Passpoint Review
The nurse should monitor the client with acute pancreatitis for which complication?
pneumonia
Which factor is most important for the nurse to consider when determining the angle at which to insert the needle for a subcutaneous injection?
amount of subcutaneous tissue
The nurse is caring for a client with a burn injury who is experiencing hypersecretion of gastric acid. The nurse should monitor for development of what complication?
gastrointestinal ulceration
A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:
notify the physician about cloudy or foul-smelling urine.
A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's child asks if the hospital can "treat the sore." What is the nurse's best initial response?
"We will collaborate with the physician to obtain an order for the wound care nurse to see the client."
A client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply.
-high-fiber, low-calorie diet -use of stool softeners -thyroid hormone replacements
A client is scheduled for a creatinine clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in
1 minute.
A client received burns to the entire back and left arm. Using the Rule of Nines, the nurse can calculate that the client has sustained burns on what percentage of the body?
27%
A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:
4 hours.
A nurse is evaluating a stage II pressure ulcer on a client. Which wound assessment findings should prompt the nurse to request a referral from the wound care nurse?
a wound measuring 2 cm × 2 cm × 0.5 cm with tan leathery appearance
A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp?
behind the ears
A client who was bitten by a wild animal is admitted to an acute care facility for treatment of rabies. Which type of isolation does this client require?
contact
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?
pulse
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. The nurse should report which finding to the health care provider (HCP)?
urine output: 20 mL/h
While in a skilled nursing facility, a client contracts scabies, which is diagnosed the day after discharge. The client is living at an adult child's home with six other people. During the client's visit to the clinic, the client asks a staff nurse, "What should my family do?" The most accurate response from the nurse is
"All family members need to be treated."
A graduate nurse is asking for information about chronic renal failure. Which statement by the nurse would be most accurate when providing teaching?
"It is characterized by azotemia, fluid volume excess, and hyperkalemia."
A nurse provides preoperative education to a client scheduled to undergo elective surgery. The nurse includes instructions about proper skin care. Which client statement indicates the need for further education?
"On the morning of the surgery, I can shave my surgical area at home to save time."
A client scheduled for hemodialysis is prescribed an oral antihypertensive daily. What is the correct action by the nurse regarding the medication?
Administer it after the hemodialysis treatment.
A client returns from extracorporeal shock wave lithotripsy with ecchymosis over the left flank area. Vital signs are within normal limits, and the client appears to be in no acute distress. Which nursing action is appropriate?
Apply a cold compress to the site.
A client reports left calf pain after undergoing a renal arteriogram through the left femoral artery. What intervention will the nurse perform first?
Assess peripheral pulses in the left leg.
A client is admitted with a diagnosis of chronic hydronephrosis. Which assessment finding requires immediate action or will assist the nurse in planning care?
Client's blood urea nitrogen (BUN) is 32 mg/dL.
The nurse is preparing information for a community health fair. Which information should the nurse include to promote healthy skin?
Drink an adequate amount of water.
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. What should the nurse do to prevent a urinary tract infection?
Empty the urinary appliance before it is one-third full.
A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?
Fluid intake should be about equal to the urine output.
Which action would be most appropriate for preventing urinary tract infections in an elderly female client?
Instruct the client to avoid tight-fitting underwear.
A client is having peritoneal dialysis. During the exchange, the nurse observes that the solution draining from the client's abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. What clinical judgment should the nurse make about the blood-tinged drainage?
It indicates abdominal blood vessel damage.
A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse?
Notify the nursing supervisor and the authorities of the possibility of abuse.
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
blood pressure elevation
Four clients are assigned to a nurse. Which client should the nurse identify who would benefit the most from hyperbaric oxygen therapy?
client with a compromised skin graft
Which finding in the client's history would be the least likely to have predisposed the client to renal calculi?
drinking less than the recommended amount of milk
The nurse is reviewing risk factors for malignant melanoma with a group of individuals in a community setting. Which risk factors should the nurse include in the instructions? Select all that apply.
freckles light-colored eyes history of severe sunburn presence of large moles
A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage?
milk
After trying for a year to conceive, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse asks about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?
