PN Adult Medical Surgical Online Practice 2023 B
A nurse is assisting with the care 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 R: Phenazopyridine reduces pain and burning during urination by exerting an anesthetic effect on the mucosa of the urinary tract.
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. R: The first action the nurse should take when using the nursing process is to collect data on the client's daily bowel elimination habits to establish a routine defecation time.
A nurse is assisting with the care 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. R: When using the nursing process, the first action the nurse should take is to collect data from the client. Therefore, the nurse should determine the client's understanding of the procedure to reinforce necessary teaching, which can help manage their anxiety.
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: Rationale: Lead impairs the emission of radiation. Therefore, the nurse should dispose of radiation implants in a lead container in accordance with facility protocol. ------------------------------ Pregnant women and children should not be allowed to visit a client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions. The nurse should use forceps to pick up a radiation implant if it becomes dislodged. The nurse should limit time spent in the client's room to 30 min during an 8 hr shift.
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 The nurse should identify that loop diuretics, such as furosemide, increase the urinary excretion of potassium, which can lead to hypokalemia. Hypokalemia increases the risk for the development of digoxin toxicity.
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?
Hbg 11 g/dL R: Epoetin alfa stimulates the production of erythropoietin and red blood cells, resulting in increased hemoglobin levels. Therefore, a hemoglobin level of 11 g/dL indicates the epoetin alfa treatment is effective.
A nurse is participating in a health fair for older adult clients. Which of the following vaccines should the nurse recommend for this age group?
Herpes zoster The nurse should recommend the herpes zoster vaccine for adults who are 60 years of age and older.
A nurse is reviewing the plan of care for a 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. Rationale: The nurse should keep an abduction pillow or a splint between the client's legs to prevent hip dislocation after surgery. ----- The nurse should encourage and assist the client to get out of bed as soon as possible after the surgery. The nurse should have the client perform incentive spirometry every 2 hr as well as deep breathing and coughing every 2 hr to prevent atelectasis. The nurse should check the neurovascular status on the extremity every 2 to 4 hr.
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 exion at 90° or less when sitting. R: A client who had a cemented total hip arthroplasty should maintain hip flexion at 90° or less when sitting to prevent hip dislocation.
A nurse is assisting with the care 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. R: The nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.
Click to highlight the findings the nurse should report to the charge nurse immediately. To deselect a finding, click on the finding again.
• Perineal pad is saturated with blood, and large clots are present is correct. The presence of vaginal bleeding and blood clots is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. • Blood pressure 98/56 mm Hg is correct. Decreased blood pressure is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse. • Heart rate 102/min is correct, Tachycardia is a manifestation of vaginal hemorrhage. Therefore, the nurse should report this finding to the charge nurse.
A nurse is reinforcing preoperative teaching with a client. Which of the following statements by the client indicates an understanding of the teaching? Select all that apply.
" I will need to do the breathing exercises every 1 to 2 hrs after surgery." "I will use my PCA medication before my knee starts to hurt too bad." "I will probably be going home with a walker."
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." Rationale: To avoid exposure to bacteria, clients who have cancer and are receiving chemotherapy should be sure that drinking water is safe. Drinking fresh, bottled water limits exposure to bacteria.
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." Rationale:Clients who have a febrile illness should not receive the influenza vaccine. ----- Clients who recently received a tuberculosis skin test can receive the influenza vaccine. Clients who have an allergy to latex can receive the influenza vaccine. Clients who have an allergy to shrimp or shellfish can receive the influenza vaccine.
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 to the medication?
"I have gained 3 lbs since my last appointment" R: Hyperthyroidism can cause weight loss. Therefore, the nurse should identify weight gain as an indication that the methimazole therapy has been effective
The nurse is reinforcing discharge teaching with the client. Which of the following client statements indicates an understanding of the teaching? Select all that apply.
"I should schedule several rest periods throughout the day" "I should notify my provider if my temperature is higher than 101 degrees Fahrenheit".
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 typically painless." R: Clients should report a lump that is not painful because testicular cancer is typically painless.
nurse is reinforcing discharge teaching with a client who had a mechanical mitral valve replacement. Which f the following statements by the client indicates an understanding of the teaching?
