is reinforcing teaching with a client about testicular self-examination. Which of the following instructions should the nurse include in the teaching?

"Perform testicular self-examination after taking a warm shower."

A nurse is reinforcing teaching about pursed-lip breathing with a client who has a new diagnosis of COPD. The nurse should identify which of the following client statements indicates an understanding of the teaching?

"Pursed-lip breathing works best for activities like walking up stairs."

A nurse is reinforcing teaching with an older adult client who has osteoporosis. Which of the following instructions should the nurse include in the teaching?

"Take calcium supplements with meals."

A nurse is caring for a client who has terminal pancreatic cancer. The client states, "I don't think I can go on any longer." Which of the following responses should the nurse make?

"Tell me more about the way you are feeling."

A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the following statements by the client indicates an understanding of the teaching?

"The medication should be taken before I eat breakfast every morning."

A nurse is caring for a client who has prostate cancer. The client asks the nurse why he is having difficulty with urination. Which of the following response should the nurse make?

"The tumor causes obstruction of urine from the urethra."

A nurse is reinforcing teaching with a client who is taking insulin glargine. Which of the following information should the nurse include in the teaching?

"This type of insulin should be given at the same time every day."

A nurse is reinforcing teaching regarding the use of a continuous passive motion (CPM) machine with a client who is scheduled for a total knee arthroplasty. Which of the following information should the nurse include in the teaching?

-"Your knee is flexed and extended as prescribed by your provider." -"The machine is padded with sheep skin."

A nurse is caring for a client who begins to have a seizure while ambulating in the hall. Identify the sequence of actions the nurse should follow.

-Lower the client to floor. -Place a pad beneath the client's head. -Loosen the clothing around the client's neck. -Time the length of the client's seizure. -Reorient and reassure the client.

A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

0.7

A nurse is reinforcing teaching with a client who has microcytic anemia and is prescribed a daily iron supplement. The nurse tells the client to consume foods containing vitamin C when taking the supplement to enhance iron absorption. Which of the following client food choices indicates an understanding of the teaching?

1 cup boiled broccoli

A nurse is planning care for a group of clients after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who is dehydrated, has mental confusion, and was found getting out of bed several times during the night.

A nurse is monitoring a client who is taking acarbose. Which of the following findings should the nurse identify as an adverse effect of the medication?

Abdominal cramps

A nurse is reviewing the medication administration record of a client who has osteoarthritis. Which of the following analgesic prescriptions should the nurse expect to administer when the client reports pain?

Acetaminophen

A nurse is caring for a client who had an acute ischemic stroke 1 day ago. Which of the following actions should the nurse take to reduce the risk for aspiration?

Allow for 30 min of rest before meals.

A nurse is delegating the task of repositioning a client who is in skeletal traction to an assistive personnel (AP). Which of the following instructions should the nurse give the AP?

Allow the weights to hang freely.

A nurse is planning to implement droplet precautions for a client who has manifestations of pertussis. Which of the following interventions should the nurse include when contributing to the plan of care?

Apply a mask on the client if transport is needed.

A nurse is reinforcing teaching about joint protection with a client who has an acute exacerbation of rheumatoid arthritis. Which of the following information should the nurse include in the teaching?

Apply cold packs to the inflamed joints.

A nurse is reinforcing discharge teaching to prevent dumping syndrome for a client following a partial gastrectomy for ulcers. Which of the following information should the nurse include in the teaching?

Avoid liquids at mealtimes.

A nurse is reinforcing teaching with a client who has multiple sclerosis and a new prescription for baclofen. Which of the following instructions should the nurse include in the teaching?

Avoid stopping this medication suddenly.

A nurse is collecting data on a client who is scheduled for a cardiac catheterization. Which of the following laboratory levels should the nurse review prior to the procedure?

BUN

A nurse is monitoring a client who has a wrist cast and reports intense itching underneath the cast. Which of the following actions should the nurse take?

Blow cool air into the cast using a blow dryer on a cool setting.

A nurse is collecting data from a client who has chronic kidney disease with hyperkalemia. Which of the following findings should the nurse expect related to hyperkalemia?

Bradycardia

A nurse is collecting data from a client who has hypothyroidism. Which of the following manifestations should the nurse anticipate?

