Practice Test For Final

A client is recovering from abdominal surgery. The statement by the client that most indicates the nurse needs to educate the client about pain and pain control is`

"I should expect to have pain."

A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?

"I'm thirsty all the time. I just can't get enough to drink."

A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?

A lung volume reduction

A client with thoracic trauma is admitted to the ICU. The nurse notes the client's chest and neck are swollen and there is a crackling sensation when palpated. The nurse consequently identifies the presence of subcutaneous emphysema. If this condition becomes severe and threatens airway patency, what intervention is indicated?

A tracheostomy

A nurse is taking health history data from a client. Use of which of the following medications would especially alert the nurse to an increased risk of hepatic dysfunction and disease in this client? Select all that apply.

Acetaminophen Ketoconazole Valproic acid

A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?

Acute respiratory failure

A client's health history is suggestive of inflammatory bowel disease. Which of the following would suggest Crohn's disease, rather than ulcerative colitis, as the cause of the client's signs and symptoms?

An absence of blood in stool

What is the most commonly prescribed treatment for the common cold?

Antihistamines

A nurse knows that she must obtain a signed informed consent for which of the following procedures? Select all that apply.

Arteriography Open reduction of a fracture Cystoscopy Paracentesis

High doses of which medication can produce bilateral tinnitus?

Aspirin

A client has received a diagnosis of type 2 diabetes. The diabetes nurse has made contact with the client and will implement a program of health education. What is the nurse's priority action?

Assess the client's readiness to learn.

The nurse determines that a patient is at risk for the development of thrombophlebitis. What interventions can the nurse provide to prevent this? (Select all that apply.)

Assisting the patient with leg exercises Encouraging early ambulation Avoiding placement of pillows or blanket rolls under the patient's knees

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?

Avoid eating or drinking 2 hours before bedtime.

Which action by the nurse indicates understanding of one basic principle of providing effective pain management?

Awakening a new postoperative client to take pain medication

While assessing an acutely ill client's respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?

Biot's respiration

A patient is scheduled for a fiberoptic colonoscopy. What does the nurse know that fiberoptic colonoscopy is most frequently used to diagnose?

Cancer

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate?

Cancer.

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two IV lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?

Change the second IV solution to dextrose 5% in water.

A nurse is preparing to insert a peripheral intravenous access device into the arm of a client. When preparing the skin for insertion, which of the following should the nurse use to prevent possible health-care associated bloodstream infections?

Chlorhexidine

The nurse is caring for a young adult client with a diagnosis of cerebral palsy who has been admitted for the relief of painful contractures in his lower extremities. When creating a nursing care plan for this client, what variables should the nurse consider? Select all that apply.

Client's comorbid conditions Type of procedure be performed Changes in neurologic function due to the procedure Prior effectiveness in relieving the pain

A nurse is preparing to administer a client's scheduled parenteral nutrition (PN). Upon inspecting the bag, the nurse notices that small amounts of white precipitate are present in the bag. What is the nurse's best action?

Contact the pharmacy to obtain a new bag of PN.

A physician determines that a client has been exposed to someone with tuberculosis. The nurse expects the physician to order which treatment?

Daily doses of isoniazid, 300 mg for 6 months to 1 year

Which nursing assessment is most important in a client diagnosed with ascites?

Daily measurement of weight and abdominal girth

A nurse is assessing a client receiving tube feedings and suspects dumping syndrome. What would lead the nurse to suspect this? Select all that apply.

Diarrhea Tachycardia Diaphoresis

A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.

Enlarged liver size Ascites Hemorrhoids

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?

Esophageal tumor

Which portion of the middle ear equalizes pressure?

Eustachian tube

The nurse is to discontinue a nasogastric tube that had been used for decompression. What is the first action the nurse should take?

Flush with 10 mL of water.

Which factor increases blood urea nitrogen (BUN)?

Gastrointestinal bleeding

A patient is receiving parenteral nutrition. The current solution is nearing completion, and a new solution is to be hung, but it has not arrived from the pharmacy. Which action by the nurse would be most appropriate?

Hang a solution of dextrose 10% and water until the new solution is available.