mumps
The nurse is caring for a client who has been admitted to the hospital with a leg ulcer that is infected with vancomycin-resistant s. aureus (VRSA). Which nursing actions can be delegated to a licensed practical/vocational nurse (LPN/VN)?
obtaining a wound culture during a dressing change
A client with a severe staphylococcal infection is receiving the aminoglycoside gentamicin sulfate by the I.V. route. The nurse should assess the client for which adverse reaction?
ototoxicity
A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?
supporting the client's emotional status
Which client has a need for prophylactic antibiotic therapy prior to dental manipulations?
the client who had an aortic valve replacement 5 years ago
Which client will the nurse prioritize to assess first?
the client with ESRD (end-stage renal disease) just admitted the night before
After completion of peritoneal dialysis, for which symptom should the nurse assess the client?
weight loss
The nurse is reading the nurse's note from the previous shift to evaluate the client with a risk for impaired skin integrity due to fluid volume excess. Which aspects would demonstrate this improvement?
Ambulation to the bathroom without noted dyspnea.
The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?
Apply a hydrocolloidal dressing.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate?
Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure.
A client in a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on the buttocks. The client reports that the family has been changing the hydrocolloid dressings every 3 to 5 days. Over the past few weeks, the client has been spending less time in the wheelchair. During the appointment, the nurse notes that the client is not using a cushion and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about the treatment regimen?
Ask the client to explain the treatment regimen.
A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What should the nurse do first?
Assess the patency of the urethral catheter.
The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. (0700) Monday and end at 7 a.m. (0700) Tuesday?
Collect and save the urine voided at 7 a.m. (0700) on Tuesday.
The nurse is using home telehealth monitoring to manage care for an 80-year-old who is home bound. The client spends most of the day in bed. Two months ago, the nurse detected sacral redness from friction and shearing force of being in bed. Last month, the client had increased sacral redness, and the area was classified as a stage I pressure ulcer. On this visit, the nurse is assessing the sacral area using a video camera. The nurse compares the site from a visit made 1 month ago (see figure part A) to the assessment made at this visit (see figure part B). Upon comparing the change of the pressure ulcer from this visit to the previous visit, what should the nurse do next?
Contact the health care practitioner (HCP) to request a hydrocolloid dressing.
The nurse is caring for a client with a gastrostomy tube. Fifteen minutes after a bolus feeding the client experiences bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness. What action should the nurse take?
Contact the healthcare provider to alter the enteral feeding prescription.
The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse?
Contact the healthcare provider.
The nurse is planning care for a client with stress incontinence. What goal is realistic for the nurse to establish with the client?
Decrease the number of incontinence episodes.
A client with benign prostatic hypertrophy has an elevated prostate-specific antigen (PSA) level. What should the nurse do next?
Determine if the prostatic palpation was done before or after the blood sample was drawn.
Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?
Diaphragms should not be used if the client develops acute cervicitis.
While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to do which actions? Select all that apply.
Document the condition of the client's skin. Turn the client when in bed.
When assessing an elderly client, a nurse on the day shift notes redness in the sacral region. Close assessment reveals small breaks in the skin surface. The client says the area is tender and must have lost skin when a nursing assistant on the previous shift moved the client. The client tells the nurse, "The nursing assistant on the last shift was rough. I asked the nursing assistant to look at my backside, but the nursing assistant said they were too busy." What should the nurse do first?
Document the findings.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that there is a moderate amount of mucus in the urine. What should the nurse do next?
Encourage a high fluid intake.
The nurse and parents plan for the discharge of a child with leukemia who is receiving dactinomycin and vincristine. Which intervention should the nurse include in the teaching plan?
Encourage increased fluid intake.
The nurse warms the dialysis solution before use in peritoneal dialysis. What is the expected outcome of warming the solution?
Encourage the removal of serum urea.
A client is scheduled for a creatinine clearance test. What should the nurse do to prepare the client?
Instruct the client about the need to collect urine for 24 hours.
A client has burns on both hands and upper arms. Which nursing actions will be most helpful in preventing contractures? Select all that apply.
Keep the hands elevated. Apply splints as prescribed. Collaborate with the physical therapist.
Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take?
Monitor patient blood pressure.
A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take?
Obtain the child's blood pressure.