Bradycardia

A nurse is reinforcing teaching with the family of a client who has a cervical injury and has a halo vest in place. Which of the following safety precautions should the nurse include in the teaching?

Change the sheepskin liner weekly.

A nurse is caring for a client who has an intestinal obstruction and reports a new onset of nausea. The client has an NG tube set at a low intermittent suction and is receiving continuous IV infusion of 0.9% sodium chloride. Which of the following actions should the nurse take first?

Check for kinks in the NG tube.

A nurse is assisting with the care of a client who is receiving 0.9% sodium chloride by continuous IV infusion. The client reports pain and swelling at the IV site. In which order should the nurse perform the following steps? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Check the IV site. Stop the infusion. Withdraw the IV catheter. Elevate the affected arm. Notify the charge nurse.

A nurse is caring for a client who is 2hr postoperative following an amputation of the foot. Which of the following actions should the nurse take first?

Check the incisional dressing

A nurse is caring for a client who is suspected of having a myocardial infarction. Which of the following actions should the nurse take to prepare the client for an ECG?

Cleanse the client's skin prior to electrode placement.

A nurse is changing the dressing for a client who has an abdominal incision and a Hemovac drain. Which of the following actions should the nurse take?

Cleanse the drainage plug with alcohol swabs.

A nurse is caring for a client who has a history of breast cancer. The client asks the nurse about birth control. Which of the following methods of birth control is contraindicated for this client?

Combination oral contraceptives

A nurse is caring for a client who has a new cast on her left forearm and reports severe pain in the affected arm with numbness in the fingers. The nurse finds the skin is pale and cold with sluggish capillary refill. Which of the following fracture complications should the nurse suspect?

Compartment Syndrome

A nurse is caring for a client who has been taking enalapril. The nurse should monitor the client for which of the following adverse effects?

Cough

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent. Which of the following laboratory findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL

A nurse is contributing to the plan of care for a client who has peripheral arterial disease (PAD) of the lower extremities. Which of the following interventions should the nurse include?

Dangle the extremities off the side of the bed.

A nurse is assisting in the care of a client who has AIDS-related pneumonia. The client is receiving antibiotic therapy and albuterol nebulizer treatments daily. Which of the following findings should indicate to the nurse that the client's therapeutic regimen is effective?

Decrease in exertional dyspnea.

A nurse is caring for a client who has end-stage liver disease and just underwent an abdominal paracentesis. For which of the following manifestations should the nurse monitor as an adverse effect of the procedure?

Decreased blood pressure

A nurse is preparing to administer furosemide to a client who has heart failure. Which of the following findings should the nurse report before administering the medication?

Decreased potassium

A nurse is collecting data from a client who has heart failure and is taking digoxin. Which of the following outcomes from the medication should the nurse expect?

Decreased shortness of breath

A nurse is caring for a client who has a prescription for phenazopyridine. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

Decreases pain during urination

A nurse is assisting in the plan of care regarding bowel retraining for a client who has a cervical spinal cord injury. Which of the following interventions should the nurse plan to implement first?

Determine the client's daily elimination habits.

A nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority?

Determine the client's understanding of the procedure.

A nurse is caring for four clients. Which of the following conditions should the nurse identify as a risk for developing vascular disease?

Diabetes mellitus

A nurse is caring for a client who has just returned to the unit following a bronchoscopy. Which of the following findings should the nurse report to the provider?

Diminished breath sounds

A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?

Diminished headache

A nurse is caring for an adult client who has age-related macular degeneration. Which of the following findings should the nurse expect?

Distorted central vision of the eyes.

A home health nurse is caring for a client who has COPD. The client tells the nurse that he becomes short of breath while eating despite the use of home oxygen. Which of the following instructions should the nurse include?

Drink beverages at the end of meals

A nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?

Dyspnea

A nurse is collecting data from a client who has hypokalemia. Which of the following findings should the nurse identify as the priority?

Dysrhythmia

A nurse is caring for a client who is receiving chemotherapy. The client mentions that she has a loss of appetite because she has sores in her mouth and that food no longer tastes good. Which of the following suggestions to the client should the nurse make?

Eat several, small-portioned meals daily.

A nurse is reinforcing teaching with a client who has circulatory compromise in the lower extremities due to peripheral vascular disease. Which of the following actions should the nurse take?

Educate the client about choosing the low-fat, low-cholesterol foods.