A client with a long-standing diagnosis of type 1 diabetes has a history of poor glycemic control. The nurse recognizes the need to assess the client for signs and symptoms of peripheral neuropathy. Peripheral neuropathy constitutes a risk for what nursing diagnosis?

Infection

The nurse is managing a gastric (Salem) sump tube for a patient who has an intestinal obstruction and will be going to surgery. What interventions should the nurse perform to make sure the tube is functioning properly?

Keep the vent lumen above the patient's waist to prevent gastric content reflux.

The nurse is assessing a patient with nonproliferative (background) retinopathy. When examining the retina, what would the nurse expect to assess? Select all that apply.

Leakage of fluid or serum (exudates) Microaneurysms Focal capillary single closure

A positive Rovsing's sign is indicative of appendicitis. A nurse knows to assess for this indicator by palpating the:

Left lower quadrant.

A nurse is caring for a client with an abnormally low blood glucose concentration. What glucose level should the nurse observe when assessing laboratory results?

Less than 70 mg/dL (3.7 mmol/L)

The health care provider orders the insertion of a single lumen nasogastric tube. When gathering the equipment for the insertion, what will the nurse select?

Levin tube

A client with a history of type 1 diabetes has just been admitted to the critical care unit (CCU) for diabetic ketoacidosis. The CCU nurse should prioritize what assessment during the client's initial phase of treatment?

Maintaining and monitoring the client's fluid balance

The nurse is educating the patient with diabetes about the importance of increasing dietary fiber. What should the nurse explain is the rationale for the increase? Select all that apply.

May improve blood glucose levels Decrease the need for exogenous insulin Help reduce cholesterol levels

During surgery a patient develops hypothermia. The circulating nurse would monitor the patient closely for which of the following?

Metabolic acidosis

A patient has serous otitis media with significant hearing loss in the right ear. The patient states, "I have not been able to hear for 2 months." What procedure does the nurse anticipate preparing the patient for?

Myringotomy

The nurse is assessing a client with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?

Nystagmus

A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?

Oxygen saturation of 90%

The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?

PaCO2

An elderly client comes into the emergency department reporting an earache. The client and has an oral temperature of 37.9° (100.2ºF) and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?

Palpate the client's parotid glands to detect swelling and tenderness.

A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?

Parotid

A nurse would implement droplet precautions for a client with which condition? Select all that apply.

Pertussis Mumps Parvovirus B 19

A nurse implements aseptic technique as a means to break the chain of infection at which element?

Portal of entry

When caring for a client with acute pancreatitis, the nurse should use which comfort measure?

Positioning the client on the side with the knees flexed

The nurse is caring for a client needing emergency surgery. Which preoperative teaching is least important to prepare the client for surgery?

Post-discharge diet

A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

Potassium-rich foods

The nurse screens a middle-aged client's vision and notes that the client has difficulty reading print unless it is placed at arm's length. The client tells the nurse that the same problem happened to his father. The nurse is aware that the health care practitioner will refer this client to an ophthalmologist for correction of what vision problem?

Presbyopia

A nurse is preparing to discharge a client newly diagnosed with peptic ulcer disease. The client's diagnostic test results were positive for H. pylori bacteria. The health care provider has ordered the "triple therapy" regimen. Which medications will the nurse educate the client on?

Proton-pump inhibitor and two antibiotics

A client who is postoperative from bariatric surgery reports foul-smelling, fatty stools. What is the nurse's understanding of the primary reason for this finding?

Rapid gastric dumping

Which route of medication administration should the nurse consider first after IV removal in a postoperative client with an NPO (nothing by mouth) order?

Rectal

A client is treated for gastrointestinal problems related to chronic cholecystitis. What pathophysiological process related to cholecystitis does the nurse understand is the reason behind the client's GI problems?

Reduced or absent bile as a result of obstruction impacts digestion.

The nurse advises the patient who has just been diagnosed with acute gastritis to:

Refrain from food until the GI symptoms subside.

The nurse, caring for a patient with emphysema, understands that airflow limitations are not reversible. The end result of deterioration is:

Respiratory acidosis.

A nurse works in a bariatric clinic and cares for client with obesity who will or have undergone bariatric surgery. What is the nurse's understanding of how the procedure works?