"I will notify my dentist about this procedure." R: The nurse should remind the client to notify their dentist about the mechanical mitral valve replacement before any procedures so antibiotic therapy can be initiated to reduce the risk for endocardial infection.
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." Rationale: The nurse should instruct the client to perform testicular self-examination after taking a warm shower or bath. This causes relaxation of the scrotal skin, which allows for better palpation of the testes.
A nurse is preparing to administer phytonadione 7 mg subcutaneously to a client who has an IN 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 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 R: The nurse should recommend kidney beans as the best source of fiber because 1/2 cup contains 6.5 g of fiber
A nurse is preparing to perform intermittent urinary catheterization for a female client who has been unable to void following surgery 6 hr ago. Which of the following catheters should the nurse use to perform this procedure?
B- clear plastic with blue cap
A nurse is assisting with the care for a client who reports stomatitis. Which of the following dietary recommendations should the nurse make?
Eat soft foods R: The nurse should remind a client who has stomatitis to eat soft, nonirritating foods to decrease irritation to the oral mucosa.
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. R: The nurse should encourage the client to complete ADLs and provide assistance as needed. Performing self-care increases the client's independence, strength, and level of functioning.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Hypovolemia Insert a large gauge IV Initiate a fluid challenge blood pressure Urine output
A nurse is reinforcing teaching with the caregiver of a client who is terminally ill about manifestations of impending death. Which of the following manifestations should the nurse include?
Incontinence of the bowel and bladder. Rationale:The nurse should inform the caregiver that incontinence of the bowel and bladder is a manifestation of impending death. Other manifestations include hypotension, bradycardia, restlessness, and coolness of the skin.
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 cleint in a side-lying position. Rationale: The greatest risk to the client following a stroke is aspiration. The nurse should position the client in a lateral, or side-lying, position to allow any secretions to drain out of the mouth, decreasing the risk for aspiration. Additionally, the nurse should have suction equipment available in the event that any secretions are present in the oral cavity.
A nurse is reinforcing teaching about hospice care with a client who has terminal cancer. Which of the following statements should the nurse make?
"Hospice care will provide support for you and your loved ones during the dying process." R: The nurse should reinforce teaching with the client that hospice care supports clients and their loved ones with the goal of helping provide a peaceful and dignified death.
A nurse in a long-term care facility is collecting data from a client who reports ful 1088 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 R: Small liquid stools can be the result of fecal material being expelled around an impaction.
The nurse is collecting data on the client. For each client finding, click to specify if the finding is consistent with Appendicitis, Diverticular disease, or Crohn's disease. Each finding may support more than 1 disease process.
Blood in the stool is consistent with diverticular disease and Crohn's disease. Clients who have diverticular disease can have a decreased hemoglobin and hematocrit level from chronic or severe bleeding, and their stools should be checked for occult or frank bleeding. Anemia relating to Crohn's disease is common because of slow bleeding, and the stools of client's who have Crohn's disease might contain bright red blood. Pain in the right lower quadrant is consistent with appendicitis and Crohn's disease. Pain in the right lower quadrant is a manifestation of appendicitis. Clients who have inflammation from Crohn's disease usually have constant pain located in the right lower quadrant. Clients who have diverticular disease might experience pain in the left lower quadrant. Mucus in the stool is consistent with Crohn's disease. Clients who have Crohn's disease usually have mucus and fat in their stools. Nausea is consistent with appendicitis, diverticular disease, and Crohn's disease. Clients who have appendicitis, diverticular disease, or Crohn's disease might experience nausea.
A nurse is monitoring a client who has a 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. R: Using a blow dryer on a cool setting to blow cold air into the cast is an effective way to relieve the client's itching without damaging the skin.
A nurse is assisting with the care of 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 R: The nurse should anticipate a prescription for an escharotomy to relieve constriction of the client's chest due to a burn injury. Following removal of the eschar, chest wall movement will be possible, and the client's oxygenation should improve.
A nurse is assisting with the care for a client who has an area indicating potential breakdown over the sacrum. Which of the following actions should the nurse take?