A client comes into the emergency department with severe back pain radiating to the left lower groin. The healthcare provider prescribes morphine sulfate 5-10 mg IV every 2 hours. One hour after receiving 10 mg of morphine, the client is restless and distressed, reporting the pain is still at 8 of 10. What action will the nurse take?
Reassess the client's pain and associated symptoms, and report findings to the healthcare provider to advocate for better pain control.
A client is diagnosed with genital herpes (herpes simplex virus type 2, or HSV-2). What information should the nurse give to the client about managing this health problem?
Reducing stressful life events may decrease the incidence of herpetic outbreaks.
A registered nurse (RN) is working with the licensed practical nurse (LPN) to care for a group of clients in a nursing home. How should the RN expect the LPN to communicate changes in the clients' wound status?
The RN communicates daily with the LPN about the condition of each resident.
A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?
This condition puts the client at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.
During nursing rounds, a nurse checks on a client on bed rest who reports an itchy rash. The nurse assesses the client's skin for erythematous, slightly edematous areas on the client's back, posterior lower legs, and posterior elbows. The health care provider's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are correct? Select all that apply.
This is an allergic reaction. Based on the location, it is likely that detergents in the bed linens caused the rash. Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area involved.
The client is having peritoneal dialysis. During the exchange, the nurse observes that the flow of dialysate stops before all the solution has drained out. What should the nurse do next?
Turn the client from side to side.
Which teaching approach for the client with chronic renal failure who has difficulty concentrating due to high uremia levels would be most appropriate?
Validate the client's understanding of the material frequently.
The nurse is applying a hand mitt restraint for a client with pruritus (see figure). What should the nurse do first?
Verify the prescription to use the restraint.
At a health care facility, clients with major burns are transferred to a burn center. The nurse anticipates the transfer of which clients to the burn center? Select all that apply.
an adult with 1.5% total body surface area third-degree burns of face an adult with an electrical burn a child with burns of hands and feet
The nurse is assessing the skin of an older adult client. Which finding requires intervention?
an elevated irregularly shaped mole
The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle by doing which?
avoiding alcohol
The nurse is assessing a client who experienced second- and third-degree burns of the arms and hands from a kitchen grease fire. After determining that the client did not experience an inhalation injury, which assessment should be completed next?
blood pressure and heart rate
A client returns to the intensive care unit after coronary artery bypass graft surgery, which was complicated by a prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. Which assessment finding indicates a potential complication related to this occurrence?
blood urea nitrogen level (BUN) of 40 mg/dL
Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply.
bran cereal broccoli navy beans
A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for:
cardiac arrhythmia.
The nurse is caring for a client during the first 72 hours after thyroidectomy. The nurse should assess for which signs of complications of this surgery?
carpal spasms and facial numbness
Which hospitalized client is at highest risk for catheter associated urinary tract infection (CAUTI)?
client with diabetes mellitus
A female client is experiencing bladder control problems. Which outcome indicates the success of nursing interventions to promote urinary continence for this client?
continence for 24 hours a day
The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?
decreased ability to detect thirst
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance?
decreased serum sodium level
The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question?
dextrose 5% in water (D5W)
To treat a urinary tract infection, a client is ordered sulfamethoxazole-trimethoprim. The nurse should teach the client that sulfamethoxazole-trimethoprim is most likely to cause which adverse effect?
diarrhea
A client has prostatic hypertrophy. What should the nurse assess when conducting a focused assessment of the client's ability to urinate?
difficulty starting the flow of urine
A child has been prescribed diphenhydramine hydrochloride to help control the itching from atopic dermatitis. The nurse should instruct the parents to report which conditions? Select all that apply.
drowsiness thick mucous nausea
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
hoarseness of the voice
A client has a diagnosis of dehydration. What indicators would the nurse assess to determine an improvement in dehydration? Select all that apply.
increased weight increased blood pressure
A nurse is teaching a client about skin cancer. Which risk factors for skin cancer should the nurse explain? Select all that apply.
increasing age exposure to chemical pollutants long-term exposure to the sun genetics immunosuppression
The nurse is caring for a client with acute renal failure. Rank in chronological order the phases of acute renal failure. All options must be used.
initial insult oliguric phase diuretic phase recovery phase
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?
limiting fluid intake
While assessing the skin of a 45-year-old, fair-skinned female client, the nurse notes a lesion on the medial aspect of her lower leg. It has irregular borders, with various shades of black and brown. The client states that the lesion itches occasionally and bled slightly a few weeks ago. She also reveals a history of sunburns. Based on these signs and symptoms, the nurse suspects
melanoma
A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include:
periorbital edema.