Restricts the client's ability to eat.

The nurse cares for a client after an endoscopic examination and prepares the client for discharge. The nurse includes which instruction?

Resume regular diet.

A nurse is working as part of the surgical team in the semi-restricted area. Which of the following would be appropriate to wear? Select all that apply.

Scrub clothes Caps

A client has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the client knows to do what action?

Slowly taper down the dose of prednisone, as prescribed.

An adult client has just been diagnosed with small cell lung cancer. The client asks the nurse why the doctor is not offering surgery as a treatment for his cancer. What fact about lung cancer treatment should inform the nurse's response?

Small cell cancer of the lung grows rapidly and metastasizes early and extensively.

The nurse is planning the care of a client with hyperthyroidism. What should the nurse specify in the client's meal plan?

Small, frequent meals, high in protein and calories

A nurse cares for a client who is post op from bariatric surgery. Once able, the nurse encourages oral intake for what primary purpose?

Stimulate GI peristalsis

An x-ray of a trauma client reveals rib fractures and the client is diagnosed with a small flail chest injury. Which intervention should the nurse include in the client's plan of care?

Suction the client's airway secretions.

Which are accurate clinical manifestations of a retinal detachment?

Sudden onset of a greater number of floaters

A client with peptic ulcer disease has been prescribed sucralfate. What health education should the nurse provide to this client?

Take the medication 2 hours before or after other medications

Which nursing instruction is correct to provide the client following a barium enema?

The stools may be a white or clay colored.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting.

A client with low back pain is being seen in the clinic. In planning care, which teaching point should the nurse include?

Use the large muscles of the leg when lifting items.

A client is postoperative day 1 following gastrostomy. The nurse is planning interventions to address the nursing diagnosis of Risk for Infection Related to Presence of Wound and Tube. What intervention is most appropriate?

Wash the area around the tube with soap and water daily.

A middle-aged obese female presents to the ED with severe radiating right-sided flank pain, nausea, vomiting, and fever. A likely cause of these symptoms is:

acute cholecystitis

A client reports a sudden onset of tinnitus, hearing loss, and vertigo. The nurse carefully reviews the client's medication list to determine whether the client is taking a medication that might cause ototoxicity. Which medications would the nurse be most concerned with? Select all that apply.

aspirin lasix cisplatin

The nurse is conducting a community education program on peptic ulcer disease prevention. The nurse includes that the most common cause of peptic ulcers is:

gram-negative bacteria.

A client has symptoms suggestive of peritonitis. Nursing management would not include:

limiting analgesics to avoid the formation of paralytic ileus.

It is important for the nurse to provide required information and appropriate explanations of diagnostic procedures to clients with respiratory disorders in order to

manage decreased energy levels.

The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse

obtains a light, mirror, gauze, and curved hemostats.

The nurse inspects a client's tongue. Which finding would the nurse evaluate as an indication of potential oral cancer?

red plaque on undersurface of tongue

A client presents at the walk-in clinic reporting diarrhea and vomiting. The client has a documented history of adrenal insufficiency. Considering the client's history and current symptoms, the nurse should anticipate that the client will be instructed to increase intake of:

sodium.

The nurse is admitting a client whose medication regimen includes regular injections of vitamin B12. The nurse should question the client about a history of:

total gastrectomy.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching?

"How did this happen? I've been faithful my entire marriage."

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it?

"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."

After teaching a client who has had a Roux-en-Y gastric bypass, which client statement indicates the need for additional teaching?

"I need to drink 8 oz of water before eating."

A diabetic educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The educator is aware that the client will require further teaching when the client states what?

"I will not take my insulin on the days when I am sick, but I will certainly check my blood sugar every 2 hours."

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."

Which statement indicates that a client with diabetes mellitus understands proper foot care?

"I'll wear cotton socks with well-fitting shoes."

A nurse is conducting a class on how to self-manage insulin regimens. A client asks how long a vial of insulin can be stored at room temperature before it "goes bad." What would be the nurse's best answer?

"If you are going to use up the vial within 1 month it can be kept at room temperature."