Minimize the time the head of the bed is elevated. R: The nurse should minimize the time the head of the bed is elevated to reduce pressure on the sacral area.
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." Glucocorticoids cause immunosuppression and may mask infection. The client should limit contact with sources of possible infections, such as large groups of people.
A nurse is reinforcing teaching with a client who is taking levothyroxine. Which of the followi is statements by the client indicates an understanding of the teaching?
"The medication should be taken before I eat breakfast every morning." R: The nurse should remind the client to take levothyroxine at the same time each day, preferably 1 hr before breakfast.
A home health nurse is assisting with the care for a client who has COPD. The client reports shortness of breath while eating, despite the use of home oxygen. Which of the following recommendations should the nurse make?
"Use a bronchodilator 30 minutes before your meal." R: The dient should use a bronchodilator 30 min before meals to prevent shortness of breath while eating.
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." R: The nurse should reinforce teaching with the client that there is a risk for infertility as a result of this infection,
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." R: Tieres who are receiving chemotherapy should clean their toothbrushes by soaking them in a hydrogen peroxide or bleach solution. This solution rids the toothbrush of bacteria and prevents infection.
A nurse is assisting with the care of a client who had a cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent postprocedure complications? (Select all that apply.)
*Monitor the insertion site for bleeding is correct. The nurse should monitor the client's insertion site for manifestations of hemorrhaging.* Position the affected extremity at a 45º angle is incorrect. The nurse should keep the client flat with the affected extremity extended, not flexed. Restrict the client's fluid intake is incorrect. The nurse should encourage fluid intake for the client following the cardiac catheterization to assist with evacuating the contrast medium from the client's system. *Maintain the pressure dressing is correct. The nurse should maintain the client's pressure dressing to prevent hemorrhaging and allow for the cannulation site to heal.* *Check the client's peripheral pulses is correct. The nurse should assess the client's peripheral pulses to help identify signs of arterial occlusion.*
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? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A (red) is correct. FRONTAL LOBE Injury to the frontal lobe can result in alterations to motor function or voluntary movement. This involves the ability to speak and the ability to move purposefully. ----- (Yellow) The nurse should identify that injury to the parietal lobe results in alterations to higher-level activities, such as writing, and processing sensory information, such as proprioception, pain, temperature, touch, and pressure. (purple) The nurse should identify that injury to the occipital lobe results in alterations in visual perception and the ability to track movement of an object. Injuries to this area can result in an inability to recognize objects, faces, or the written word. (teal)The nurse should identify that injury to the temporal lobe results in alterations in the ability to understand the spoken language and impaired short-term memory.
A nurse is assisting with the care of 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. R: The greatest risk to the client is death from anaphylaxis. Therefore, the nurse should administer epinephrine to reduce bronchospasms and laryngeal edema.
A nurse is assisting with the care for a client who reports shortness of breath and has an oxygen saturation 90%. Which of the following actions should the nurse take?
Administer oxygen via nasal cannula R: The nurse should administer oxygen via nasal cannula to a client who reports shortness of breath and has an oxygen saturation below the expected reference range. The nurse should continue to monitor the client and adjust the oxygen flow rate as needed.
The nurse is assisting with the care of the client who is preoperative for an exploratory laparotomy. Select the 4 actions the nurse should take.
Administer phenytoin with a sip of water on the day of surgery. Assist with the administration of gentamicin 100 mg IV. Assist with the administration of dextrose 5% in lactated Ringer's. Contact the wound, ostomy, and continence nurse.
Complete the following sentence by using the lists of options.
After reviewing the findings in the client's medical record, the nurse should first address the client's abdominal distention , followed by the client's Acute pain R: • Abdominal distention is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is abdominal distention. The nurse should address this finding to reduce the risk for life-threatening • Acute pain is correct. When using the greatest risk framework, the nurse should identify that a manifestation of an inflammatory intestinal disorder is acute abdominal pain. The nurse should address this finding to reduce the risk for life-threatening complications, such as obstruction or infection.
A nurse is prioritizing care for the client. Complete the following sentence by using the lists of options.