A nurse is reviewing the medical record of a client who has acute pancreatitis. Which of the following findings should the nurse anticipate?

Elevated serum amylase level

A nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube. Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications?

Encourage the client to use an incentive spirometer every hour while awake.

A nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises.

A nurse is reinforcing teaching with a client who has asthma and a new prescription for a corticosteroid. Which of the following findings should the nurse include as an adverse effect of the medication?

Frequent colds

A nurse is reviewing the medication record of a client who is taking digoxin. Which of the following medications should the nurse identify as increasing the risk for the client to develop digoxin toxicity?

Furosemide

A nurse is reviewing the laboratory results of a client who has chronic kidney failure and is receiving epoetin alfa. The nurse should identify that which of the following laboratory values indicates the treatment is effective?

Hgb 11 g/dL

A nurse is caring for a client who has difficulty swallowing. Which of the following actions should the nurse implement to prevent aspiration?

Give the client liquids with increased viscosity.

A nurse is contributing to the plan of care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) infection and is on contact isolation precautions. Which of the following actions should the nurse take?

Have a designated stethoscope in the client's room.

A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus about glycosylated hemoglobin (HbA1c) testing. Which of the following information should the nurse include in the teaching?

HbA1c results measure glucose control for the prior 3 months

A nurse is caring for a female client who is being treated for dehydration due to nausea and vomiting. Which of the following findings should the nurse report to the provider?

Heart rate 120/min

A nurse is participating in a health fair for older adult clients. Which of the following immunizations should the nurse recommend for this age group?

Herpes zoster

A nurse is collecting data from a 55-year-old female client who reports vaginal dryness and hot flashes. The client is interested in trying hormone replacement therapy (HRT). Which of the following should the nurse recognize as a contraindication to HRT?

History of treatment for blood clots

A nurse is reinforcing teaching with a client who has a new diagnosis of tuberculosis (TB) and a prescription for isoniazid and rifampin. Which of the following information should the nurse include in the teaching?

Household family members should be tested for TB.

A nurse is preparing to auscultate the bowel sounds of a client who has a mechanical bowel obstruction in the descending colon. When listening in the left upper quadrant, the nurse should identify this sound as which of the following? (Click on the audio button to listen to the clip.)

Hyperactive bowel sounds

A nurse is contributing to the plan of care for a client who is postoperative following a total knee arthroplasty. The client is using a continuous passive motion (CPM) machine. Which of the following interventions should the nurse recommend for the plan of care?

Keep a sheepskin pad between the client's extremity and the CPM.

A nurse is reviewing the plan of care for an older adult client who is 1 day postoperative following a total hip arthroplasty. Which of the following interventions should the nurse contribute to the plan of care?

Keep an abduction pillow between the client's legs.

A nurse is assisting with the development of a plan of care to manage pain for a client who has herpes zoster with lesions on the lower extremities. Which of the following interventions should the nurse include in the plan of care?

Keep bed linens off of the affected areas.

A nurse is contributing to the plan of care for a client who was admitted to the neurological unit following a stroke 3 hr ago. Which of the following interventions should the nurse identify as the priority?

Keep the client in a side-lying position.

A nurse is caring for a client who is in Buck's traction. Which of the following interventions should the nurse perform to reduce skin breakdown?

Keep the skin dry and free of perspiration.

A nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture. Which of the following findings should the nurse recognize as abnormal?

Lack of sensation between the first and second toes

A nurse is assisting a client who reports difficulty falling asleep. Which of the following activities should the nurse recommend to promote sleep?

Listen to soft music before sleeping.

A nurse observes a client who is lying in bed experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Loosen clothing around the client's neck.

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty. Which of the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed.

A nurse is reinforcing teaching with a client who is postoperative following a cemented total hip arthroplasty. Which of the following instructions should the nurse include in the teaching?

Maintain hip flexion to 90 degrees or less when sitting

A nurse is caring for an older adult client who has a reddened area over the sacrum. Which of the following actions should the nurse take?

Minimize the time the head of the bed is elevated.

A nurse in an oncology clinic is reinforcing teaching about Mohs surgery with a client who has skin cancer. Which of the following information should the nurse include in the teaching?

Mohs surgery is a horizontal shaving of thin layers of the tumor.