The wife of a client is concerned because her husband is requiring increasingly high doses of analgesia. She states, "He was in pain long before he got cancer because he broke his back about 20 years ago. For that problem, though, his pain medicine wasn't just raised and raised." What would be the nurse's best response?

"Much cancer pain is caused by tumor involvement and needs to be treated in a way that brings the client relief."

A client comes to the clinic reporting pain in the epigastric region. What statement by the client suggests the presence of a duodenal ulcer?

"My pain resolves when I have something to eat."

When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?

"You shouldn't experience a headache after this type of anesthesia."

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how his health will be affected by the absence of an appendix. How should the nurse best respond?

"Your appendix doesn't play a major role, so you won't notice any difference after your recovery from surgery."

The physician schedules an elective surgical procedure for a patient who smokes cigarettes. When should the nurse recommend that the patient cease smoking before the surgical procedure to minimize risks associate with cigarette smoking?

1 to 2 months

The nurse administers a tube feeding to a client via the intermittent gravity drip method. The nurse should administer the feeding over at least which period of time?

30 minutes

A patient is receiving continuous tube feedings via a small bore feeding tube. The nurse irrigates the tube after administering medication to maintain patency. Which size syringe would the nurse use?

30-mL

The health care provider ordered an IV solution for a dehydrated patient with a head injury. Select the IV solution that the nurse knows would be contraindicated.

5% DW

A patient is being seen in the ophthalmology clinic for a suspected detached retina. What clinical manifestations does the nurse recognize as significant for a retinal detachment? Select all that apply.

A visual field of floating particles A definite area of blank vision Momentary flashes of light

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?

Actinic cheilitis

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant.

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl. His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Administering 1 ampule of 50% dextrose solution, per physician's order

The nurse is caring for a patient with hyperparathyroidism and observes a calcium level of 16.2 mg/dL. What interventions does the nurse prepare to provide to reduce the calcium level? Select all that apply.

Administration of calcitonin Intravenous isotonic saline solution in large quantities Monitoring the patient for fluid overload

The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply.

Albumin level Glucose level Protein level

The nurse has been assigned to care for various clients. Which client is at the highest risk for a fluid and electrolyte imbalance?

An 82-year-old client who receives all nutrition via tube feedings and whose medications include carvedilol and torsemide.

The nurse is reviewing lab work on a newly admitted client. Which of the following diagnostic studies confirm the nursing diagnosis of Deficient Fluid Volume? Select all that apply.

An elevated hematocrit level Electrolyte imbalance

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?

Anemic hypoxia

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?

Assess lung sounds bilaterally.

A client is admitted to the health care center with abdominal pain, nausea, and vomiting. The medical reports indicate a history of type 1 diabetes. The nurse suspects the client's symptoms to be those of diabetic ketoacidosis (DKA). Which action will help the nurse confirm the diagnosis?

Assess the client's breath odor

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?

Assess the graft for color and temperature.

A client had a central line inserted for parenteral nutrition and is awaiting transport to the radiology department for catheter placement verification. The client reports feeling anxious and has a respiratory rate of 28 breaths/minute. What is the next action of the nurse?

Auscultate lung sounds

A client arrives in the emergency department reporting shortness of breath. She has 3+ pitting edema below the knees, a respiratory rate of 36 breaths per minute, and heaving respirations. The nurse auscultates the client's lungs to reveal coarse, moist, high-pitched, and non-continuous sounds that do not clear with coughing. The nurse will document these sounds as which type?

Crackles

When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)

Decreased gag reflex Increased presence of collagen in alveolar walls Decreased presence of mucus

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics

Increased appetite and thirst may indicate that a client with chronic pancreatitis has developed diabetes mellitus. Which of the following explains the cause of this secondary diabetes?

Dysfunction of the pancreatic islet cells

A nurse is assessing a client for GI dysfunction. What is the most common symptom in a client with GI dysfunction?

Dyspepsia

A client has suspected fluid accumulation in the pleural space of the lungs and is scheduled for a thoracentesis. The nurse will implement which of the following for this procedure? Select all that apply.

Educate the client about the need to cleanse the thoracic area. Apply pressure to the puncture site after the procedure. Complete a respiratory assessment after the procedure.