At 1000, the nurse should first address the client's Oxygen saturation followed by the client's Heart rate
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. ( to prevent dislocation of the replacement hip). - Nurse should instruct client to wait 90 days before crossing legs. Crossing legs early int heh postoperative period can result in dislocation of the replacement hip. -Nurse should inform the client that she ay lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip. - Nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip.
A nurse is reinforcing teaching with the client. Which of the following instructions should the nurse include? Select all that apply.
Avoid drinking fluids with meals. Eat several small meals per day. Consume high-protein snacks.
A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test, Which of the following instructions should the nurse include in the teaching?
Avoid eating red meat for 3 days prior to the test.
A nurse is reinforcing teaching with a client who is scheduled for a guaiac fecal occult blood test. Which of the Folliowing instractions should the nurse include in the teaching?
Avoid eating red meat for 3 days prior to the test. R: The nurse should remind the client to avoid eating red meat for 3 days prior to the guaiac fecal occult blood test because this can lead to a false positive result.
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. r-The nurse should instruct the client to avoid stopping baclofen suddenly because it can result in adverse reactions, including seizures, paranoia, and hallucinations.
A nurse is assisting with the care of a client who has a newly inserted water-seal closed chest tube. Which of the following findings should the nurse report to the provider?
Chest drainage is greater than 70 mL/hr. RAT: The nurse should identify that chest drainage of greater the 70 mL/hr can indicate a complication and should be reported to the provider. Water fluctuates in the water-seal chamber. Water should fluctuate in the water-seal chamber. The water rises and falls upon the client's respiratory effort. Therefore, this finding does not need to be reported to the provider.
A nurse is changing the dressing for a client who has an abdominal incision and a closed-suction drain. Which of the following actions should the nurse take?
Cleanse the drainage plug with alcohol swabs. Rationale: The nurse should cleanse the drain opening and plug with alcohol swabs to remove excess drainage and discourage pathogens from entering the drainage system. The nurse should secure the drainage tube to the client's gown to allow for ambulation. Pinning the gown to the client's bedding can result in dislodgement of the drain. The nurse should wear clean gloves to empty the drainage system because the exterior of the drain is not sterile. The nurse should use a precut or folded gauze dressing to fit around the drainage tube. If the nurse cuts the gauze dressing, small threads and fibers can embed in the incision and increase inflammation and infection.
The nurse is reviewing the client's medical record. Click to highlight the findings below that indicate that the client has a potential problem. To deselect a finding, click on the finding again.
Client is short of breath and has a productive cough with yellow mucus States, "I could barely breathe when I got up this morning and I had a throbbing headache" Client is diaphoretic Crackles heard in posterior lung
A nurse is assisting with the care for a client who has a new cast on their 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 R: Compartment syndrome is a complication that involves increased pressure within a compartment (an area that supports blood vessels, bones, and nerves) leading to circulatory compromise to the limb. The pressure can be caused externally by a cast that is too tight or internally by the inflammation or edema from the injury. Circulatory impairment causes pallor and paresthesia of the extremities, a delay in capillary refill, and, without immediate treatment, can cause nerve damage and necrosis.
The nurse is assisting with the plan of care for the client. For each potential provider prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.
Cough and deep breathe every 2 hr is anticipated Obtain a sputum culture and sensitivity is anticipated Titrate oxygen to keep oxygen saturation greater than 90% is anticipated. Place client on a 1,500 mL fluid restriction is contraindicated Administer acetaminophen 500 mg PO every 6 hr PRN is anticipated. Administer famotidine 40 mg PO daily is nonessential.
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 R: Creatinine 1.9 mg/dL. is not within the expected reference range. Therefore, the nurse should report the finding to the provider before the client has a CT scan with an IV contrast agent. This finding places the client at risk for developing contrast-induced nephropathy.
A nurse is contributing to the plan of care for a client who has peripheral arterial disease of the lower extremities. Which of the following interventions should the nurse include?
Dangle the extremities o the side of the bed. R: The nurse should include in the plan of care to have the client dangle their lower extremities off the side of the bed to aid in reducing pain by increasing arterial blood flow. The client should not raise the lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.