The nurse is caring for a client with toxic epidermal necrolysis. When reviewing the client's medical record, the nurse would suspect which medication to be a probable cause of this disorder?
phenytoin
Which is an advantage of using biologic burn grafts such as porcine (pigskin) grafts? Porcine grafts:
promote the growth of epithelial tissue.
The client is in the oliguric phase of acute renal failure. For which risk should the nurse assess the client?
pulmonary edema
A client with atopic dermatitis is ordered a potent topical corticosteroid to be covered with an occlusive dressing. To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
related to percutaneous absorption of the topical corticosteroid
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?
ring or donut
When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which menu for lunch?
roast beef sandwich, milkshake, and cottage cheese
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion?
scale
A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?
stage II pressure ulcer
A client arrives at the emergency department with deep partial-thickness and full-thickness burns over 15% of his body. At admission, the client's vital signs are: blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.
starting an I.V. infusion of lactated Ringer's solution administering 6 mg of morphine I.V. administering tetanus prophylaxis as ordered
A client has been admitted with severe burns. Lactated Ringer's has been ordered to infuse via a pump. Why is this solution being used?
to prevent signs of hypovolemic shock and restore circulation
An adolescent client is hospitalized with acute glomerulonephritis. The nurse reviews the client's urine chemistry laboratory reports (see figure). Which finding does the nurse draw to the attention of the health care provider (HCP)?
urine specific gravity
Which factor would have the least influence on the survival and effectiveness of a burn victim's porcine grafts?
use of analgesics as necessary for pain relief
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?
white blood cell (WBC) count of 20,000/mm3 (0.02 L)
A client seeks medical care for severe sunburn. Which teaching should the nurse provide to reduce the client's risk of skin damage from sun exposure?
"Apply sunscreen even on overcast days."
The nurse is providing client education during the rehabilitation phase of a burn injury. Which statement by the client indicates that more instruction is required?
"I will report any skin discoloration to the primary healthcare provider immediately."
A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?
"I'll eat plenty of fruits and vegetables."
A client reports to a physician's office for intradermal allergy testing. Before testing, the nurse provides client teaching. Which client statement indicates a need for further education?
"If I notice tingling in my lips or mouth, gargling may help the symptoms."
A healthcare provider orders an emollient for a client with pruritus of recent onset. The client asks why the emollient should be applied immediately after a bath or shower. How should the nurse respond?
"To prevent evaporation of water from the hydrated epidermis."
The nurse is caring for a client with acute renal failure and edema. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
-Make sure the urinal is within the client's reach. -Remind the client that all urine is to be saved for intake and output measurement. -Weigh the client every morning using the standing scale. -`Measure and record vital signs.
A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply.
-Perform a face-to-face behavior evaluation every hour. -Tie the restraints in quick-release knots. -Document the client's condition. -Document alternative methods used before the restraints were applied. -Document the client's response to the intervention.
A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply.
-Weigh the client daily. -Measure urine specific gravity. -Monitor intake and output.
Following a transurethral resection of the prostate (TURP), a client is receiving a normal saline 0.9% irrigation solution at 200 mL/hour. The client has a peripheral IV running at 125 mL/hour and has consumed 300 mL of water. After 8 hours, the nurse empties 3100 mL of fluid from the Foley bag. What is the 8-hour urinary output for this client? Record the answer as a whole number.
1500
A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority?
Assess urine output hourly.
A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula. What intervention will the nurse include in the care plan?
Auscultate the AV fistula for a bruit.
After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?
"I'll have to wear an external collection pouch for the rest of my life."
A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address?
"I'm allergic to shellfish."
A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?
"Increase your fluid intake to 2 to 3 L per day."