A nurse cares for a client who is postoperative bariatric surgery and has experienced frequent episodes of dumping syndrome. The client now reports anorexia. What is the primary reason for the client's report of anorexia?

Fear of eating

The nurse is caring for a client with a suspected megacolon. The nurse anticipates that one of the findings of assessment will be

Fecal incontinence

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?

Fluoroscopy

Which condition in a client with pancreatitis makes it necessary for the nurse to check fluid intake and output, check hourly urine output, and monitor electrolyte levels?

Frequent vomiting, leading to loss of fluid volume

A nurse is assessing the abdomen of a client just admitted to the unit with a suspected GI disease. Inspection reveals several diverse lesions on the client's abdomen. How should the nurse best interpret this assessment finding?

GI diseases often produce skin changes.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

A client who has developed a painless penile ulcer is diagnosed with syphilis. What treatment would physician prescribe?

IV penicillin G; single dose

The nurse is working on a general medical unit. A client is scheduled for an upper gastrointestinal series. Upon return to the nursing unit, what does the nurse identify as the client goal?

Increase the amount of fluids

Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes?

Increased appetite and thirst

Which measure may increase complications for a client with COPD?

Increased oxygen supply.

Exercise lowers blood glucose levels. Which of the following are the physiologic reasons that explain this statement. Select all that apply.

Increases lean muscle mass Increases resting metabolic rate as muscle size increases Decreases total cholesterol Increases glucose uptake by body muscles

A client has been taking a 10-day course of antibiotics for pneumonia. The client has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the client about?

Nystatin

When assessing a client with infectious diarrhea, which of the following would lead the nurse to suspect that the client is experiencing severe dehydration?

Rapid, thready pulse

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery?

Record the observation

The nurse is explaining glycosylated hemoglobin testing to a diabetic client. Which of the following provides the best reason for this order?

Reflects the amount of glucose stored in hemoglobin over past several months.

The nurse is providing an education program to reduce the incidence of infection currently on the rise in the community. What areas should the nurse focus on when presenting this program? (Select all that apply.)

Regulated health practices Sanitation techniques Immunization programs

A nursing instructor is preparing a class about gastrointestinal intubation. Which of the following would the instructor include as reason for this procedure? Select all that apply.

Remove gas and fluids from the stomach Diagnose gastrointestinal motility disorders Flush ingested toxins from the stomach Administer nutritional substances

The client is postoperative for a right total-knee arthroplasty, and medications include lidocaine 5% (Lidoderm). Past history includes a left mastectomy and herpes zoster following treatment with chemotherapy. The best nursing action is to:

Remove the patch after 12 hours.

A 76-year-old client had surgery for an abdominal hernia. The PACU nurse observes that the client is confused and is trying to climb out of the bed and pull at the cardiac monitor lines. At this time, what interventions by the nurse are appropriate? Select all that apply.

Reorient the client. Assess for hypoxia. Assess urine output.

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to

Report decreased congestion.

A client with type 2 diabetes has been managing his blood glucose levels using diet and metformin. Following an ordered increase in the client's daily dose of metformin, the nurse should prioritize which of the following assessments?

Reviewing the client's creatinine and BUN levels

A client is being discharged after a liver transplant and the nurse is performing discharge education. When planning this client's continuing care, the nurse should prioritize what risk diagnosis?

Risk for Infection Related to Immunosuppressant Use

The nurse observes the physician palpating the abdomen of a client that is suspected of having acute appendicitis. When the abdomen is pressed in the left lower quadrant the client complains of pain on the right side. What does the nurse understand this assessment technique is referred to?

Rovsing sign

The nurse should assess for an important early indicator of acute pancreatitis. What prolonged and elevated level would the nurse determine is an early indicator?

Serum lipase

The nurse is admitting a patient to the intensive care unit with a diagnosis of acute pancreatitis. What does the nurse expect was the reason the patient came to the hospital?

Severe abdominal pain

The nurse is working in a long-term care facility. Which clues that the nurse notes suggest that the client is not hearing what the nurse said? Select all that apply.

The client does not want to be social. The client responds inappropriately. The client nods the head and smiles. The client withdraws from activity.