A nurse is assisting with the care 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 R: Following an abdominal paracentesis, the nurse should monitor the client for a decrease in blood pressure. This finding indicates hypovolemia as a result of excess fluid withdrawal. Depending on the amount of fluid withdrawn, hypovolemia can lead to shock.
A nurse is collecting data from a client who is receiving sumatriptan. Which of the following is an expected outcome?
Diminished headache Rationale: Sumatriptan is a vascular headache suppressant prescribed for relief of migraines or cluster headaches. Therefore, the nurse should monitor the client for a diminished headache as an expected outcome of the medication. --------------- Nasal and throat discomfort are possible adverse effects of sumatriptan. Muscle pain and stiffness are possible adverse effects of sumatriptan. The nurse should not expect sumatriptan to decrease peripheral edema.
A nurse is collecting data from a client who is being treated for hypovolemia due to nausea and vomiting. Which of the following findings should the nurse report to the provider?
Heart rate 120/min Rationale: The client's heart rate of 120/min is above the expected reference range and indicates that the client's hypovolemia has not resolved. Therefore, the nurse should report this finding to the provider to obtain additional prescriptions for fluid replacement.
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 4L/min via nasal cannula. Rationale: The nurse should remind the client to have a pneumococcal immunization at age 65 and every 10 years thereafter to protect them from acquiring pneumonia. --------------------------- The nurse should collect a sputum culture to identify the organism causing the client's infection. Antimicrobial sensitivities are obtained from the sputum culture to guide the provider in prescribing antibiotics. However, there is another prescription the nurse should implement first. The nurse should administer antibiotics to treat the infection. A broad spectrum antibiotic, such as ceftriaxone, is administered when sepsis is suspected because it treats both gram-positive and gram-negative bacteria. After the results of the blood and sputum cultures are obtained, the provider will often change to a more specific antibiotic. However, there is another prescription the nurse should implement first. The nurse should obtain blood cultures to identify the organism causing the client's infection. Antimicrobial sensitivities obtained from the blood cultures will guide the provider in prescribing treatment. However, there is another prescription the nurse should implement first.
A nurse is assisting with the care 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 R: Ecchymosis around the umbilicus is a sign of intra-abdominal bleeding, which is a finding consistent with pancreatitis.
A nurse is assisting with the care 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. R: The nurse should expect a prescription to irrigate the urethral catheter because this will clear the tubing of any blood clots or tissue pieces and allow for a better flow.
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 machine. R: The nurse should plan to keep a sheepskin pad between the dient's extremity and the cOM madhune to protect the client's skin. The nurse should check the client's skin condition frequendy wile the cient is using the CPM machine.
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. Rationale: The nurse should keep bed linens off of the affected areas by using a bed cradle, which will relieve pain caused by the linens rubbing against the lesions. ------- The nurse should apply cool compresses to help relieve pain caused by the lesions. The nurse should initiate airborne and contact precautions for a client who is immunocompromised and has widespread herpes zoster lesions. Otherwise, the nurse should follow standard precautions.
A nurse is assisting with the care of a client who has hearing loss. Which of the following actions should the nurse take?
Lower voice pitch when speaking R: The nurse should lower their voice pitch when speaking to a client who has hearing loss. Clients who have hearing loss have difficulty hearing high-pitched sounds.
A nurse is assisting with the care for a client who has meningococcal pneumonia. Which of the following personal protective equipment should the nurse use?
Mask R: The nurse should identify that a client who has meningococcal pneumonia requires droplet precautions, which include wearing a mask when providing care within 1 m (3 feet) of the client.
A nurse is assisting with the care for a client following a thyroidectomy. Which of the following findings should alert the nurse to the possibility of parathyroid gland injury?
Muscle twitching R: A common complication of a thyroidectomy is parathyroid gland injury, leading to hypocalcemia. Clients experiencing hypocalcemia can have twitching, numbness, and tingling of fingers, toes, and around the mouth.
A nurse is contributing to planning care for a client who overdosed on oxycodone. Which of the following medications should the nurse recommend for the client?
Naloxone R: Naloxone is an opioid antagonist used to prevent respiratory depression as a result of opioid overdose. The nurse should recommend this medication for the client.