A nurse is caring for a client undergoing testing for multiple sclerosis. Which of the following findings should the nurse expect?

Muscle spasticity

A nurse is caring for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?

Muscle twitching

A nurse is reviewing the medical record for an older adult client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take?

Notify the charge nurse of the client's BUN level.

A nurse is assisting with the discharge planning for a client who is postoperative following a total hip arthroplasty. Which of the following instructions should the nurse include in the discharge plan?

Obtain a raised toilet seat.

A nurse is preparing to assist a client out of bed 4 hr following a laparoscopic cholecystectomy. Which of the following actions should the nurse take first?

Obtain the client's blood pressure.

A nurse is contributing to the plan of care to promote a restful night's sleep for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Offer a small snack at bedtime.

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide. Which of the following findings should the nurse instruct the client to report to the provider?

Onset of nausea

A nurse enters the room of a client whose transfusion of packed RBCs was initiated 15 min ago by the RN. The client reports dyspnea and urticaria. Which of the following actions should the nurse perform first?

Stop the infusion.

A nurse is assisting with an educational program for clients who have been newly diagnosed with diabetes mellitus. Which of the following instructions should the nurse include in the program regarding insulin?

Opened insulin can be stored on a cool countertop away from light.

A nurse is caring for a client who is 24 hr postoperative following an abdominal surgery. Which of the following findings requires immediate attention from the nurse?

Oxygen saturation of 88%.

A nurse is monitoring an older adult client who has a history of an enlarged prostate and is experiencing suprapubic discomfort. Which of the following actions should the nurse take first?

Palpate the abdomen.

A nurse is caring for a client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

Perform pin site care daily.

A nurse is preparing to remove a client's NG tube. Which of the following interventions should the nurse take to decrease the risk of aspiration?

Pinch the NG tube.

A nurse is caring for a client following a gastrectomy. Which of the following actions should the nurse take to decrease episodes of dumping syndrome?

Place the client in the supine position after meals.

A nurse is caring for a client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take?

Position pillows between the bony prominences.

A nurse is reviewing the laboratory results of a client who has type 2 diabetes mellitus. The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing?

Prealbumin 12 mg/dL

A nurse is reviewing the chart of a client who is experiencing an adrenal crisis, which was precipitated by the client not taking her medication for several days. The nurse should identify that withdrawal from which of the following medications potentiated the adrenal crisis?

Prednisone

A nurse is caring for a client who is 1 day postoperative following a hip arthroplasty. The client is exhibiting hypotension, tachycardia, and tachypnea. The nurse should recognize that these findings indicate which of the following complications?

Pulmonary embolism

A nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect?

Red macular rash

A nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching her feet when walking.

A nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood.

A nurse is reinforcing discharge teaching about wound care with a family member of a client who is postoperative. Which of the following should the nurse include in the teaching?

Report purulent drainage to the provider.

A nurse is caring for a client who is in Buck's traction for a fractured hip. The client reports increased pain at the site of the fracture. Which of the following actions should the nurse take?

Reposition the client

Following a blood draw procedure for a fasting blood sugar (FBS) test, a client tells the nurse, "I'm glad they took my blood because I'm really hungry. All I've had since midnight is water and some juice." Which of the following actions should the nurse take?

Reschedule the FBS test for early the next morning.

A nurse is repositioning a client who has lower back pain. Which of the following positions is appropriate for the client?

Semi-Fowler's with knees flexed

A nurse is contributing to the plan of care for a client who has pericarditis. In which of the following positions should the nurse plan to place the client to decrease pain?

Upright, leaning forward

A nurse is reviewing the medical record of a client who has a prescription for morphine. Which of the following findings should the nurse report to the provider?

Urinary retention

A nurse is reinforcing teaching with a client who has diabetes mellitus and a new prescription for regular and NPH insulin. Which of the following instructions on preparing the insulins should the nurse include?

Withdraw the regular insulin before withdrawing the NPH insulin.

A nurse is caring for a client who has a prescription for digoxin 0.25 mg PO daily. While taking the client's apical pulse, the nurse notes a rate of 58/min. Which of the following actions should the nurse take?

Withhold the dose.

A nurse in a clinic is assisting with the development of a pamphlet about STIs. Which of the following information should the nurse recommend to include in the pamphlet?

Women have a higher risk of contracting STIs than men.