A client is prescribed corticosteroid therapy. What would be priority information for the nurse to give the client who is prescribed long-term corticosteroid therapy?

The client is at an increased risk for developing infection.

Why would a client with COPD report feeling fatigued? Select all that apply.

The client is using all expendable energy just to breathe. Lung function gradually decreases over time in clients with COPD.

A client is being prepared for a same-day surgical procedure and is discussing with the nurse what potential ramifications this type of surgery has. Which of the following would the nurse correctly identify? Select all that apply.

The client will leave the hospital sooner than in the past. Need for teaching is increased. The client must be prepared to take on more self-care than he or she may have done in the past.

The nurse is inserting a Levin tube for a patient for gastric decompression. The tube should be inserted to 6 to 10 cm beyond what length?

The distance measured from the tip of the nose to the earlobe and from the earlobe to the xiphoid process

A nurse is admitting a client diagnosed with late-stage gastric cancer. The client's family is distraught and angry that she was not diagnosed earlier in the course of her disease. What factor most likely contributed to the client's late diagnosis?

The early symptoms of gastric cancer are usually not alarming or highly unusual.

Which homeostatic mechanism would the body of a critically ill client use to maintain normal pH?

The lungs eliminate carbonic acid by blowing off more CO2.

A client with diabetes begins to have digestive problems and is told by the physician that they are a complication of the diabetes. Which of the following explanations from the nurse is most accurate?

The pancreas secretes digestive enzymes.

How does the nurse determine that the patient may have hidden fears about the impending surgical procedure? (Select all that apply.)

The patient avoids communication with the nurse. The patient repeatedly asks questions that have previously been answered. The patient talks incessantly.

When conducting an eye exam, the nurse practitioner is aware that a diagnostic clinical manifestation of glaucoma is:

The presence of halos around lights.

An client is described as having pectus carinatum. What would be the physical manifestation of this condition?

The sternum protrudes and the ribs are sloped backward.

A nurse practitioner treating a patient who is diagnosed with hepatitis A should provide health care information. Which of the following statements are correct for this disorder? Select all that apply.

There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral-anal contact during sex. Typically there is a spontaneous recovery.

The mother of a client with cancer comes to the nurse concerned with her daughter's safety. She states that the dose of morphine that her daughter requires to control her pain is getting "higher and higher." As a result, the mother is afraid that her daughter will overdose. The nurse should educate the mother about what aspect of her daughter's pain management?

There is no absolute maximum opioid dose and her daughter is becoming more tolerant to the drug.

When preparing to insert a nasogastric tube, the nurse determines the length of the tube to be inserted. The nurse places the distal tip of the tube at which location?

Tip of patient's nose

A client with a decreased level of consciousness is in a recumbent position. How should the nurse best assess the lung fields for a client in this position?

Turn the client to enable assessment of all the patient's lung fields.

The patient is NPO prior to having a colonoscopy. The patient is to take a daily blood pressure pill prior to the procedure. Until when may water be given prior to the procedure?

Up to 2 hours before surgery

The nurse is caring for a postsurgical client who speaks very little English. How should the nurse most accurately assess this client's pain?

Use a chart with English on one side of the page and the client's native language on the other so he can rate his pain.

A nurse is creating a care plan for a client with a nasogastric tube. How should the nurse direct other members of the care team to check correct placement of the tube?

Use a combination of at least two accepted methods for confirming placement.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

Using a Venturi mask to deliver oxygen as ordered

A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?

Venous thromboemboli

Which intervention should the nurse implement during the intraoperative period to protect the client from injury? Select all that apply.

Verify scheduled procedure with client. Assess the client for allergies. Confirm the consent form is signed.

The client is receiving 50% dextrose parenteral nutrition with fat emulsion therapy through a peripherally inserted central catheter (PICC). The nurse has developed a care plan for the nursing diagnosis "Risk for infection related to contamination of the central catheter site or infusion line." The nurse includes the intervention

Wear a face mask during dressing changes.

The nurse is caring for a client with a decrease in airway diameter causing airway resistance. The client experiences coughing and mucus production. Upon lung assessment, which adventitious breath sounds are anticipated?

Wheezes