A nurse is reviewing the medical record for a client who is experiencing nausea and vomiting. Based on the client data, which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)
Notify the charge nurse of the client's BUN R: The client's BUN level is above the expected reference range of 10 to 20 mg/dL, which can indicate impaired renal function. The nurse should anticipate interventions to restore the client's fluid volume.
The nurse is contributing to the plan of care for the client who has peritonitis and Crohn's disease. For each potential intervention, click to specify if the intervention is indicated or contraindicated for the client.
Obtain blood cultures - indicated obtain the client's vital signs every 15 min - indicated Administer a hypotonic IV solution - contraindicated insert a nasogastric tube - indicated
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. Rationale: The nurse should offer the client a small snack of carbohydrates or a glass of milk as part of the bedtime routine, which can help the client relax and prepare for sleep.
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 R: The nurse should reinforce teaching with the clients that opened insulin vials do not require refrigeration, but can be placed in a cool location for up to 4 weeks, out of direct sunlight.
The nurse is reviewing the client's diagnostic results. Which of the following findings require follow up? Select all that apply.
PaCO2 WBC count Chest x-ray Oxygen saturation BUN
A nurse is monitoring a 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. RAT: When providing client care, the nurse should first use the least restrictive intervention. Therefore, the nurse should palpate the abdomen to determine if the client has a distended bladder from urinary retention.
A nurse is assisting with the care of a client who is at risk for developing pressure injuries. Which of the following actions should the nurse take?
Position pillows between the bony prominences. R: The nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure injury development.
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 This laboratory value is below the expected reference range, indicating that the client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition.
A nurse is assisting with the care 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 R: Manifestations of a pulmonary embolism include hypotension, tachycardia, and tachypnea.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Reduce the temperature in the clients room. Limit visitors Hyperthyroidism Increased temperature Weight daily
A nurse is reinforcing discharge teaching for the caregivers 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 their feet when walking. R: The nurse should remind the client's caregivers to frequently remind the client to maintain correct posture and prevent falls by not watching their 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. Rationale: When communicating with a client who has hearing loss, the nurse should rephrase, rather than repeat, discharge instructions when they are not understood. When communicating with a client who has hearing loss, the nurse should keep their hands away from their mouth to promote lip reading. When communicating with a client who has hearing loss, the nurse should speak in a normal tone of voice. Higher pitched sounds can impede hearing by accentuating vowel sounds and concealing consonants. When communicating with a client who has hearing loss, the nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading.
The nurse is reviewing the client's medical record. Select the 3 findings that require nursing intervention.
Temperature WBC Potassium
A nurse in a telemetry unit is collecting data from a client who has a newly inserted permanent pacemaker. Which of the following findings should the nurse report to the provider?
The client experiences hiccups when sitting.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is experiencing manifestations of pancreatitis as evidenced by amylase and lipase
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The nurse is caring for the client who has manifestations of peritonitis therefore, the priority finding for the nurse to report is laboratory values
A nurse is assisting with the care for a client who has Cushing's syndrome and expresses concern regarding physical changes associated with the syndrome. Which of the following should the nurse recognize as a physical change caused by this disorder?
Truncal obesity's R: Truncal obesity is a manifestation of Cushing's syndrome that occurs due to a redistribution of fat. The client also usually has fatty tissue edema between the scapula, also known as "buffalo hump". The nurse should use therapeutic communication techniques to investigate the client's body image concerns.
A nurse is collecting data from a client who has 30% body surface area deep partial-thickness and full-thickness burns. Which of the following findings indicates that fluid resuscitation is adequate?
Urine output is 50 mL/hr. R: The nurse should closely monitor the client's urinary output as an indicator of effective fluid resuscitation. A urinary output greater than 30 to 50 mL/hr indicates that fluid resuscitation is adequate.
A nurse is assisting with the care for a client who has a methicillin-resistant Staphylococcus aureus (MRSA) nfection 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. R: The nurse should provide teaching to the visitors regarding the infection control measures for a client who is on contact isolation precautions. Contact precautions require visitors to put on a gown and gloves prior to entering the room of a client who has MRS4 to prevent the spread of infection