The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with which product?
soap
A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom?
tension and fatigue before menses and through the second day of the menstrual cycle
Which factor should be checked when evaluating the effectiveness of an alpha-adrenergic blocker given to a client with benign prostatic hyperplasia (BPH)?
voiding pattern
A client is to receive belladonna and opium suppositories, as needed, postoperatively after transurethral resection of the prostate (TURP). The nurse should give the client these drugs when he demonstrates signs of which symptom?
pain from bladder spasms
A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client?
"See your health care provider (HCP) for an early diagnosis and treatment of a sore throat."
In the emergency department, a client reveals to the nurse a lethal plan for dying by suicide and agrees to a voluntary admission to the psychiatric unit. Which information would the nurse discuss with the client to answer the question "How long do I have to stay here?" Select all that apply.
-"You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs." -"Let's talk after the health care team has assessed you." -"Because you have stated that you want to hurt yourself, you must be safe before being discharged."
The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease. What should the nurse instruct the client to do? Select all that apply.
-Avoid a diet high in fatty foods. -Avoid beverages that contain caffeine. -Avoid all alcoholic beverages.
The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question?
Arrange for a person with an ostomy to visit the client preoperatively.
A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?
Assess urine for excessive bleeding.
A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply.
Avoid sleeping on the left arm. Wear wrist watch on the right arm. Assess fingers on the left arm for warmth.
A client is started on sulfamethoxazole-trimethoprim for reports of severe burning on urination and frequent, urgent voiding of small amounts of urine. As the nurse explains the medication, the client requests something to relieve the painful urination. Which treatment order would the nurse anticipate for the client's discomfort?
phenazopyridine
An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?
negligence
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. What information should the nurse give to the client?
Report any difficulty urinating.
During dialysis, the client has disequilibrium syndrome. What should the nurse do first?
Slow the rate of dialysis.
The nurse suspects an air embolism in a client receiving hemodialysis. Place the actions by the nurse in the correct order. All options must be used.
Stop the hemodialysis. Place client on left side in Trendelenburg position. Notify the rapid response team. Administer oxygen. Assess vital signs.
A nurse is about to admit a client to the medical surgical unit directly from the healthcare provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which action is the nurse's priority?
Strict intake and output assessment and documentation
A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology?
the client with diabetes insipidus
The nurse is caring for a client that has a low potassium level. What medication(s) would the nurse be concerned about administering to this client? Select all that apply.
-digoxin -furosemide
The nurse is obtaining a health history from a client with a sexually transmitted disease. Which description from the client indicates the likelihood of syphilis? "In my genital area I have:
a moist ulcer."
After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physician. Which of the following, if stated by the client as a complication, indicates a need for additional teaching?
Headache.
Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease?
enhance myocardial oxygenation
A client with type 2 diabetes mellitus who is taking metformin is scheduled for a computed tomography (CT) with contrast of the abdomen tomorrow. Which priority nursing assessment is done before the procedure?
ensuring that the metformin has been withheld for 48 hours prior to the scan
A client receiving dialysis directs profanities at the nurse and then abruptly hangs his head and pleads, "Please forgive me. Something just came over me. Why do I say those things?" The nurse interprets this as which finding?
emotional lability
When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?
high purine
Which factor would put the client at increased risk for pyelonephritis?
history of diabetes mellitus
The nurse should monitor the client with Cushing's disease for which finding?
hypokalemia
A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?
increasing fluid intake to 3 L/day
A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.
-numbness -tingling -muscle twitching and spasms
A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse include in the discharge instructions? Select all that apply.
-Avoid odor-producing foods, such as onions, fish, eggs, and cheese. -Drink at least 3,000 mL of fluid each day.
A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.
-Begin an intravenous (I.V.) infusion of lactated Ringer's solution. -Administer 6 mg of IV morphine. -Administer tetanus prophylaxis, as ordered.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
-Infuse a unit of PRBCs in less than 4 hours. -Stop the transfusion if a reaction occurs, but keep the line open. -Inspect the blood bag for leaks, abnormal color, and clots.
A client comes to the emergency department reporting sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?
kidney
An older adult is admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence and has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply.
-fluid restriction vital signs every 2 -hours -bed alarm -Foley catheter
